Exercise Induced Leg and Calf Pain in an Athlete

A 19-year-old female athlete was referred for exertional leg pain after presenting with deep soleus calf cramping with plantar paresthesia when running on inclines or during repetitive jumping. Her symptoms were significantly worse during the cross-country season. Her medical comorbidities were otherwise unremarkable. Her physical examination revealed reduced pulses in her anterior and posterior tibial arteries with forced plantar flexion bilaterally. Complete blood count, chemistries, lipid, and thyroid stimulating hormone studies were normal. Compartment pressures were measured using the Stryker computer system (Stryker Surgical, Kalamazoo, Michigan) due to claudication symptoms referable to the posterior superficial muscle groups. Resting pressures were measured bilaterally and were normal (<25 mmHg). Non-invasive lower extremity arterial studies were performed and demonstrated normal ankle-brachial indices at rest that decreased to 0.70 and 0.80 during dorsiflexion and plantar flexion bilaterally. Arterial lower extremity ultrasound at the popliteal artery was performed and demonstrated normal triphasic arterial signals at rest with absence of signals during plantar flexion (Figure 1). Magnetic resonance imaging of the lower extremities demonstrated the absence of musculotendinous anomalies.

Figure 1: Arterial lower extremity ultrasound at the left popliteal artery during plantar flexion.

Figure 1

What is the most likely diagnosis of her exertional leg pain?

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