Pain and powerless feeling in the leg during cycling may indicate a serious problem that limits the performance in cyclists. Apart from the well-known muscular and neurological origin, such complaints can also be attributed to flow limitations in the iliac arteries caused by functional lesions (kinking and/or excessive length of vessels) and/or intravascular lesions (endofibrosis). Reliable insight in the prevalence is lacking. Most intravascular lesions (≈ 90 %) are located in the external iliac artery. The diagnosis is frequently missed because physiotherapists and medical doctors are often unacquainted with the problem. The only finding in physical examination, discriminating for a vascular problem, is a bruit in the inguinal region with the thigh maximally flexed. Available diagnostic techniques are proven to be inadequate for this specific lesion, which has characteristics other than those of atherosclerotic lesions. Moreover, common techniques in a vascular laboratory do not incorporate the specific sport conditions necessary for provoking the complaints. Provocative testing on a bicycle ergometer with high intensity of exercise, combined with postexercise blood pressure measurements (at the ankle of both legs, or the ankle to arm pressure ratio) is used. Imaging techniques (echo-doppler, arterial digital subtraction angiography, magnetic resonance imaging and angiography) are necessary for proper classification of the problem. The application of specific provoking manoeuvres (hip flexion, psoas contraction, high-intensity exercise) in combination with these imaging techniques prove to be potentially valuable, although the diagnostic accuracy has to be established. Treatment should be tailored to the specific problems of the individual patient. Conservative treatment mainly indicates an advice to change sports activity. Surgical mobilization of the iliac arteries for functional lesions, and vascular reconstructions in case of intravascular lesions are possible, although long-term follow-up is lacking. Percutaneous transluminal angioplasty and intravascular stent are contra-indicated because of high risks for dissection and reactive intimal hyperplasia, respectively.
Key words:
Iliac artery - endofibrosis - claudication - cycling - endurance sports
References
-
1
Abraham P, Chevalier J M, Leftheriotis G, Saumet J L.
Lower extremity disease in sports.
Am J Sports Med.
1997;
25
581-4
-
2
Abraham P, Leftheriotis G, Bourre Y, Chevalier J M, Saumet J L.
Echography of external iliac artery endofibrosis in athletes.
Am J Sports Med.
1993;
21
861-3
-
3
Abraham P, Saumet J L, Chevalier J M.
External iliac artery endofibrosis in athletes.
Sports Med.
1997;
24
221-6
-
4 Åstrand P O, Rodahl K. Textbook of Work Physiology: physiological bases of exercise. 3rd edition. New York:; McGraw Hill Book Company, 1986: 152
-
5
van den Berg M, Boers G HJ, Franken D G, Blom H J, van Kamp G J.
Hyperhomocysteinuria and endothelial dysfunction in young patients with peripheral arterial occlusive disease.
Eur J Clin Invest.
1995;
25
176-81
-
6
van den Berg M, Stehouwer C DA, Bierdrager E, Rauwerda J A.
Plasma homocysteine and severity of atherosclerosis in young patients with lower-limb atherosclerotic disease.
Arterioscl Tromb Vasc Biol.
1996;
16
165-71
-
7 Brukner P, Khan K. Clinical Sportsmedicine. 1st edition. New York:; McGraw-Hill Book Company, 1993: 8-25
-
8
Chevalier J M, Enon B, Walder J, Barral X, Pillet J, Megret A, L'Hoste Ph, Saint-André J P, Davinroy M.
Endofibrosis of the external iliac artery in bicycle racers: an unrecognized pathological state.
Ann Vasc Surg.
1986;
1
297-303
-
9
Chevalier J M, L'Hoste P M, Bouvat E, Megret A, Saint-André J P, Ruault Ph.
L'endofibrose artérielle du sportif de haut niveau: formes inhabituelles.
J Traumatol Sport.
1991;
8
176-81
-
10 Chevalier J M. Pathologie vasculaire du cyclistes. Encyclopedie Medico-Chirurgicale. 1997 A10: 11-675
-
11
Cook P S, Erdoes L S, Selzer P M, Rivera F J, Palmaz J C.
Dissection of the external iliac artery in highly trained athletes.
J Vasc Surg.
1995;
22
173-7
-
12
Davis R R, Hull M L.
Measurement of pedal loading in bicycling: II Analysis and results.
J Biomechanics.
1981;
14
857-72
-
13
Desvaux B, Abraham P, Colin D, Leftheriotis G, Saumet J L.
Ankle to arm index following maximal exercise in normal subjects and athletes.
Med Sci Sports Exerc.
1996;
28
836-9
-
14
Fitzgibbon G M, Kafka H P, Leach A J.
Coronary bypass fate and patient outcome: angiographic follow-up of 5065 grafts related to survival and reoperation in 1388 patients during 25 years.
J Am Coll Cardiol.
1996;
28
616-26
-
15
Gallo D, Soury P, Plisonnier D, Panet M, Peillon C, Testarts J, Watelet J.
Aneurisme dissécant de l'artère iliaque externe, une evolution inhabituelle de l'endofibrose du sportif.
J Mal Vasc.
1996;
21
95-7
-
16
Glagov S, Zarins C K, Masawa N, Xu C P, Bassiouny H, Giddens D P.
Mechanical functional role of non-atherosclerotic intimal thickening.
Frontiers Med Biol Engng.
1993;
5
37-43
-
17
Gregor R J, Wheeler J B.
Biomechanical factors associated with shoe/pedal interfaces. Implications for injury.
Sports Med.
1994;
17
117-31
-
18
von Hayek H.
Das Verhalten der Arterien bei Beugung der Gelenke.
Z Anat Entwickl Gesch.
1935;
105
25-36
-
19
Hiatt W R, Hirsch A T, Regensteiner J G, Brass E P.
Guidelines for clinical trials in peripheral arterial disease.
Circulation.
1995;
92
614-21
-
20
Hoes M JAJM, Binkhorst R A, Smeekes-Kuyl A EMC, Vissers A CA.
Measurement of forces on pedal and crank during work on a bicycle ergometer at different loads.
Int Z Angew Physiol Einschl Arbeitsphysiol.
1968;
26
33-42
-
21
Hull M L, Davis R R.
Measurement of pedal loading in bicycling: I Instrumentation.
J Biomechanics.
1981;
14
843-56
-
22
Jäger K A, Philips D J, Martin R L.
Non invasive mapping of lower limb arterial lesions.
Ultrasound Med Biol.
1985;
11
515-21
-
23 Kaandorp D W, Schep G, Kapinga K, Wijn P FF. A new segmentation algorithm for visualising complex vessel geometrics acquired by Gd-enhanced 3D MR angiography. Proc Sixth Meeting Int Soc for Magnetic Resonance in Medicine: Sydney,; 1998 811
-
24
Kohler T R, Nance D R, Cramer M M.
Duplex scanning for diagnosis of aorto-iliac and femoropopliteal disease: a prospective study.
Circulation.
1987;
76
1074-80
-
25
Lassen N A, Kamp M.
Calf muscle blood flow during walking studied by the Xe-133 method in normals and in patients with intermittent claudication.
Scand J Clin Lab Invest.
1965;
17
447-53
-
26
Lopez J-F, Magne J-L, Champetier J.
The femoral artery and flexion of the hip joint.
Surg Radiol Anat.
1989;
11
275-81
-
27
Lüscher T F, Lie J T, Stanson A W, Houser O W, Hollier L H, Sheps S H.
Arterial fibromuscular dysplasia.
Mayo Clinic Proc.
1987;
62
931-52
-
28
May A G, van de Berg L, de Weese J.
Critical arterial stenosis.
Surgery.
1963;
54
250-9
-
29
Monti M, Jaeger M, Guisan Y, Payot M, Massoni S.
Diagnostic de l'insufficance artérielle périphérique chez le sportif amateur claudicant et clepistage (syndrome de la stenose artérielle iliaque isolée chez le jeune cycliste sans facteur de risque) due par examen doppler et test sur tapis roulant.
Rev Med Suisse Romande.
1984;
104
823-30
-
30
Moore W S, Malone J M.
Effect on flow rate and vessel caliber on critical arterial stenosis.
J Surg Res.
1979;
26
1-9
-
31
Mosiman R, Walder J, van Melle G.
Stenotic intimal thickening of the external iliac artery: illness of the competition cyclist? - report of two cases.
Vasc Surg.
1985;
19
258-63
-
32
Pillet J, Enon B, Reigne B, L'Hoste Ph.
La plicature de l'artère fémorale commune un diagnostic différential de l'endofibrose de l'artère iliaque externe du coureur cycliste.
J Chir (Paris).
1992;
129
512-3
-
33
Pils K, Bochdansky Th, Jantsch H S, Ernst E.
Intermittent leg ischemia during competition cycling.
Lancet.
1990;
336
189
-
34
Prince M R, Yucel E K, Kaufman J A, Harrison D C.
Dynamic gadolinium enhanced three-dimensional abdominal MR-arteriography.
J Magn Reson Imag.
1993;
3
877-81
-
35
Rousselet M C, Saint-André J P, L'Hoste Ph, Enon B, Megret A, Chevalier J M.
Stenotic intimal thickening of the external iliac artery in competition cyclists.
Hum Pathol.
1990;
21
524-9
-
36
Rutherford R B.
Standards for evaluating results of interventional therapies for peripheral vascular disease.
Circulation.
1991;
83 (Suppl. I)
6-11
-
37 Rutherford R B. Vascular Surgery. W. B. Saunders Company 4th edition 1995: 18-44
-
38
Scheerlinck T AM, van den Brande P.
Post-traumatic intima dissection and thrombosis of the external iliac artery in a sportsman.
Eur J Vasc Surg.
1994;
8
645-7
-
39
Schep G, Sala H AGM, Bruyninckx C MA.
Leg complaints in cyclists, description of a relatively unknown occupational disease.
Geneesk en Sport.
1995;
27
182-4
-
40 Scholten F G, Wensing P JW. Arterial tortuosity in the femoropopliteal region during knee flexion: a MRA study. In: Scholten FG, Wensing PJW (ed). Atherogenesis in the distal part of the femoral artery: a functional study of local factors. Utrecht:; Thesis, Utrecht University, 1995: 53-66
-
41
Sise J, Shackford S, Rowley R.
Claudication in young adults: a frequently delayed diagnosis.
J Vasc Surg.
1989;
10
68-74
-
42 Strandness D E, Dawson D L. Indirect noninvasive testing and duplex scanning. In: Strandness DE, van Breda A (eds). Vascular diseases, surgical and interventional therapy. Livingston, ; Churchil, 1994: 139-99
-
43
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
155-6
-
44
Udolf E J, Klemens H B, Harrington D P, Kaufman S L, White R I.
Hemodynamic significance of iliac artery stenosis: pressure measurements during angiography.
Radiol.
1979;
132
289-93
-
45
Wolf E A, Summer D S, Strandness D E.
Correlation between nutritive blood flow in limbs of patients with intermittent claudication.
Surg Forum.
1972;
23
238-9
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