An Unusual Cause of Leg Pain

A 23-year-old competitive athlete comes to the primary health care facility complaining about progressively worsening pain and cramps in his left buttock and lower leg over the last 3 months. The pain has been so severe during exercise that he could not participate in the last competition. He mentions that pain is exacerbated by running or vigorous cycling and usually is relieved after 2 minutes of rest. Two years ago, he underwent surgical repair for a femoral shaft fracture. He is otherwise healthy except for the use of omeprazole occasionally for gastroesophageal reflux disease (GERD) symptoms. Clinical examination revealed an audible 2/6 murmur in left common iliac artery and pain exacerbation in left thigh, buttock and calf after hip hyperflexion. A computed tomography angiography (CTA) was ordered and detected a 90% stenosis of proximal segment of left common iliac artery with collateral blood flow and considerable stenosis of left external iliac artery. The patient was referred to a sports medicine specialist and underwent a surgical repair of the stenotic artery and returned to his previous level of performance within 2 months.

Which of the following risk factors have mainly contributed to disease manifestation?

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