Midterm outcomes from a 20-year experience treating functional popliteal artery entrapment syndrome in athletes

Functional popliteal artery entrapment syndrome (FPAES) is a rare condition affecting young, active individuals presenting with claudication, swelling, or paresthesias, and often impairing athletic performance. Our standardized approach to this disease process involves testing with arterial duplex/digit plethysmography and provocative computed tomography angiography followed by surgical debulking consisting of popliteal artery release and resection of the anterolateral quadrant of the medial head of the gastrocnemius muscle and four-compartment fasciotomy. We sought to determine risk factors for clinical success vs recurrent symptoms in athletes undergoing surgery for FPAES.

Retrospective review was conducted for consecutive athletes undergoing surgery for FPAES at a single institution. Demographics, preoperative symptoms, imaging findings, operative details, and postoperative outcomes were recorded, with primary outcome being return to prior level of sport, and secondary outcomes postoperative complications and long-term symptom recurrence.

From 2005 to 2025, we operated on 125 limbs of 73 athletes. Most athletes competed at the collegiate level (38.4%), were female (64.5%), and had bilateral symptoms (84.2%). The most common sports represented were running (43.8%), soccer (26.0%), basketball (5.5%), lacrosse (5.5%), and water sports (5.5%). Surgical debulking was guided by computed tomography angiography compression of the gastrocnemius muscle and mean muscle volume resected was 6.86 cm³. Concurrent fasciotomies were performed in 90 of 125 cases (72.0%). Symptom improvement at latest follow-up (mean, 14 months) was reported in 86.5% of limbs, with 82.4% able to return to prior competitive level of sport. On multivariable regression, concurrent fasciotomy (odds ratio, 3.03; P = .038) and male sex (odds ratio, 5.16; P = .038) were associated with a higher likelihood of return to sport. Delayed symptom recurrence was observed in 11.2% of limbs, at a median time to recurrence of 369 days (interquartile range, 210-747 days). In a Cox proportional hazards model, males had a significantly lower risk of long-term recurrence compared with females (hazard ratio, 0.08; P = .016).

FPAES is a rare yet impactful condition that limits athletes' ability to perform at high levels. This study represents the largest reported cohort to date, providing a 20-year experience of a standardized radiographic workup, symptom inventory, and definitive surgical treatment. Partial debulking of the medial head of the gastrocnemius after popliteal artery release is a safe and effective intervention, and when combined with concurrent fasciotomy seems to further improve outcomes. Male athletes seem to have improved outcomes with higher rates of return to sport and lower rates of symptom recurrence.