Lower Extremity Paresthesias And Weakness In A Cyclist

HISTORY: A 49 year old male avid cyclist without significant past medical history presented to sports medicine clinic with 4 months of left hip pain and LLE paresthesias. He first noticed a sensation of a “tight band” around his left thigh while cycling which would resolve with rest. Symptoms progressed to pain in left hip radiating to his left anterior thigh while cycling. He began to notice a feeling of weakness in his LLE with use of stairs. He reported when he was a 15 year old middle-distance runner, he had bilateral lower extremity numbness when running, which continued for several years but eventually went away after decreasing distance running. He denied any history of back pain or bowel/bladder changes. There was no known family or personal hx vascular disease. Patient was not a smoker. PHYSICAL EXAM: Full ROM of left hip, negative FABER, and negative FADIR tests. No tenderness at left hip joint, left mid thigh/glutes or left greater trochanter. Strength was 5/5 for hip flexion/extension/abduction/adduction. Sensation of the left lower extremity was grossly intact to light touch. Symmetric quadriceps tone was appreciated. His left lower extremity was warm with normal skin color. Left dorsalis pedis and left posterior tibial pulses 1+. Right dorsalis pedis and posterior tibial artery pulses 2+. Patellar and achilles reflexes 2+ bilaterally. DIFFERENTIAL DIAGNOSIS: 1. Peripheral Vascular Disease2. Incomplete arterial occlusion3. Arterial Endofibrosis TEST AND RESULTS: 1. Left Hip Radiograph —Grossly preserved left hip joint —Mild CAM deformity —No acute fractures 2. US Duplex Arterial Left Lower Extremity —Complete occlusion of the left external iliac artery with reconstitution at the distal segment and distal hemodynamic changes 3. CT Angiography Abdomen Plus Bilateral Iliofemoral —Occlusion of the left external iliac artery. All other vessels are patent. Distal branches to the left leg received flow through collaterals. FINAL WORKING DIAGNOSIS: Chronic Complete Left External Iliac Artery Occlusion TREATMENT AND OUTCOMES: 1. Referral to Vascular Surgeon2. Bypass surgery was discussed with patient who initially elected conservative management3. Symptoms persisted during cycling for several months with patient ultimately choosing left external iliac bypass surgery4. Outcome pending at time of case submission