External Iliac Artery Endofibrosis in Athletes

Iliac Artery Endofibrosis is a vascular condition primarily affecting endurance athletes, especially cyclists and triathletes, causing exercise-induced leg pain, often in the thigh and calf area. It is characterized by subintimal fibrosis, distinct from atherosclerosis, with different risk factors. The condition is likely underdiagnosed, with haemodynamic evidence present in up to 10–20% of professional road cyclists. Delayed diagnosis due to lack of awareness can lead to anxiety and unnecessary musculoskeletal and neurological investigations.

 

Causes and Risk Factors

External iliac artery endofibrosis occurs due to repetitive stress on the external iliac artery, leading to thickening of the arterial wall and reduced blood flow.

• The cycling position is believed to contribute to this condition by causing compression and repetitive folding of the artery, especially during high-intensity activity.
• Micro-trauma from extreme exercise may lead to progressive thickening of the arterial walls, restricting blood flow.
• Hypertrophy of the psoas muscle may further contribute to arterial compression, increasing the risk of blood flow obstruction.

Athletes typically experience exercise-induced thigh or calf pain, which worsens with intense exertion, such as racing, hill climbing or riding into strong winds. The pain subsides rapidly when exercise intensity is reduced.

 

Diagnosing External Iliac Artery Endofibrosis

This questionnaire can aid in early detection and guide further clinical evaluation for patients experiencing exercise-induced leg pain.

 

Differential Diagnosis

• Iliac Artery Occlusion
• Femoral Artery Endofibrosis
• Popliteal Artery Entrapment Syndrome
• Chronic Exertional Compartment Syndrome
• Deep Vein Thrombosis (DVT)
• Lumbar Radiculopathy
• Hip Impingement Syndrome
• Sports Hernia (Athletic Pubalgia)
• Myofascial Pain Syndrome
• Peripheral Nerve Entrapment (e.g., Meralgia Paresthetica)

Physiotherapy Management of External Iliac Artery Endofibrosis

Physiotherapy is a crucial component of conservative and post-surgical management of external iliac artery endofibrosis. By focusing on biomechanical corrections, strength and flexibility training, vascular re-education and modified cardiovascular conditioning, physiotherapists can help athletes manage symptoms, prevent recurrence, and optimize performance.

Goals of Physiotherapy Management

1. Reduce arterial compression and optimize blood flow.
2. Improve biomechanical efficiency to prevent excessive arterial stress.
3. Enhance cardiovascular conditioning while avoiding vascular overload.
4. Optimize soft tissue flexibility and mobility to minimize external compression.
5. Provide post-surgical rehabilitation if intervention was required.

1. Patient Education and Activity Modification

• Identify symptom triggers (e.g., prolonged high-intensity cycling, uphill riding, sprinting).
• Encourage gradual return to activity by modifying cycling intensity, duration, and positioning.
• Monitor symptoms using pain scales and exercise logs to track improvements or worsening of symptoms.
• Teach proper warm-up and cool down strategies to optimize vascular response.

Cycling Modifications

• Adjust saddle height and positioning to prevent excessive hip flexion and arterial compression.
• Optimize pedaling mechanics to reduce excessive psoas activation.
• Vary training intensity to prevent repetitive arterial stress.

2. Biomechanical and Postural Corrections

Correcting muscle imbalances and posture helps reduce arterial stress by minimizing vascular compression. Addressing pelvic alignment and hip mobility prevents arterial restriction, while enhancing core and lower limb stability optimizes movement efficiency, reducing strain on the circulatory system.

Key Areas to Address

• Pelvic Alignment – Excessive anterior pelvic tilt can increase stress on the external iliac artery.
• Hip Mobility & Flexibility – Restricted hip movement can cause compensatory arterial compression.
• Lower Limb Strength & Stability – Improves circulation and vascular efficiency during exercise.

 

3. Flexibility & Soft Tissue Management

Since tight muscles can contribute to arterial compression, stretching and soft tissue mobilization are important.

Key Stretching Exercises (Hold for 30-45 sec, repeat 2-3 times per day)

• Hip Flexor Stretch (Lunge Stretch) – Reduces psoas tightness, which can compress the artery.
• Quadriceps Stretch – Prevents anterior hip tightness and improves thigh circulation.
• Hamstring Stretch – Enhances lower limb mobility and vascular flow.
• Glutes Stretch (Figure-4 Stretch) – Improves hip mobility and pelvic balance.

Soft Tissue Release Techniques

• Foam Rolling for Quads, Hamstrings, and Glutes – Enhances circulation and reduces stiffness.
• Manual Therapy (if indicated) – Myofascial release techniques can improve arterial mobility.

 

4. Strength and Conditioning Program

Key Strength Exercises (Perform 2-3 sets, 10-15 reps, 3-4 times per week)

• Core Strengthening (Planks, Dead Bug, Bird-Dog) – Improves lumbo-pelvic stability.
• Glutes Activation (Bridges, Clamshells) – Reduces excessive reliance on hip flexors.
• Hip Flexor & Psoas Strengthening (Resistance Band Marches, Hanging Leg Raises) – Improves hip control without excessive compression.
• Quadriceps Strengthening (Leg Press, Step-Ups) – Enhances lower limb endurance.
• Posterior Chain Strengthening (Hamstring Curls) – Balances muscle activation patterns.

Cardiovascular Training Modifications

• Use alternative endurance training methods (e.g., swimming, rowing, elliptical) to maintain cardiovascular fitness without aggravating symptoms.
• Gradually reintroduce cycling with modified intensity and progressive load adjustments.

5. Neuromuscular and Vascular Re-Education

Vascular Mobilization Exercises (Enhances arterial flexibility and prevents stiffness)

• Leg Elevations – Improves venous return and reduces arterial congestion.
• Toe Taps in Supine – Encourages blood flow activation in the lower limb.
• Active Hip Circles – Enhances vascular elasticity in the iliac region.
• Bicycle Kicks in Supine – Simulates low-impact cycling motion without excessive arterial compression.

Blood Flow Optimization Strategies

• Intermittent Compression Therapy – Enhances circulatory recovery post-exercise.
• Contrast Baths (Cold-Warm Water Immersion) – Improves vascular responsiveness.

 

6. Post-Surgical Physiotherapy (If Surgery Was Required)

After angioplasty, stenting or bypass surgery, physiotherapy focuses on:

Phase 1: Early Recovery (Weeks 1-4)

• Pain & Swelling Management – Cryotherapy, elevation and gentle compression.
• Gentle Mobility Exercises – Assisted hip and knee range of motion exercises.
• Isometric Strength Exercises – Initiate core and lower limb activation without excessive strain.

Phase 2: Progressive Rehabilitation (Weeks 4-8)

• Gradual Return to Strength Training – Low-resistance hip, glutes and quadriceps exercises.
• Stationary Cycling (Low Resistance) – Controlled cycling to assess vascular response.

Phase 3: Return to Full Activity (Weeks 8-12+)

• Progressive Cardiovascular Training – Gradual return to cycling, swimming or running.
• High-Intensity Strength Training – Advanced lower limb and core exercises.
• Sport-Specific Drills – Reintroduce full cycling mechanics and intensity training.

Surgical Treatment Options

Bypass Surgery

• A graft (either synthetic or taken from another blood vessel) is used to bypass the diseased section of the external iliac artery, restoring normal circulation.
• This is a more invasive procedure but may offer a more durable solution for severe cases.

Open Endarterectomy

• The thickened arterial wall (caused by fibrotic changes) is surgically removed, allowing for improved blood flow.
• This approach is sometimes preferred when the artery is not completely blocked but significantly narrowed.

Some athletes successfully return to high-level competition after surgery. However, long-term outcomes remain uncertain, particularly in endurance athletes who continue to place high mechanical stress on the iliac artery. Recurrent symptoms or further vascular complications may occur, making long-term monitoring essential.