The sound of the baby beginning to fuss brought the 36-year-old man to his feet. He didn’t want the noise to wake his sleeping wife, who was pregnant with their second child. But with his first few steps, a familiar agony gripped the back of his left leg. Had he pulled that muscle again? He hobbled to the crib and changed the 6-month-old’s diaper, then eased his way back to the couch. He was worried. This kind of injury was usually caused by vigorous exercise, he thought. But he had only been walking.
The off-and-on pain had started three years earlier during a basketball game at the gym near his home in San Francisco. He was dribbling down the court when he felt a jolt in the back of his left calf, as if someone had kicked him. He was able to finish the game, but his leg ached for a couple of days. He figured he had pulled something. But since then, the same thing had happened again and again. Eventually he went to see his doctor, who diagnosed him with an Achilles’ tendon strain and suggested rest.
The Achilles’ tendon is the largest and strongest tendon in the body, and it is frequently injured by serious athletes. It connects the three muscles of the calf — the soleus, the gastrocnemius and the tiny plantaris — to the heel. And this man was an athlete. He exercised every day to help manage the stress of a full life of work and family. He biked an hour to and from work, up and down the hills of San Francisco, and took on bigger hills on the weekends. He played basketball and tennis a couple of nights a week. But this pain put an end to all that, sometimes for weeks at a time.
Many Doctors, Many Theories
Rest did help, but any serious exertion rekindled the pain. His doctor sent him to an orthopedic surgeon, who recommended physical therapy to help him loosen what the doctor suspected were tight hamstrings. He went, week after week, for nearly a year and a half. He got to be such good friends with his therapist that he attended his wedding that year. But it didn’t change the pattern of exertion, pain, rest and then re-injury.
When P.T. didn’t work, the surgeon prescribed splints that kept his foot at a 90-degree angle. He was supposed to wear them at night, but they were torturous and he couldn’t bear it. He was prescribed a boot to wear during the day. That helped, but only by keeping his ankle immobilized and his Achilles and calf at rest. Over years of searching for an answer, he went through five boots. Each time he started biking, running or playing tennis again, the pain would return.
A sports doctor who specialized in helping athletes avoid surgery tried injecting his calf and Achilles with platelet-rich plasma, a pricey treatment that didn’t help. Another doctor injected him with amniotic stem cells, another expensive treatment that didn’t work. He searched the internet for doctors who specialized in tendon issues. He traveled to Pittsburgh, to Phoenix, to Orlando, Fla. Had many M.R.I.s and ultrasounds. Had more physical therapy, and a list of other treatments he knew nothing about with names like prolotherapy and tenotomy. A sports medicine surgeon in Phoenix diagnosed him with plantaris friction syndrome, in which the plantaris muscle tendon rubs against the Achilles where both attach to the heel. He recommended surgery.
The man was ready to try anything. At this point, nearly six years since the ill-fated basketball game, he could barely walk his 2-year-old daughter the two blocks to her day care without pain. His calf was on fire and his foot felt cold and numb and became pale, even bluish, when he walked more than 20 minutes. Surgery seemed like a small price to pay to be able to exercise, or even just walk, again. His wife suggested that he find someone to do this surgery closer than Phoenix.
The patient found a surgeon at Stanford. But that doctor wasn’t sure plantaris friction syndrome was the right diagnosis. He referred him to a neurosurgeon, who referred him to a physiatrist there, Dr. Michael Fredericson. (A physiatrist is a doctor who specializes in physical medicine and rehabilitation; they see a lot of patients with sports-related issues.) The patient told Fredericson he was desperate — especially since, over the past few months, the pain had started in his right leg, too.
Fredericson wasn’t sure he could help, but he was willing to try. After hearing the patient’s story and examining him, the doctor considered possible causes. First, the patient’s calf pain occurred only when he was moving, he noted. And the nature of the pain seemed to come from both the muscles and the nerves that powered them. He realized that the answer was not going to be one of the usual suspects.
“We can figure this out,” he said. “Do you have good insurance?” Identifying the disorder would entail a lot of costly testing. The patient said he indeed had very good insurance through his work and would pay for anything not covered. He needed an answer.
A Gantlet of Tests
Over the next several weeks, the man had a series of uncomfortable tests. First Fredericson looked for chronic exertional compartment syndrome, in which increased blood and other fluids from exercise make the muscle larger than the compartment that houses it. The patient exercised until he felt the pain in his calves, and then long, needlelike probes were inserted deep into his muscles to measure the pressure inside the compartment. The pressure readings were normal.
Then they looked for evidence of tarsal tunnel syndrome, in which the nerve that provides sensation and power to the muscles in the calf, ankle and bottom of the foot is compressed by one of the ligaments in the ankle. The doctor sent a small shock of electricity to the man’s foot, then measured the time it took to travel up into the nerves of the calf. If he had tarsal tunnel syndrome, the time would be longer than expected. But no, this test was also normal.
A third possibility was a rare disorder called popliteal artery entrapment syndrome, in which the head of the gastrocnemius muscle, which is behind the knee, grows larger, often as a result of regular exercise. In certain positions, this enlarged muscle can compress the popliteal artery as it travels down the leg, cutting off blood to the muscles below and causing pain.
To test for this, the blood flow into each calf was measured at the ankles and then compared with the blood flow into the man’s arms. Normally, the pressure should be close to the same. And when measured at rest, they were.
But when the patient flexed his feet, the pressure in both legs dropped significantly, indicating reduced blood flow at his ankles. Clearly there was some kind of blockage in the lower legs that was positional. It was severe in his left leg and, surprisingly, even worse in the right.
To identify where the blockages were, he had an angiogram: Contrast was injected into his arteries and the vessels lit up by the dye were captured by a C.T. scanner. It was clear from these pictures that the blood flow was severely reduced when he flexed his feet. The narrowing occurred just behind each knee at the head of one of the calf muscles.
With exercise, this portion of the biggest muscle in the calf had grown larger and now was compressing the popliteal artery whenever he flexed his foot. He would need two surgeries, Fredericson told him, to reduce the size of this muscle in each leg.
His second surgery was completed this January and he’s now pain free. The patient hopes it will be enough, though he was told that people with this rare disorder can experience a recurrence even after surgery. He is slowly working his way back to being able to exercise at the intensity that he used to. His goal is to be able to ride his bike with his children and maybe play tennis. He has given up basketball completely in favor of yoga and Pilates, to lengthen his muscles and increase flexibility. He still exercises every day, but has added baking bread and meditating to help him manage his stress. And if he and his wife ever have another child, he told me recently, he’ll vote to name the baby Frederic.
Lisa Sanders, M.D., is a contributing writer for the magazine. Her latest book is “Diagnosis: Solving the Most Baffling Medical Mysteries.” If you have a solved case to share, write to her at [email protected].
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