Flow Limitations in the Iliac Arteries in Endurance Athletes. Current Knowledge and Directions for the Future

Abstract

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 (approximately 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.

Lower body problems and injury in cycling

“…We now appreciate that such a presentation represents a vascular dysfunction due to a stenotic thickening in the external iliac artery (Taylor et al, 1997) (Fig. 4) that constitutes about 90% of intravascular lesions (Schep et al, 1999). Cyclists with this condition (although it is not exclusive to cyclists) present with symptoms similar to intermittent claudication such as paraesthesia and a loss of power in part of or throughout the whole lower limb, brought on particularly by extreme maximal effort in racing or training (Taylor et al, 1997).…”

“…For example, one area in which progress has been made is in the diagnosis of vascular problems in cycling, especially those that may masquerade as referred pain from the lumbar spine or the sacroiliac joint. Unfortunately, for many years doctors, physiotherapists and many other practitioners involved in examining and treating cyclists frequently missed the diagnosis of vascular pathology simply because they were unacquainted with the problem (Schep et al, 1999). Consequently, cyclists were thought to have a neurological cause for their symptoms even though the neurological examination was normal (Abraham et al, 1997) and sought inappropriate treatments, in some cases for several years, before the correct diagnosis was made (Scavèe et al, 2003).…”

“…None-invasive equipment to measure the ankle/brachial pressure index during provocative exercise tests has been reported and have been proven to be useful in aiding an early diagnosis (Taylor and George, 2001). Further investigations would usually involve angiography, magnetic resonance angiography, arteriography or echo Doppler ultrasound scanning (Schep et al, 1999). Figure 4 Thickened intima of the external iliac artery (from Taylor et al, 1997, p. 256).…”

Iliac Artery Endofibrosis in a Middle-Aged Female Long-Distance Runner

“…1,2 Vascular problems in young healthy athletes are unusual and are easily overlooked, often leading to diagnostic delays as symptoms are commonly attributed to musculoskeletal or neurologic causes. 3,4 Young athletes present with symptoms due to arterial flow limitation in the lower limb, which progressively worsen during exercise, disappearing when training is stopped. 5 Indicators may include vague lower limb pain, cramps, numbness, weakness, claudication, and unexplained performance deterioration.…”

“…6 The common iliac artery, femoral artery, or the profunda femoris artery may be involved. 7 There seems to be a left iliac artery predominance 3,5,6 ; however, in 15% of the cases, presentation is bilatResting duplex Doppler ultrasonography examination revealed the right external iliac artery eral, and in rare cases, arterial dissection is founded. 6 totally occluded and filled with hypoechoic thromHistologic findings indicate intimal and medial artery bus.…”