The currently recognized classification system for PAES differentiates six subtypes (I–VI; Table 1), based on the underlying anatomical or functional deviations:

Types I–V: These subtypes are determined by anatomically identifiable abnormalities in the course of the popliteal artery concerning the surrounding muscular structures. The prevalence of anatomical variants of PAES is estimated to range from 0.62% to 3.5% within the general population.

Type VI (Functional PAES (FPAES)): In contrast to the anatomical subtypes, this variant is characterized by the absence of structural malformations. Initially described by Rignault et al. in 1985 [5].

The functional subtype is attributed to muscular hypertrophy, primarily of the medial head of the gastrocnemius muscle, and dynamic neurovascular irritation during movement [1].

In the following case, we will outline our treatment strategy, emphasizing our cooperative, interdisciplinary approach that encompasses early diagnosis, surgical management, and follow‑up care.

This case report was meticulously prepared and documented following the CARE guidelines, ensuring comprehensive adherence to standardized reporting practices for case reports.

Physical examination revealed palpable pedal pulses on the left side; however, they were absent on the right side. Provocation testing, which involved both dorsal and plantar flexion, resulted in the right foot demonstrating lividity and trophic changes during prolonged dorsiflexion.

The ankle–brachial index (ABI) measured at 1.0 on the left and 0.6 on the right.

Duplex sonography of the right popliteal artery indicated a bi‑triphasic flow pattern with the leg extended, which transitioned to a monophasic signal during foot flexion (Figure 1).

No arterial wall abnormalities or cystic changes were observed along the course of the right popliteal artery.

To further investigate the condition, a 4D MRA (3 Tesla magnetic resonance imaging (MRI)) was performed, revealing a high‑grade stenosis approximately 15 mm in length at the distal segment of the superficial femoral artery (SFA) extending into the P1 segment of the popliteal artery during plantarflexion. Conversely, during dorsiflexion, complete occlusion was noted over an extent of approximately 30 mm (Figure 2).

An additional native MRI of the soft tissue in the popliteal fossa confirmed an extrinsic medial course of the popliteal artery, which passed medial to the medial head of the gastrocnemius muscle, corroborating the findings from the angiography (Figure 3).

After an interdisciplinary consultation involving radiologists and orthopedic surgeons, the decision was made that surgical decompression of the popliteal artery would constitute the most appropriate course of treatment.

During the surgical procedure, it was determined that the popliteal artery was compressed by an aberrant tendinous slip of the medial head of the gastrocnemius muscle (Figure 4a). The mechanical compression was clearly identified intraoperatively. Under dynamic provocation (both plantar and dorsiflexion), a dense, constrictive tendinous structure proximal to the femoral condyles was recognized as the source of mechanical narrowing of the artery.

This case illustrated a combined form of PAES in the young patient—a hybrid presentation between Type I and Type III—attributed to the additional muscular slip of the gastrocnemius muscle.

The aberrant anatomical structure was meticulously exposed and surgically divided. Subsequently, the artery was repositioned to ensure complete alleviation of compression within the popliteal fossa (Figure 4b).

In order to prevent recurrent vascular entrapment, the medial head of the gastrocnemius muscle was repositioned and secured with 3‑0 Vicryl^® suture (Ethicon, Johnson & Johnson) for stabilization.

This surgical intervention facilitated the establishment of a decompressed region surrounding the neurovascular bundle in the popliteal fossa.

Intraoperative duplex sonographical assessment confirmed the establishment of a triphasic signal in the pedal arteries during both plantar and dorsiflexion, thereby verifying the successful decompression of the vessel.

During diagnostic evaluations and intraoperative assessment, the wall of the popliteal artery exhibited no abnormalities. Consequently, in light of the significant improvement in perfusion, vascular reconstruction was deemed unnecessary.

The postoperative course was smooth, and the patient was discharged on the third day after surgery. Partial mobilization and physiotherapy were effectively initiated on the ward. The young patient regained full range of motion and resumed full weight‑bearing activities, allowing a return to daily activities with minimal complaints shortly after discharge.

After a period of two weeks, the patient’s mobilization had returned to a state comparable to his preoperative condition. By four to six weeks post‑surgery, he gradually reintegrated into light athletic activities, and after approximately three months, he was once again fully engaged in his preferred hobby (playing football) without the recurrence of previous foot symptoms.

A one‑year follow‑up was conducted, during which the patient expressed high levels of satisfaction with the outcome and reported freedom from any symptoms during physical activity or exertion. Duplex sonographic examination indicated a normal triphasic flow pattern in both the right popliteal artery and the pedal arteries, with a palpable foot pulse (Figure 5).

In addition, a psychosocial evaluation was conducted utilizing the German version of the SF‑36 questionnaire [6].

To assess postoperative outcomes, this evaluation was performed one year post‑surgery, empowering the examination of long‑term effects and providing a comprehensive insight into the patient’s overall health status. The results are summarized as follows:

Informed consent was not required. According to the German law and in written agreement with the rules of the Medical Ethical Board of the Ärztekammer Niedersachsen in Hannover Germany, no ethical approval was needed for this study (exemption because of study type and content).