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High sport sneakers may lead to peripheral artery occlusion in Zumba (R) dancers

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78 Case report
Vasa 2014; 43: 78 – 80
© 2014 Hans Huber Publishers, Hogrefe AG, Bern
C. Schrimpf et al.: Arterial occlusion by sport sneakers
DOI 10.1024/0301-1526/a000332
High sport sneakers may lead to peripheral artery
occlusion in Zumba® dancers
Claudia Schrimpf1, Kirsten Haastert-Talini2, Christian von Falck3, Saad Rustum1, Mathias Wilhelmi1,
and Omke E. Teebken1
1 Department Cardiothoracic, Transplantation, and Vascular Surgery, Hannover Medical School, Hannover, Germany
2Department of Neuroanatomy, Hannover Medical School, Hannover, Germany
3Department of Radiology, Hannover Medical School, Hannover, Germany
Introduction
Aneurysms of peripheral arteries are
extremely rare.  ey may be caused
by atherosclerosis, infection [1, 2]
neuro bromatosis [3], vasculitis such
as Morbus Behcet [4] or trauma [5].
e latter is usually related to pseu-
doaneurysms [6].
Herein, we describe the development
of a traumatic true aneurysm of a dis-
tal artery, where recurrent friction
was most likely identi ed as the cause.
Case report
A 38-year-old sportive female pre-
sented in our clinic with recurrent
pain and paresthesia of the right foot.
e symptoms had occurred for the
rst time four months a er starting
Zumba®, a cardiovascular training
combining  tness with Latin dance
moves. Symptoms started with in-
termittent pain in the middle foot
during a step aerobic training and
were returning with higher intensity
during Zumba training performed
a few days later.  e pain was ac-
companied by blueish, exsanginous
toes and training had to be stopped.
e symptoms vanished shortly af-
ter pausing. Restarting the workout
caused the symptoms to recur and the
workout had to be stopped again. Be-
sides Zumba training the patient had
also been performing step aerobics on
an advanced level (twice a week) and
regular running exercise (weekly) for
more than ten years. With time other
sportive activities like running and
even regular walking also became too
painful to be performed so that the
patient seeked medical advice.
First, the patient presented to an or-
thopedic specialist, who excluded a
musculoskeletal cause. Due to ongo-
ing paresthesia of the lateral foot,
the patient was then seen by a neu-
rologist, where a regular nerve con-
ducting speed was measured, rul-
ing out a neurogenic pathology.  e
patient’s history showed no signs of
vasculitis, connective tissue disease
or hypertension. An angiologist or-
dered an MRI of the right ankle a er
detecting a good pulse but a slightly
diminished Doppler signal over the
dorsal artery of the foot.  e MRI
showed a thrombosed aneurysm
of the right anterior tibial artery at
the transition to the dorsal artery of
the foot (Figure 1).  e pathology
was discussed in an interdisciplin-
ary conference and we decided to
perform diagnostic angiography of
the right lower limb arteries and po-
tentially attempt an interventional
recanalisation.  e exam showed
a segmental lack of contrast at the
aneurysm site (Figure 2).  e arte-
rial arch of the foot was  lled via the
posterior tibial artery, interdigital
arteries could be detected and no
additional occlusions were apparent.
Key message
Distal peripheral artery aneurysms
are extremely rare.  e majority are
trauma related and then classi ed as
false. Recurrent friction of a high-top
sneaker resulted in the formation of
a true aneurysm of the anterior tibial
artery. Herein we report on a young
woman who developed a true aneu-
rysm of the distal anterior tibial artery
following recurrent trauma caused by
Zumba® and wearing high sport shoes.
Figure 1: MRI of the thrombosed
aneurysm at the anterior tibial
artery.
Figure 2: Angiography of the foot
showing a segmental lack (black
arrows) of contrast at the location
site of the aneurysm.
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79
Case report
C. Schrimpf et al.: Arterial occlusion by sport sneakersVasa 2014; 43: 78 – 80
© 2014 Hans Huber Publishers, Hogrefe AG, Bern
Conservative treatment of the aneu-
rysm was not considered an option
due to the risk of peripheral embo-
lism in case of resuming training. A
venous bypass was discussed but since
the prospective landing zone on the
proximal dorsum of the foot was not
likely to deliver long-term patency,
we decided to ligate and resect the
aneurysm (Figure 3) and to obtain
a histologic examination.  e result
revealed unspeci c vascular prolifera-
tion with old thrombus in peripheral
parts of the aneurysm.  e peri- and
postoperative course was uneventful
and at 12-month follow-up there were
no recurrent ischemic symptoms.
Discussion
Aneurysms of distal peripheral arter-
ies are extremely rare. Besides infec-
tion and systemic diseases the ma-
jority of distal peripheral aneurysms
are of iatrogenic origin, i.e. due to
interventions or surgical procedures.
While aneurysm formation due to
trauma most o en leads to false an-
eurysm, searching the pubmed da-
tabase (1952 2013, anterior tibial
artery aneurysm, 07.08.2013) merely
revealed six true aneurysms of the an-
terior tibial artery or dorsal artery of
the foot [7 – 9], while 44 pseudoaneu-
rysms were found.  e vast majority
occurred accidentally during ankle
arthroscopy (12 cases).
We believe that the aneurysm in our
patient was caused by recurrent fric-
tion of the sneaker´s tongue and up-
per rim (Figure 4) to the distal tibial
artery. Although the patient had been
wearing the same type of sports shoes
for more than 10 years for step arobic,
those shoes did not seem to be ap-
propriate for Zumba. For running,
the young lady had always used low
sports sneakers. While running and
step aerobic mostly contain straight-
forward movements with jumps onto
a step, Zumba training requires high
frequency repetitive movements
twisted sidewards.  erefore shoes
appropriate for step aerobics might
not be suitable for Zumba. We did
not  nd another reference, where
recurrent, latent trauma could be
identi ed as the reason for aneu-
rysm development. True anterior
tibial artery aneurysms were found
caused by atherosclerosis (2 cases) [8,
10], neuro bromatosis (1 case) [3],
trauma (2 case) [11, 12] and infection
(1 case) [13].
Regular physical activity and / or aer-
obic exercise training does not only
improve  tness but is associated with
a decrease in cardiovascular mortality
[14]. Zumba
®
is a highly e cient car-
diovascular workout that combines
endurance with Latin dance moves
and therefore gains more and more
popularity, especially among women.
It is important for a clinician to be
familiar with the demanding training
programs to help patients select the
optimal individual training program
and also to detect potential compli-
cations involved. To prevent future
injuries, appropriate training equip-
ment should be at hand. For physical
activities that require quick sideward
moves and a high  exibility in the sole
of the foot, selection of the optimal
sports shoe should be given high pri-
ority. Based on the reported case, we
advise the selection of a low sports
sneaker with cushioning that does not
impinge on the vasculature, so as to
prevent vascular trauma.
Conclusions
We think that in times of increasing
popularity of cardiovascular dance
tness training it is important to
recommend proper sports shoes to
prevent later vascular damage.  e
selected shoe should provide cush-
ioning and support, but should not
in uence arterial blood  ow.  ere-
fore we recommend low sport shoes
for Zumba training since high shoes
might cause friction in typical twist-
ed sideward moves, speci c for latin
dance  tness training. In addition we
Figure 3: (A) Preoperative land-
marks showing the location of
the aneurysm between the two
marked black arrows; (B) Intraop-
erative situs showing the anterior
tibial artery accessed via a proxi-
mal and distal insicion and secured
proximately via a vessel loop.
Figure 4: (A) Sport sneaker caus-
ing friction at the anterior tibial
artery, white arrows depict area
of maximal friction, of note is
the lateral localization due to re-
peated sideward movements (B)
preoperative landmarks showing
the location of the aneurysm.
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80 Case report
Vasa 2014; 43: 78 – 80
© 2014 Hans Huber Publishers, Hogrefe AG, Bern
C. Schrimpf et al.: Arterial occlusion by sport sneakers
recommend ruling out rare possi-
bilities for pain and paresthesia (i. e.
existence of peripheral aneurysms)
especially in younger patients to
prevent future peripheral embolism.
Conflicts of interest
ere are no con icts of interest
existing.
Key words
Peripheral artery occlusion, anterior
tibial artery aneurysm, sports injury
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Correspondence address
Dr. Claudia Schrimpf, MD
Cardiothoracic- Transplantation-
and Vascular Surgery
Hannover Medical School
Carl-Neuberg Str. 1
30625 Hannover
Germany
Schrimpf.Claudia@mh-hannover.de
Submitted: 09.09.2013
Accepted a er revision: 11.11.2013
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