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Endofibrosis of the external iliac artery.

Endofibrosis of the external iliac artery: when your leg stops responding to you

Some athletes have to stop exercising because of an unbearable sharp pain in one of their legs. This continuous damage, which leaves your leg practically ‘numb’ and without strength, only disappears when you stop doing sport. This condition usually originates in the pelvic area, where there is a narrowing of the external iliac artery. This causes less blood to flow through the area. This is known as external iliac artery endofibrosis. Its main consequence is the inability to practice sport at high intensity.

This pathology remains largely unknown today. However, some world cycling figures (sport in which most cases occur) have suffered from it as the winner of the Vuelta a España 2015 Fabio Aru or the multiple world champion Pauline Ferrand-Prévot .

Other athletes such as long distance runners, footballers, butterfly swimmers or rowers are also susceptible to this injury.

The paucity of scientific research on this topic complicates its treatment. For this reason, we have contacted professional experts in the field so that they can shed light on the endofibrosis of the external iliac artery.

Endofibrosis of the external iliac artery: causes

The external iliac artery is a large artery that runs through the pelvis as a continuation of the common iliac artery and precedes the femoral artery. There is one on each leg and its main function is to water that area. It is the only artery with mobility in the pelvis, presenting this characteristic in its central part while the rest lacks mobility.

Juan de Dios Beas, a specialist in sports medicine and medical director of Beiman Clinics , notes that these types of arteries are designed “to be standing and not sitting,” despite their mobility. Thus, an abnormal position, such as that of a cyclist when pedalling, can cause the artery to kink excessively. All this leads to a narrowing that, if repeated frequently, causes endofibrosis: “If we are constantly straining the artery we can irritate it,” says Beas.

Do not be alarmed because not all athletes who contract excessively psoas (muscle associated with the external iliac artery) will have this problem: “The training load is important in this regard,” says José Ramón Alvero. Alvero is a specialist in Physical Education and Sports Medicine, professor at the University of Malaga and one of the great references when it comes to treating this injury.

Determining the amount of training from which endofibrosis of the external iliac artery originates is highly complicated: “A person who cycles 5,000 kilometres (km) a year will probably not have endofibrosis, but a person who cycles 40,000 km, such as a professional, may have a greater chance”. Therefore, the main causes of this injury are the particular anatomy of the human body and a repeated sporting gesture. For this last reason it is important to know if the exercise mechanics are correct.


The most obvious symptom of suffering from this pathology is the functional impotence in high intensity exercises that force you to interrupt your sports practice. The athlete, according to Juan de Dios Beas, is forced to stop because blood does not reach that area: “The caliber of the vessel has been reduced and, at a certain level of exercise, not enough blood reaches the muscle so it can not develop the strength that the athlete needs at that time. Stopping the exercise allows the flow to adjust to the area that is damaged and to irrigate. The specialist points out, as signs of this endofibrosis, pain and discomfort in that area.

Another obvious characteristic of this lesion is that at rest there are no symptoms. It is during great efforts when this lack of irrigation is produced: “It is defined as a ‘leg that stops responding'”, clarifies
Noelia Alonso Gómez
Noelia Alonso Gómez Gómez, vascular surgeon at the Hospital Central de la Defensa Gómez-Ulla in Madrid and Clinical Professor and Doctor of the University of Alcalá de Henares (UAH).

Alonso adds another symptom of his own such as the “impression of a large thigh during supramaximal efforts”. This feeling can be checked by paying attention to whether the elastic of the trousers is too tight.


The initial treatment for external iliac artery endofibrosis is conservative. That is to say, it is intended that the athlete does not try to undergo surgery. However, Juan de Dios Beas clarifies that in elite athletes “most of the time the most appropriate option is surgery because the preventive factors have already been covered.

The preventive factors to which it refers are a decrease in the physical exercise load and a change of posture, for which it is vital the
figure of the biomechanist
. “The lack of response to conservative measures or an inability to undergo activity modification is what leads to surgery,” says Noelia Alonso.

José Ramón Alvero goes further and specifies that practically all these endofibrosis have to be treated with surgery because “the artery has narrowed”, so it is necessary to repair the damage because “there are alterations of irrigation and to exercise physical work.

Surgery specialist Noelia Alonso comments, regarding surgery, that the health professional must know this injury very well to perform a correct operation and should not confuse it with an iliac stenosis. Thus, he stresses that “endovascular treatment is not indicated because of the high risk of fracture of the stent (spring devices to widen vessels) due to the high mechanical load to which it is subjected”.

Alonso notes that the operation removes the plaque blocking the artery through an incision in the pelvis and adding a possible graft if necessary. Prosthetic material is contraindicated.

Recovery time

After the operation, the athlete wants to know the recovery time. The sports doctor José Ramón Alvero stresses that each case must be treated individually but in “two or three months you can return to normal training.

Do not forget that the operation can have complications. For example, Alonso recalls that “sometimes the artery cannot be freed because of the risk of damaging surrounding structures and finally requiring the patient to undergo a bypass (detour through another artery)”. This results in more cuts to the pelvis and therefore a longer recovery period.

What does seem clear is that the ultimate goal is that the athlete recovers normality in their sports practice at the highest level. Intention that seems to be achievable without problems. The best example is Fabio Aru: operated on in April 2019 and present, three months later, nothing less than in the Tour de France.

Source: @grupoBeiman via

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