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The Ankle Brachial Index (ABI) is a non-invasive test used to diagnosis popliteal artery entrapment syndrome (PAES), external iliac artery entrapment syndrome (EIAE), and peripheral arterial disease.  It is a forgotten test that should be performed in anyone contemplating surgery for Chronic Exertional Compartment Syndrome.  It involves no needles.  It is the measurement of blood pressure in all four extremities simultaneously along with measurement of your blood flow waveform.

Below are the results of an Ankle Brachial Index (ABI) treadmill stress test performed at New Jersey Sports Medicine and Performance Center on a young athlete with exertional leg pain who failed a fasciotomy for exertional compartment syndrome.  Post exercise the ABI dropped to .6 which is abnormal.   With exercise his arm pressures went up appropriately but his leg pressures dropped.






 

 

 

 

 

 

 

The following are the results of an ABI treadmill stress test in the same athlete post botox injection treatment at New Jersey Sports Medicine for popliteal artery entrapment syndrome (PAES).  Post botox injection, his ABI remained 1.03 in his left leg and .94 in his right leg which is normal.  Post botox injection with exercise his arm and leg pressures both went up appropriately giving him a normal ABI.







 

 

 

 

 

 

 

Isner-Horobeti in 2014 reported a similar case of an athlete mistakenly diagnosed with chronic exertional syndrome (CECS) who underwent unsuccessful compartment release (fasciotomy). They were subsequently diagnosed with bilateral functional popliteal artery entrapment syndrome (PAES) and underwent another failed surgery, (arteriolysis - surgical release of the artery from surrounding tissue), before being treated successfully with injection of botox in the gastrocnemius muscle.

This is an all too common story I repeatedly see in my practice.

This was a case of a male high school soccer player who suffered the same story.

The ABI tests shown above are from a 15 year old high school athlete who complained of bilateral exertional leg pain for more than one year prior to presenting to my office. After 10 minutes of playing soccer he had to stop due to severe tightness and pain in his calves.

He failed physical therapy. He failed “nerve injections'' by another sports medicine physician. And after 9 months of symptoms, he underwent an anterior and lateral fasciotomy.

After his fasciotomy and return to play at 2 months, he had worse pain, with inability to perform any aerobic exercise.

He was seen by a vascular surgeon who performed an MRA (Magnetic Resonance Imaging scan with IV contrast) and was told it was normal. The MRA was performed at rest with no provocative measures.

He underwent a chronic exertional compartment test at another doctor's office post surgery reported to be normal.

He had bilateral tibia/fibula MRIs which showed no muscle edema and no bone marrow edema, read as ‘unremarkable’.

He was now presenting to Dr. Silberman at New Jersey Sports Medicine.

At his first visit a Treadmill Stress ABI test was performed shown above. With exercise the ABI dropped to .66 in the left leg and .64 in the right leg. The same results Isner Horoboti reported in their case.

The decision for botox treatment was made after the abnormal ABI stress test.  Botox injections were performed in December for popliteal artery entrapment syndrome (PAES) and again repeated in May for continuing symptoms more distal in soleus region.

He returned to sport pain free and did not return to the office until June the following year after playing pain free for one year.  Botox was repeated which gave him another year of pain free soccer.  It was repeated again recently prior to him going off to college to play soccer.

Botox is a neurotoxin that blocks the release of acetylcholine, the principal neurotransmitter at the neuromuscular junction, causing muscle weakness. It is postulated that localized injection under ultrasound guidance stops the gastrocnemius muscles from compressing the popliteal artey. The effect of the toxin itself on the nerve may last up to 3 to 6 months. The treatment effect though may be permanent cure, several years, one to two years, or similar to the medication lasting only about 5 months, in which case it may be repeated. Thus the exact mechanism is unknown.

A lower dosage of Botox is used in athletes versus in those with muscle spasticity. Some athletes are back to training in 2 weeks and sports by 4 weeks with no decrease in performance.

The take home pearls from this all too familiar story are:

The initial vascular study for a running athlete with exertional leg pain must be a provocative treadmill ankle brachial index stress test where the runner achieves at least 85% of maximal heart rate.

Intensity is more important than duration.

The ABI test must be performed immediately post cessation of running with two healthcare providers rapidly applying the blood pressure cuffs.

Plantar and dorsiflexion of the ankles performed in vascular labs for older patients with claudication is not sufficient.

Older patients have internal obstruction. Younger athletes have external compression. Running stress is required for testing athletes with exertional compartment syndrome and or popliteal artery entrapment syndrome.

Any athlete considering fasciotomy for exertional compartment syndrome should have a provocative treadmill stress ankle brachial index (ABI) test.

Seeing a vascular surgeon and being told it is not vascular based on a non treadmill ABI stress test is not sufficient.

The provocative treadmill stress ankle brachial index (ABI) test is far superior than an MRA in detecting functional popliteal artery entrapment syndrome. An MRA at rest has a zero percent chance of diagnosing functional popliteal entrapment syndrome. Even a provocative stress MRA with plantar and dorsiflexion maneuvers is inferior to a provocative treadmill stress ankle brachial index (ABI) test for diagnosis of functional popliteal entrapment syndrome.

An MRA can diagnose anatomical and structural causes; however, radiologists and vascular surgeons rarely observe and comment on the anatomy of the musculature and the course of the vessels. They only report whether vessels are patent.

You may know more about exertional compartment syndrome, popliteal artery, entrapment syndrome and Botox than your treating physicians.

You can’t undo surgery. Surgery always results in scar formation (fibrosis) which may make the condition worse. It should always be the last resort.

 

 

New Jersey Sports Medicine and Performance Center is the only regional center that performs a stress ABI, the Ankle Brachial Index on athletes with treadmill and bicycling provocative measures used to diagnose iliac artery
endofibrosis or iliac artery kinking and popliteal artery entrapment syndrome, two common causes of the often undiagnosed and frustrating condition of exertional leg pain in the athlete.













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Dr. Silberman is also the only physician in the region who can perform both exertional compartment testing along with the stress ankle brachial index (ABI) test when evaluating athletes for exertional compartment syndrome.  
 

Functional popliteal artery entrapment syndrome may be treated with botox injections under ultrasound guidance.  The cost of botox injections for functional popliteal artery entrapment syndrome (fPAES) is $500 for each leg (plus the cost of medication at the pharmacy).