Recognising Vascular Causes of Leg Complaints in Endurance Athletes. Part 2: The Value of Patient History, Physical Examination, Cycling Exercise Test and Echo-Doppler Examination

Abstract

Leg complaints at maximal exercise in endurance athletes may have many causes, including arterial flow limitations in the iliac arteries. Such flow limitations can evolve into serious health problems due to increasing intravascular obstruction or even complete obstruction as a result of dissection or thrombosis. Early detection is therefore of clinical importance, but conventional diagnostic tools often prove inadequate. In the current study simple sports-specific tests are examined for their diagnostic power. Test variables derived from patient history, physical examination, cycling exercise testing followed by arterial pressure measurements at the ankle, and echo-Doppler examination with provocative manoeuvres were tested in 92 symptomatic legs (80 patients). A validated clinical classification acted as a reference. Several test variables proved useful. However, no single test variable combined a high sensitivity with a high specificity. Multivariate testing resulted in the correct classification of 91 % of patients, reaching a sensitivity of 0.90 and specificity of 0.93 (kappa 0.76). Four patients wrongly classified as non-vascular suffered from kinking in the common iliac artery that could not be visualised using the diagnostic tools currently available in this study. In conclusion: simple sports-specific tests accurately diagnose iliac artery obstruction in endurance athletes.

Endurance exercise - iliac artery - endofibrosis - echo-Doppler - claudication - cycling

References

• 1 Abraham P, Chevalier J M, Leftheriotis G, Saumet J L. Lower extremity disease in sports.  Am J Sports Med. 2997;  25 581-584
• 2 Abraham P, Saumet J L, Chevalier J M. External iliac endofibrosis in athletes.  Sportsmedicine. 1997;  4 221-226
• 3 Bradshaw C. Exercise related lower leg pain: vascular.  Med Sci Sports Exerc. 2000;  32 S34-S36
• 4 Chevalier J M. Pathologie vasculaire du cycliste.  Encycl Med Chirurg Franc. 1997;  675 A10-11
• 5 Rutherford R B. Vascular surgery.  WB Saunders company 2000 fifth edition
• 6 Ruurda J P, Rijbroek A, Vermeulen E GJ, Wisselink W, Rauwerda J A. Arterial insufficiency in athletes due to ‘endofibrosis'.  Ned Tijdschr Heelkd. 2000;  9 124-126
• 7 Schep G, Bender M HM, Schmikli S L, Wijn P FF. Color Doppler used to detect kinking and intravascular lesions in the iliac arteries in endurance athletes with claudication.  Eur J Ultrasound. 2001; accepted for publication; 
• 8 Schep G, Kaandorp D W, Bender M HM, Weerdenburg H, van Engeland S, Wijn P FF. Magnetic resonance angiography used to detect kinking in the iliac arteries in endurance athletes with claudiction.  Physiol Meas. 2001;  22 475-487
• 9 Schep G, Kaandorp D W, Bender M HM, van Engeland S, Weerdenburg H, Titulaer B M, Wijn P FF. Excessive length of the iliac arteries in endurance athletes with flow limitations measured by MRA.  Med Sci Sports Exerc. 2001; accepted for publication; 
• 10 Schep G, Bender M HM, vd Tempel G, Wijn P FF, de Vries W R, Eikelboom B C. Top endurance athletes with claudication due to functional iliac obstruction; detection and treatment.  The Lancet. 2001; accepted for publication; 
• 11 Schep G, Bender M HM. Comment on the article: ”Arterial insufficiency in athletes due to ‘endofibrosis'”.  Ned Tijdschr Heelkd. 2000;  9 127-128
• 12 Schep G, Bender M HM. Lettre to the MSSE editor concerning exercise-related lower leg pain-vascular.  Med Sci Sports Exerc. 2000;  32 1970-1971
• 13 Schep G, Bender M HM, Schmikli S L, Mosterd W L, Hammacher E R, Scheltinga M, Wijn P FF. Recognising the vascular cause of leg complaints in endurance athletes. Part 1: validation of a clinical decision algorithm.  Int J Sports Med. 2002;  23 307-312
• 14 Schep G, Bender M HM, Kaandorp D, Hammacher E R, de Vries W R. Flow limitations in the iliac arteries in endurance athletes current knowledge and directions for the future.  Int J Sports Med. 1999;  20 421-428
• 15 Sise J, Shackford S, Rowley R. Claudication in young adults; a frequently delayed diagnosis.  J Vasc Surg. 1989;  10 68-74
• 16 Taylor A J, Tennant W G, Batt M E, Wallace W A. Traumatic occlusion of the external iliac artery in a racing cyclist: a cause of ill defined leg pain.  Br J Sports Med. 1997;  31 155-156