We report a case of acute popliteal artery occlusion in a young male farmer as a result of prolonged squattin

Marya, KM

Yadav, V

English

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Squatting -An Unusual Cause Of Popliteal Artery Thrombosis

Marya KM

Yadav V

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OJHAS  Vol 5 Issue 4(5) -  Marya KM, Yadav V. Squatting - An Unusual Cause Of Popliteal Artery Thrombosis
Published Quarterly
Mangalore, South India
ISSN 0972-5997
Volume 5, Issue 4; Oct -Dec 2006
Squatting -An Unusual Cause Of Popliteal Artery Thrombosis 
Authors
Marya KM
Ex-Lecturer, Department of Orthopaedics, Paraplegia & Rehabilitation, Pt. BD Sharma 
Postgraduate Institute of Medical Sciences, Rohtak, India
Yadav V
Department of Orthopaedics, Paraplegia & Rehabilitation, Pt. BD Sharma 
Postgraduate Institute of Medical Sciences, Rohtak, India
Address For Correspondence
Dr. K. M. Marya 
#986, Sector 15,
Faridabad - 121007, INDIA
E-mail: drkmmarya@yahoo.com
Citation
Marya KM, Yadav V. Squatting -An Unusual Cause Of Popliteal Artery Thrombosis 
Online J Health Allied Scs.2006;4:5
URL
http://www.ojhas.org/issue20/2006-4-5.htm
Open Access Archives
http://cogprints.ecs.soton.ac.uk/view/subjects/OJHAS.html
http://openmed.nic.in
1
Submitted: Dec 22, 2006; Accepted: Mar 22, 2007; Published Mar 26, 2007
Case Report
OJHAS  Vol 5 Issue 4(5) -  Marya KM, Yadav V. Squatting - An Unusual Cause Of Popliteal Artery Thrombosis
Abstract:
We  report  a  case  of  acute  popliteal 
artery  occlusion  in  a  young  male 
farmer  as  a  result  of  prolonged 
squatting
Key  Words:  Popliteal  artery, 
Thrombosis 
Introduction:
We  report  a  hitherto  un-described 
cause of  acute popliteal  artery occlu-
sion in a young male farmer free from 
any  other  medical  condition.  The  oc-
clusion was caused by a thrombus of 
10.6mm length, which formed in situ in 
the popliteal artery, as a result of pro-
longed squatting by the farmer in the 
fields  in  the  harvesting  season.  Pro-
longed  periods  of  squatting  are  very 
commonly endured by farmers in tropi-
cal countries during harvesting season. 
The  hyperflexion  induced  kink  of  the 
artery  probably  caused arterial  stasis 
and  intimal  endothelial  damage.  Ex-
treme flexion of the knee, as in squat-
ting,  has been implicated as a major 
cause of common peroneal nerve pal-
sy1. We could not find any report in the 
literature  surveyed  describing  squat-
ting induced spontaneous popliteal ar-
terial thrombosis.
Case Report:
A  27-years-old  man  reported  to  our 
institute  with  painful,  swollen, 
discoloured  and cold  left  leg,  for  the 
last 24 hours. He had been engaged in 
manual  harvesting  activities  in  his 
fields the previous day. After squatting 
for  7  hours  at  a  stretch,  he  noticed 
numbness in his left leg. Assuming it to 
be  a  mild  problem,  he  remained 
confined to his home and did not seek 
any  medical  attention.  Gradually  his 
limb started becoming pale and bluish 
and  he  noticed  weakness  of  ankle 
movements.  He then reported to  our 
institute. 
On examination, his left limb had signs 
of  ischaemia  below  the  knee  and 
paraesis  of  ankle  extensors,  flexors, 
evertors and invertors was noticed as 
well. The limb was colder as compared 
to the other side. Gangrenous patches 
were present in the first,  second and 
third toes and also on plantar surface 
of  sole  in  an area of  5  by  7cms.  No 
popliteal  pulse  was  palpable  and  all 
distal  pulses were also absent.  Capil-
lary  circulation  was  present  but  was 
sluggish. A detailed investigation was 
carried  out.  He  was  found  to  suffer 
from  no  other  medical  condition. 
Echocardiography  was  within  normal 
limits. Tests to rule out systemic infec-
tion  as  a  source  of  infective  emboli 
were  negative.  Serum  cholesterol, 
blood pressure,  AST and ALT enzyme 
levels,  blood lipid  profile,  coagulation 
profile were all within normal limits.
Doppler study of the limb showed de-
creased  peak  flow  velocity  in  the 
femoral  artery,  a  10.6mm  thrombus 
completely  occluding  the  lumen  of 
popliteal  artery  with  no  flow  distally 
apart from a few collaterals (Fig 1a & 
1b).
Immediate  open surgical  thrombecto-
my was performed. Per-operatively, in-
tima  of  the  arterial  wall  was  found 
damaged. At the last follow-up, the pa-
tient had recovered completely, apart 
from  mild  sensory  deficit  over  the 
plantar  aspect  of  the  left  foot  and  a 
mild  motor  deficit  with  power  grade 
4/5 on MRC scale in ankle dorsiflexors.
2
OJHAS  Vol 5 Issue 4(5) -  Marya KM, Yadav V. Squatting - An Unusual Cause Of Popliteal Artery Thrombosis
Fig.  1a  &  b:  Doppler  study  of 
popliteal  artery  showing  no  flow pat-
tern.  Femoral  artery  flow  is  sluggish 
with peak flow velocity of 102cms/sec-
ond; anterior and posterior tibial arter-
ies and dorsalis pedis artery shows no 
flow. Few collaterals maintain the dis-
tal circulation.
Discussion:
Squatting,  a  posture  commonly 
adopted  by  manually  harvesting 
farmers in many countries, is a known 
cause  of  common  peroneal  nerve 
palsy.1,2 This  posture  involves  hyper-
flexion  at  the  knee  and  not  only 
unilateral,  even  bilateral  peroneal 
nerve  palsy  is  known  to  occur  after 
prolonged squatting.3 The mechanism 
involves  hyper-flexion  at  the  knee, 
which  causes  an  acute  kinking  of 
popliteal vessels in addition to putting 
pressure  on  the  common  peroneal 
nerve.  Prolonged  squatting  in  the 
present case probably caused stasis of 
blood flow secondary to an acute kink 
in  the  popliteal  artery  resulting  in 
development  of  thrombosis.  Possibly, 
the  extreme  flexion  attitude  also 
caused  micro  trauma  to  the 
endothelium, initiating the coagulation 
cascade  and  culminating  in  a 
thrombus  that  totally  occluded  the 
arterial lumen.
Acute arterial thrombosis in situ occurs 
most frequently in atherosclerotic ves-
sels  at  the  site  of  stenosis  or 
aneurysm,  and  in  arterial  bypass 
grafts.  Less  frequent  causes  include 
trauma  to  an  artery,  thoracic  outlet 
syndrome,  entrapment  of  popliteal 
artery by abnormal placement of medi-
al head of gastrocnemius muscle, poly-
cythemia  and  hypercoagulable  disor-
ders. Acute arterial occlusion has also 
been reported as  the  presenting fea-
ture  in  acute  promyelocytic 
leukaemia.4 Awareness should also be 
created  amongst  Orthopaedic  sur-
geons performing knee arthroplasty as 
acute popliteal artery occlusion has oc-
curred after a total knee arthroplasty.5 
None  of  these  aetiological  factors 
could be found in the present case. A 
review  of  the  available  literature  did 
not reveal any report of squatting in-
duced  spontaneous  popliteal  artery 
thrombosis.
Over  the  past  several  decades,  pre-
ferred treatment options for acute limb 
ischaemia  have  alternated  between 
medical and surgical approaches. More 
recently, direct intra-arterial thrombol-
ysis became the standard of care after 
several randomised trials demonstrat-
ed the benefit of this approach as com-
pared with acute surgical intervention. 
Despite all  of the experience with di-
rect intra-arterial thrombolysis for the 
treatment of acute limb ischaemia, the 
optimal thrombolytic approach has not 
been  clearly  established.6 Percuta-
neous techniques reportedly offer ex-
cellent  early  and  mid-term results  in 
selected  patients  presenting  with 
acute ischaemia with  popliteal  and/or 
tibial  arterial  occlusion.7 Surgical 
thrombectomy is the method of choice 
3
OJHAS  Vol 5 Issue 4(5) -  Marya KM, Yadav V. Squatting - An Unusual Cause Of Popliteal Artery Thrombosis
for treating a large sized thrombus, al-
though controversy still exists regard-
ing  the  use  of  thrombolytic  therapy 
and  anticoagulants.  For  traumatic  in-
juries,  however,  interposition  vein 
grafting using the long saphenous vein 
is  a  better  alternative.  Appropriate 
handling of acute ischaemic conditions 
implies  the  use  of  both  thrombolysis 
and  appropriate  surgical  procedures, 
including  distal  bypass  grafts.8 Me-
chanical  thrombectomy might  offer  a 
useful  alternative as a first-line treat-
ment  for  arterial  occlusion  when  the 
procedure is performed during the ear-
ly phase.9
Farmers,  especially  of  tropical  coun-
tries, who engage in manual harvest-
ing practises should be made aware of 
this  potentially  disastrous  complica-
tion, and advised to intermittently ex-
tend their  knees while  harvesting,  so 
that such situations can be averted.  
References:
1. Katirji  B.  Peroneal  neuropathy. 
Neurol Clin. 1999;17:567-91.
2. Sangwan SS, Marya KM, Kundu 
ZS, Yadav V, Devgan A, Siwach 
RC. Compressive peroneal neu-
ropathy during harvesting sea-
son in Indian farmers.  Tropical 
Doctor 2004: 34(4):244-46.
3. Togrol  E,  Çolak  A,  Kutlay  M, 
Saraçoğlu  M,  Akyatan  N,  Akin 
ON.  Bilateral  peroneal  nerve 
palsy  induced  by  prolonged 
squatting.  Mil  Med.  2000; 
165:240-2.
4. Kalk  E,  Basu  S,  Rose  P, 
Chachlani  N. Acute arterial  oc-
clusion  as  the  presenting  fea-
ture  in  acute  promyelocytic 
leukaemia.  Br  J  Haematol. 
2001;115:2.
5. Ohira T, Fujimoto T, Taniwaki K. 
Acute popliteal artery occlusion 
after  total  knee  arthroplasty. 
Arch  Orthop  Trauma  Surg. 
1997;116:429-30.
6. Laird  JR.  The  management  of 
acute  limb  ischemia:  tech-
niques  for  dealing  with  throm-
bus.  J  Interv  Cardiol. 
2001;14:539-46.
7. Desgranges  P,  Kobeiter  K, 
d'Audiffret  A,  Melliere  D, 
Mathieu D, Becquemin JP. Acute 
occlusion of popliteal and/or tib-
ial arteries: the value of percu-
taneous  treatment.  Eur  J  Vasc 
Endovasc  Surg.  2000;20:138-
45.
8. Nilsson  L,  Albrechtsson  U,  Jo-
nung T, Ribbe E, Thorvinger B, 
Thorne J,  Astedt  B,  Norgren L. 
Surgical  treatment  versus 
thrombolysis  in  acute  arterial 
occlusion:  a  randomised  con-
trolled  study.  Eur  J  Vasc  Surg. 
1992;6:189-93.
9. Kasirajan  K,  Marek  JM,  Langs-
feld M. Mechanical thrombecto-
my as a first-line treatment for 
arterial  occlusion.  Semin  Vasc 
Surg. 2001;14:123-31.
4


Acute arterial occlusion as the presenting feature in acute promyelocytic leukaemia.

Acute occlusion of popliteal and/or tibial arteries: the value of percutaneous treatment.

Acute popliteal artery occlusion after total knee arthroplasty. Arch Orthop Trauma Surg.

Bilateral peroneal nerve palsy induced by prolonged squatting. Mil Med.

Compressive peroneal neuropathy during harvesting season in Indian farmers. Tropical Doctor

Mechanical thrombectomy as a first-line treatment for arterial occlusion. Semin Vasc Surg.

Peroneal neuropathy. Neurol Clin.

Surgical treatment versus thrombolysis in acute arterial occlusion: a randomised controlled study.

The management of acute limb ischemia: techniques for dealing with thrombus.

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Squatting -An Unusual Cause Of Popliteal Artery Thrombosis

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