RS13 - Clinical outcomes from a 20-year experience treating functional popliteal artery entrapment syndrome in athletes

Objectives: 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 provocative testing with arterial duplex/digit plethysmography and CTA followed by surgical debulking of the anterolateral quadrant of the medial head of the gastrocnemius muscle and fasciotomy. We sought to determine risk factors for clinical success versus recurrent symptoms in athletes undergoing surgery for FPAES.

Methods: 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.

Results: From 2005-2025 we operated on 73 patients and treated 125 limbs. Most patients were female (64.5%) and had bilateral symptoms (84.2%). The most common sports represented were running (43.8%) and soccer (26.0%) (Figure 1). Most athletes (38.4%) competed at the collegiate level, 16.4% were professional or semi-professional.

Gastrocnemius debulking was guided by CTA compression and mean muscle volume resected was 6.86cm3. Concurrent fasciotomies were performed in 90 of 125 cases (72.0%). Symptom improvement was reported in 86.5% of patients, with 82.4% able to return to prior competitive level of sport. On multivariable regression, concurrent fasciotomy (OR 3.03, 95%CI 1.06–8.65, p=0.038) and male gender (OR 5.16, 95%CI 1.10–24.25, p=0.038) were associated with a higher likelihood of return to sport.

The most common postoperative complication was mild superficial wound dehiscence (4.8%). Delayed symptom recurrence was observed in 11.2% of patients, at a mean time to recurrence of 490 days. In the Cox proportional hazards model, males had a significantly lower risk of long-term recurrence compared to females (HR = 0.08, 95%CI: 0.01–0.62, p=0.016) (Figure 2).

Conclusions: 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 on a standardized radiographic workup and surgical treatment. Partial debulking of the medial head of the gastrocnemius is a safe and effective intervention, and when combined with concurrent fasciotomy appears to further improve outcomes. Male athletes appear to have improved outcomes with higher rates of return to sport and lower rates of symptom recurrence.