KIN 424 2024 Sport-related Vascular Problems.pdf

Sport-Related Vascular Conditions in Endurance Athletes Jem Arnold, MPT, PhD candidate [email protected] Images: Tami Lim Ledesma anatamiart.net sportsinjurybulletin.com/diagnose--treat/uncommon-injuries-external-iliac-artery-endofibrosis Sport-Related Vascular Conditions in Endurance Athletes FLIA...

Sport-Related Vascular Conditions in Endurance Athletes Jem Arnold, MPT, PhD candidate [email protected] Images: Tami Lim Ledesma anatamiart.net sportsinjurybulletin.com/diagnose--treat/uncommon-injuries-external-iliac-artery-endofibrosis Sport-Related Vascular Conditions in Endurance Athletes FLIA - Flow Limitations in the Iliac Artery Adductor Canal Compression PAES - Popliteal Artery Entrapment Syndrome CECS - Chronic Exertional Compartment Syndrome FLIA - Flow Limitations in the Iliac Artery Adductor Canal Compression PAES - Popliteal Artery Entrapment Syndrome CECS - Chronic Exertional Compartment Syndrome Superficial femoral aa. 3 Rocha Luz, et al. 2017. Lower Limb Ulcers. Vascular Diseases for the Non-Specialist. http://dx.doi.org/10.1007/978-3-31946059-8_17 FLIA - Flow Limitation in the Iliac Artery Blood flow limitation during exercise Ischemia hypoxia claudication Pain, burning, powerlessness ○ Non-specific symptoms Kinking, compression Stenosis: functional Progressive: months endofibrosis structural years https://www.sportsinjurybulletin.com/uncommon-injuries-external-iliac-artery-endofibrosis/ https://cyclingtips.com/2021/03/filippo-ganna-is-not-a-robot/ Zugail AS, Shaabi HI, Idir S, et al. (2020) Cyclist Endofibrosis (Exercise-Induced Arterial Endofibrosis) Treated by Drug-Coated Balloon Angioplasty. Case reports in vascular medicine. 4 FLIA - Prevalence Young, healthy, very fit athletes Male & female cyclists, skaters, runners, … Estimated 1-in-5 professional cyclists ○ Occupational hazard in sport 5 https://cyclingtips.com/2021/03/filippo-ganna-is-not-a-robot/ https://www.nbcnews.com/storyline/sochi-olympics/team-effort-dutch-speed-skaters-pursue-double-gold-n35481 Vascular Presentation Claudication (pain, burning, weakness) Working muscles (quads, calf, …) Bilateral or Unilateral ○ FLIA is unilateral, CECS is bilateral (why?) Symptoms resolve within ~5-min rest Ruled out more common MSK diff Dx Typically has not responded to previous interventions (physio, training changes) 6 7 https://ukdaily.news/marianne-vos-wins-the-sprint-in-rosheim-as-the-boss-of-the-peloton-11267.html https://www.velonews.com/news/cyclocross/marianne-vos-powers-to-first-victory-in-rainbow-jersey/#_pay-wall https://www.cyclingnews.com/news/tour-de-france-femmes-already-more-than-a-dream-come-true-for-marianne-vos/ https://www.velonews.com/news/cyclocross/what-marianne-vos-gage-hecht-and-others-said-after-a-soggy-uci-cyclocrossworld-cup-in-fayetteville/ 8 Diagnosis - Functional Assessment Patient history, questionnaire Functional assessment ○ Provocative exercise test 9 @howtheracewaswon https://www.instagram.com/p/CnhTo_ngnN4/ Diagnosis - Functional Assessment Patient history, questionnaire Functional assessment Ankle-brachial pressure index (ABI) Muscle Oxygenation (NIRS) 10 Diagnosis - Ankle-brachial pressure index (ABI) https://www.nhlbi.nih.gov/health-topics/peripheral-artery-disease#diagnosis Mittleider D. (2018) Noninvasive Arterial Testing: What and When to Use. Seminars in Interventional Radiology. 11 Muscle Oxygenation Near-Infrared Spectroscopy NIRS Muscle O2 Saturation 12 Muscle Oxygenation 13 Muscle Oxygenation 14 15 16 17 18 19 Diagnosis - Echo-Doppler Ultrasound 1. Aterial kink 2. Excessive length (tortuosity) Endofibrosis / Stenosis 20 Van Hooff M, et al. (2022) Surgical Shortening of Lengthened Iliac Arteries in Endurance Athletes: Short-Term and Long-Term Satisfaction. J Vasc Surg. https://dx.doi.org/10.1016/j.jvs.2022.10.001 Diagnosis - Peak Systolic Velocity Ultrasound imaging Peak Systolic Velocity (PSV) Mittleider D. (2018) Noninvasive Arterial Testing: What and When to Use. Seminars in Interventional Radiology. Garlanger KL, Jelsing EJ, Finnoff JT. (2017) External Iliac Artery Vasospasm in an Elite Female Runner. Sports Health. https://www.cvphysiology.com/Hemodynamics/H007 21 Diagnosis - Magnetic Resonance Angiography (MRA) 22 23 Diagnosis - Computed Tomography (CT) Scan 24 Zugail AS, Shaabi HI, Idir S, et al. (2020) Cyclist Endofibrosis (Exercise-Induced Arterial Endofibrosis) Treated by Drug-Coated Balloon Angioplasty. Case reports in vascular medicine. 25 Aker A, Nader K, Jaffe R. (2019) Iliac Artery Rupture During Transfemoral Transcatheter Aortic Valve Implantation. J INVASIVE CARDIOL Management 26 Bike & Body Position Modification 27 1. Blocken B, van Druenen T, Toparlar Y, Andrianne T. (2018) Aerodynamic Analysis of Different Cyclist Hill Descent Positions. Journal of Wind Engineering and Industrial Aerodynamics. https://www.sciencedirect.com/science/article/pii/S0167610518305762 28 Bike & Body Position Modification Goal: open hip angle ○ Reduce kink & compression ○ Reduce hemodynamic stress ○ Relieve symptom burden ○ Mitigate progression of endofibrosis? ○ Allow improved adaptations? 29 Surgical Management 1. Arterial release (kink, fixation) 2. 30 van Hooff M. (2023) Iliac Artery Flow Limitations in Athletes: Novel Diagnostics, Efficacy and Safety after Surgery: Maastricht University. Surgical Management 1. Arterial release (kink, fixation) 2. Shortening (excessive length, tortuosity) 31 van Hooff M. (2023) Iliac Artery Flow Limitations in Athletes: Novel Diagnostics, Efficacy and Safety after Surgery: Maastricht University. Surgical Management 1. Arterial release (kink, fixation) 2. Shortening (excessive length, tortuosity) 3. Patch reconstruction (endofibrosis / stenosis) 32 van Hooff M. (2023) Iliac Artery Flow Limitations in Athletes: Novel Diagnostics, Efficacy and Safety after Surgery: Maastricht University. 33 @CentreforInnovation Centre for Innovation - Leiden University Lecture 2-6: Kidney transplant surgery https://youtu.be/fELn4Fe9Ccc 34 Wuarin L, et al. (2019) External Iliac Artery Endofibrosis in a Female Cyclist: A Case Report. Ann Vasc Surg. 35 Arnold J, et al. (2021) Evaluating Arterial Blood Flow Limitation Using Muscle Oxygenation and Cycling Power. Clin J Sport Med. https://doi.org/10.1097/jsm.0000000000000942 36 Mazurová T, et al. (2022) Endofibrosis as a Causative Agent of the Peripheral Artery Disease: A Report of Two Cases for Professional Cyclists. Cureus. Return to Sport Pre-operative Post-op week 1 Weeks 2-3 Weeks 4-6 Weeks 6-12 Weeks 13-16+ 37 Questions? 38 Break? 39 FLIA - Flow Limitations in the Iliac Artery Adductor Canal Compression PAES - Popliteal Artery Entrapment Syndrome CECS - Chronic Exertional Compartment Syndrome Superficial femoral aa. 40 Rocha Luz, et al. 2017. Lower Limb Ulcers. Vascular Diseases for the Non-Specialist. http://dx.doi.org/10.1007/978-3-31946059-8_17 Adductor Canal Compression Superficial femoral aa. & vv. compression ○ Hypertrophied quad & adductor mm. 41 https://basicmedicalkey.com/vessels-of-the-thigh/ Adductor Canal Compression Superficial femoral aa. & vv. compression Presentation: ○ Ischemia hypoxia claudication ○ Artery: Pain, burning, weakness ○ Vein: Swelling, heaviness, congestion ○ Nerve: Numbness, weakness, paraesthesia 42 https://basicmedicalkey.com/vessels-of-the-thigh/ Case Study - Powerlifter 43 https://www.t-nation.com/training/tip-build-quads-without-bars-dumbbells-or-machines/ Adductor Canal Compression Superficial femoral aa. & vv. compression Presentation: claudication, swelling, paraesthesia Diagnosis: ○ Provocative exercise Isometric muscle squeeze Cycling exercise ○ CT scan ○ NIRS? 44 https://basicmedicalkey.com/vessels-of-the-thigh/ 45 Adductor Canal Compression Superficial femoral aa. & vv. compression Presentation: claudication, swelling, paraesthesia Diagnosis: functional test & imaging Management: ○ Surgical release 46 https://basicmedicalkey.com/vessels-of-the-thigh/ FLIA - Flow Limitations in the Iliac Artery Adductor Canal Compression PAES - Popliteal Artery Entrapment Syndrome CECS - Chronic Exertional Compartment Syndrome Superficial femoral aa. 47 Rocha Luz, et al. 2017. Lower Limb Ulcers. Vascular Diseases for the Non-Specialist. http://dx.doi.org/10.1007/978-3-31946059-8_17 Popliteal Artery Entrapment Syndrome Compression of artery, vein, nerve ○ Subtypes I-VI & F ○ Structural or functional 48 https://flexfreeclinic.com/artikel/detail/253?title=popliteal-artery-entrapment-syndrome Rajasekaran S, Finnoff JT. (2016) Exertional Leg Pain. Phys Med Rehabil Clin N Am. https://doi.org/10.1016/j.pmr.2015.08.012 Popliteal Artery Entrapment Syndrome 49 Bradshaw S, et al. (2021) Popliteal artery entrapment syndrome. Cardiovasc Diagn Ther. http://dx.doi.org/10.21037/cdt-20186 Popliteal Artery Entrapment Compression of artery, vein, nerve Presentation: ○ Claudication ○ Swelling, fullness ○ Paraesthesia 50 https://www.hopkinsmedicine.org/health/conditions-and-diseases/popliteal-artery-entrapment-syndrome-paes Popliteal Artery Entrapment Syndrome Compression of artery, vein, nerve Presentation: claudication, swelling, paraesthesia Diagnosis: ○ Provocative testing ○ Duplex ultrasound imaging Hislop M, et al. (2014) Functional Popliteal Artery Entrapment Syndrome: Poorly Understood and Frequently Missed? A Review of Clinical Features, Appropriate Investigations, and Treatment Options. Journal of Sports Medicine. http://dx.doi.org/10.1155/2014/105953 Shalabi ST, et al. (2013) Claudication without risk factors: a case of popliteal entrapment syndrome. BMJ Case Rep. doi:10.1136/bcr-2013-202199 51 Popliteal Artery Entrapment Syndrome Compression of artery, vein, nerve Presentation: claudication, swelling, paraesthesia Diagnosis: ○ Provocative testing ○ Duplex ultrasound imaging ○ MR angiography, CT scan Hislop M, et al. (2014) Functional Popliteal Artery Entrapment Syndrome: Poorly Understood and Frequently Missed? A Review of Clinical Features, Appropriate Investigations, and Treatment Options. Journal of Sports Medicine. http://dx.doi.org/10.1155/2014/105953 Shalabi ST, et al. (2013) Claudication without risk factors: a case of popliteal entrapment syndrome. BMJ Case Rep. doi:10.1136/bcr-2013-202199 52 Popliteal Artery Entrapment Compression of artery, vein, nerve Presentation: claudication, … Diagnosis: functional tests, imaging Management ○ Soft tissue treatments ○ Botox injection ○ Surgical decompression (fasciotomy, myotomy) ○ Vascular repair, re-routing, bypass 53 https://physio-logical.net/calf-tightness/ Rajasekaran S, Finnoff JT. (2016) Exertional Leg Pain. Phys Med Rehabil Clin N Am. https://doi.org/10.1016/j.pmr.2015.08.012 Popliteal Artery Entrapment Syndrome 54 https://physio-logical.net/calf-tightness/ Rajasekaran S, Finnoff JT. (2016) Exertional Leg Pain. Phys Med Rehabil Clin N Am. https://doi.org/10.1016/j.pmr.2015.08.012 FLIA - Flow Limitations in the Iliac Artery Adductor Canal Compression PAES - Popliteal Artery Entrapment Syndrome CECS - Chronic Exertional Compartment Syndrome Superficial femoral aa. 55 Rocha Luz, et al. 2017. Lower Limb Ulcers. Vascular Diseases for the Non-Specialist. http://dx.doi.org/10.1007/978-3-31946059-8_17 Chronic Exertional Compartment Syndrome (CECS) Compression of fascial compartments ○ Muscle contracts, volume changes ○ Inelastic fascia ○ Compression Artery, vein, nerve https://www.mayoclinic.org/diseases-conditions/chronic-exertional-compartment-syndrome/symptoms-causes/syc20350830 Rajasekaran S, Finnoff JT. (2016) Exertional Leg Pain. Phys Med Rehabil Clin N Am. https://doi.org/10.1016/j.pmr.2015.08.012 56 Chronic Exertional Compartment Compression of fascial compartments Presentation: ○ Ischemia hypoxia claudication ○ Claudication, paraesthesia, fullness, … ○ Hernia ○ Gradual onset during a training bout ○ Rapid recovery ○ Commonly bilateral 57 https://www.sportsinjurybulletin.com/anatomy/getting-a-leg-up-on-chronic-exertional-compartment-syndrome-in-the-deepcompartment Chronic Exertional Compartment Syndrome Compression of fascial compartments Presentation: claudication & more Diagnosis: ○ Needle manometry pressure testing 58 https://emedicine.medscape.com/article/307668-workup https://www.uptodate.com/contents/acute-compartment-syndrome-of-the-extremities Chronic Exertional Compartment Syndrome Compression of fascial compartments Presentation: claudication & more Diagnosis: pressure testing Management: ○ Manual therapies (not very effective) ○ Training modification / reduction ○ Forefoot running ○ Surgery - fasciotomy 59 http://runforefoot.com/forefoot-running-reduces-leg-pain-heel-strikers/ 60 https://www.youtube.com/@skeletonheb 61 https://www.youtube.com/@skeletonheb Chronic Exertional Compartment Syndrome 62 Rajasekaran S, Finnoff JT. (2016) Exertional Leg Pain. Phys Med Rehabil Clin N Am. https://doi.org/10.1016/j.pmr.2015.08.012 FLIA - Flow Limitations in the Iliac Artery Adductor Canal Compression PAES - Popliteal Artery Entrapment Syndrome CECS - Chronic Exertional Compartment Syndrome Superficial femoral aa. 63 Rocha Luz, et al. 2017. Lower Limb Ulcers. Vascular Diseases for the Non-Specialist. http://dx.doi.org/10.1007/978-3-31946059-8_17