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Difficulty: HardPhysical Examination Findings

A 22-year-old active-duty military recruit is evaluated in the outpatient clinic for a 3-month history of left calf pain. He reports that the pain reliably develops after he runs approximately half a mile, described as a severe, deep cramping sensation that forces him to stop running. The pain completely resolves after 5 to 10 minutes of rest. He has no prior medical history, takes no medications, and has never used tobacco products. Vital signs are within normal limits. On physical examination, the lower extremities appear normal with no erythema, edema, or focal tenderness at rest. Bilateral femoral, popliteal, dorsalis pedis, and posterior tibial pulses are 2+ and symmetric while the patient is lying supine. Sensation and deep tendon reflexes are intact bilaterally. Which of the following is the most appropriate next step in the physical examination and clinical evaluation of this patient?

  1. Palpation of the pedal pulses during sustained active plantar flexion of the ankleAnswer
  2. B
    Observation of the feet for pallor during passive elevation of the legs to 45 degrees
  3. C
    Magnetic resonance angiography of the lower extremities in a resting supine position
  4. D
    Measurement of serum creatine kinase and aldolase levels
  5. E
    Invasive catheter-directed lower extremity angiography

Answer

Palpation of the pedal pulses during sustained active plantar flexion of the ankle
The correct answer utilizes a specific physical examination maneuver to diagnose Popliteal Artery Entrapment Syndrome (PAES). PAES typically affects young, athletic individuals who present with classic claudication symptoms despite having no cardiovascular risk factors and normal resting pulses. The condition is caused by an anomalous anatomical relationship where the popliteal artery passes medial to, or through, the medial head of the gastrocnemius muscle. Contraction of the muscle during active plantar flexion compresses the artery. By palpating the dorsalis pedis or posterior tibial pulses while the patient performs sustained active plantar flexion (or passive dorsiflexion), the clinician can elicit the disappearance of the pulse, heavily supporting the diagnosis before confirming with provocative duplex ultrasonography.

Step-by-Step Solution

1
Analyze the patient's demographic and symptom profile.
The patient is a young, healthy male without cardiovascular risk factors presenting with classic exertional claudication (pain with exercise, relieved by rest).
This rules out standard atherosclerotic peripheral artery disease (PAD) and points toward an anatomic or dynamic mechanical etiology.
2
Correlate the symptoms with the physical examination findings.
Resting pulses are normal, confirming that there is no fixed arterial occlusion.
The ischemia only occurs during muscular exertion, highly suggestive of Popliteal Artery Entrapment Syndrome (PAES).
3
Determine the most appropriate next diagnostic maneuver.
Perform a provocative physical examination maneuver to dynamically compress the artery.
In PAES, active plantar flexion or passive dorsiflexion causes the anomalous medial head of the gastrocnemius muscle to compress the popliteal artery, resulting in the loss of palpable pedal pulses and confirming the clinical suspicion.

Key Concept

Popliteal artery entrapment syndrome is diagnosed by demonstrating the loss of distal pulses during provocative physical examination maneuvers (e.g., active plantar flexion) in a young, healthy patient with exertional claudication and normal resting pulses.
Estimated Time:1m 30s
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Physical Examination Findings

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