The Continuing Case of the Undiagnosed Triathlete

Having an undiagnosed sports injury has been a long process and I've learned how much you have to be an advocate for your own health.

Quick Recap:

1. Left shin became inflamed while running on 4/29 to the point that running, biking, and swimming hurt and were almost impossible; I tried running through 5/15 but couldn't get through any runs and went REALLY slow so I realized I had to give up running

2. Orthopedic Physician Assistant called it a Shin Splint on 6/5, stopped biking because of the pain, took rest, even swimming hurt

3. Doctor thought it might be a Stress Fracture but a bone scan on Monday July 15th showed it was neither a shin splint or a stress fracture

So - what could it be??

On Wednesday July 17th I had an appointment with Sports Medicine Doctor, Dr. Bolin in Salem, VA as a follow up to the bone scan. He thought my problem was either:

A. Popliteal Artery Entrapment or

B. External Compartment Syndrome

Both are rare and difficult to diagnose overuse injuries. Both are due to a loss of blood flow in the leg. Popli-What you say? The popliteal artery is the artery behind your knee that carries blood to your leg. In short if it is out of position or entrapped in the gastrocnemius (calf muscle), the blood flow is decreased to your leg. There are different ways in which the artery becomes entrapped as seen in the images below:

Schemas show the six types of popliteal artery entrapment syndrome. In type 1, the artery follows an aberrant medial course around the normal medial head of gastrocnemius muscle; in type 2, the artery is displaced medially by an abnormal head of the gastrocnemius muscle, which inserts laterally on the distal femur; in type 3, the normally positioned artery is enveloped and entrapped by an aberrant accessory slip from the medial head of the gastrocnemius muscle; in type 4, the artery is entrapped by its location deep in the popliteus muscle or beneath fibrous bands in the popliteal fossa; in type 5, the artery and vein are both entrapped; and in type 6, the functional, normally positioned artery is entrapped by a normally positioned but hypertrophic gastrocnemius muscle. AS = accessory slip, LGN = lateral gastrocnemius, MGN = medial gastrocnemius. (Source: http://radiographics.rsna.org/content/32/1/E33/F29.expansion.html)

The least expensive diagnostic test is a doppler ultrasound, however, there are a large number of false positives and completely missed diagnoses with this test. When your toes are pointed (plantar flexion) and the gastrocnemius (calf) muscle is contracted there will be less blood flow shown in the doppler ultrasound and this would suggest but not confirm popliteal artery entrapment. An angiogram is more useful but costs thousands and thousands of dollars, and an MRI can be used as well but it is also more costly. However, just an ultrasound of the leg cost $900! That is pretty steep!

Doppler Ultrasound

On Wednesday July 24th I was sent to the Imaging Center in Blacksburg, one hour from Roanoke, because a specialist was supposed to be available who knew how to identify popliteal artery entrapment. However, only a technician did the scan and she was doing a venous study of both legs. I asked her "So, why are you looking at my veins when we should be concerned about my popliteal artery?" and she responded "Can I tell you the truth?.......I have NO idea". I asked her again and again to have the doctor call me. By the second day I had no call from the doctor and the Imaging Center wouldn't even tell me if he had read my ultrasound images. After hours and hours of playing fax tag with the medical records department they finally told me they would NOT release my medical records to me electronically but they would give it to my doctor's office. My local doctor's office refused to give me the results and told me I had to wait until my doctor's appointment on August 2nd. I told them it was very important for me to know  the results because if it is not popliteal artery entrapment, then I need to have the $2000 test for compartment syndrome ordered. Finally a person in medical records agreed to mail me my results which I have not yet received. 

I had the technician show me the picture of my popliteal artery and vein

Knowing that looking at the artery was important and knowing you had to contract your gastrocnemius to see if there was less blood flow, I realized they had done the wrong test but I couldn't get a doctor to call me back. During the ultrasound they never had me contract my calf muscle and they were looking at my veins. Today I called the Imaging Center AGAIN, and said "Hey, I know you are going to think I'm crazy, but I really think you did the wrong test". Luckily the woman who answered the phone actually listened to me and had the head ultrasound technician call me back and she told me I was correct. The wrong test had been ordered and done and she will bring me back in on Monday July 29th for the correct ultrasound! 

So, what it comes down to is that you have to be an advocate for your own health. Read as much as you can about what they think you might have. Google images of the diagnostic tests being performed. Luckily I had educated myself because it didn't look like anyone was contacting me to let me know they had done the wrong test! You would think the doctor reading the ultrasound images would have noticed a vein study was done when they were trying to diagnose popliteal artery entrapment?? In the meantime, the pain continues, it's constant and it's getting old. Daily tasks are tiring, difficult, and painful. The Age Group National Triathlon Championship on August 10th and 11th in Milwaukee and the Age Group World Triathlon Championship in London in September is not looking so good anymore.

After the failed ultrasound we did have a great time in Blacksburg at Bull and Bones, a restaurant with great craft beer! Goodness knows I think I needed it after that ha ha!

Lunch Pale IPA

I was also super excited to run into an amazing fellow triathlete, Tanya LeRoith!