Popliteal Artery Entrapment Syndrome

A Diagnostic and Treatment Enigma for Orthopaedic Surgeons

Timothy L. Miller, MD; Rose Backs, PA-C; Patrick S. Vaccaro, MD


J Am Acad Orthop Surg. 2021;29(17):e834-e845. 

In This Article

Abstract and Introduction


Popliteal artery entrapment syndrome (PAES) is an uncommon condition that causes recurrent posterior leg pain and foot paresthesia in running athletes. This condition occurs most commonly due to an accessory or abnormal implant of the medial head of the gastrocnemius muscle. It may mimic or coincide with other chronic conditions of the lower extremity including chronic exertional compartment syndrome but is most consistent with vascular claudication. Clinical features that distinguish PAES from other causes of leg pain include a sensation of coolness of the posterior leg during exercise and associated paresthesia of the plantar aspect of the foot. Physical examination often reveals decreased intensity of the posterior tibial or dorsalis pedis pulses with passive dorsiflexion or active plantarflexion of the ankle. Diagnostic tests that confirm the presence of PAES include lower extremity angiography during active resisted plantarflexion or maximal passive dorsiflexion, and magnetic resonance angiography done after exercise provocation. Nonsurgical treatment with physical therapy and stretching of the gastrocnemius complex should be done as the first line of treatment. When conservative treatments are ineffective, referral to a vascular specialist for surgical intervention with a muscular band excision or transection, vascular bypass, or arterial reconstruction is necessary.


Popliteal artery entrapment syndrome (PAES) is an often unrecognized cause of chronic leg pain that is diagnosed most often in running athletes, including distance runners and military personnel.[1,2] Originally described clinically by Hamming in 1959, the condition was named PAES in 1965 by Love and Whelan.[3,4] The clinical features of PAES are exercise-related posterior leg pain and calf cramping with associated paresthesia of the plantar foot.[5] The diagnosis is often challenging to make, given that the symptoms often overlap with those of other soft-tissue and bony conditions.[6,7] Although many of its symptoms are shared with those of other conditions, such as chronic exertional compartment syndrome (CECS), there are features that clinically distinguish PAES from other causes of exercise-induced leg pain.[8,9] It is in many ways a diagnosis of exclusion because the median length of symptoms before reaching its diagnosis has been shown to be 34 months.[10]