popliteal artery stenosis or occlusive disease is a common occurrence in elderly patients , diabetics , smokers and those with cardiovascular disease . it leads to significant morbidity and mortality by reducing or completely blocking blood supply through the popliteal artery and into the lower leg . we describe an unusual presentation of a 24-year - old male with a popliteal artery stenosis masquerading as an infective foot ulcer . we believe this case illustrates the importance of a meticulous history and physical examination when assessing foot ulcers . a 24-year - old male attended the department with a painful ulcer under the third metatarsal head of his left foot . this ulcer had been present for 2 months prior to presentation following a skin laceration sustained while travelling in thailand . the patient had received antibiotic therapy and surgical debridement on two occasions while abroad ; however , the ulcer had failed to heal . on closer questioning the patient reported that he sustained the injury while walking close to coral reef in the sea in thailand . there had been no history of freshwater exposure , drug misuse or of any risk - taking behaviour . initially , the patient was treated with empirical antibiotics on instruction from our microbiology department . antibiotic therapy was altered according to these sensitivities , and the erythema and swelling began to settle over the coming weeks . unfortunately , the ulcer continued to enlarge and a mri scan of the left foot revealed increased uptake in the third toe and metatarsal head indicating underlying osteomyelitis . , it proved necessary to amputate the third toe and metatarsal head as they could not be salvaged due to infective destruction . on conclusion of the procedure , the tourniquet which had been applied to the lower limb was deflated and it was noted that the left foot was slow to reperfuse . a vascular opinion was sought . ankle brachial pressure index ( abpi ) in the left leg was 0.46 when compared with 0.82 in the right leg , indicating a significant decrease in arterial blood flow to the left foot . a ct femoral angiogram demonstrated a left popliteal short segment occlusion with reforming of the tibio - peroneal trunk with small vessels . on detailed probing , a history of intermittent claudication was revealed with a claudication distance of 100 m. subsequently , a left superficial femoral artery to popliteal artery bypass was performed by the vascular team using a reverse vein graft . within 6 weeks , all antibiotic therapy had been stopped and the wound from amputation on the left foot had completely healed . stenosis of the popliteal artery is a common condition , most often seen in the context of peripheral vascular disease where an atherosclerotic pathogenesis is accountable . however , in a cohort of younger patients , there is a much broader range of pathogenesis accounting for such stenosis . conditions such as popliteal artery entrapment syndromes ( paes ) , popliteal artery aneurysm , cystic adventitial disease , multiple hereditary exostosis , some arteritis disorders ( e.g. takayasu 's ) and some rare congenital syndromes ( e.g. cutis marmorata telangiectatica congenital ) must be considered . in each of these conditions , there is an underlying disease process that culminates in a reduction in the cross - sectional area in the popliteal artery and consequently , flow through the vessel is decreased in accordance with laplace 's law . , there is an insidious process that can be unmasked by an acute insult ( e.g. trauma and embolism ) . the presentation of congenital popliteal artery stenosis is very similar to that in peripheral vascular disease , with intermittent claudication , slow healing wounds and transitory change in skin colour and temperature . a persistent wound or ulcer in a young and otherwise fit individual with no obvious predisposing factors is a red flag and should prompt further investigation . a thorough history with targeted questioning of the above presenting symptoms is important , followed by rigorous physical examination . initial bedside assessment of vascular status should be performed with abpis and doppler flow studies . blood flow may be posturally dependent in approximately a third of paes cases ; however , this is unlikely to be the case with a fixed stenosis of the popliteal artery . ct is a useful adjunct if external compression of the artery is a possibility ; furthermore , mri is useful in adventitial cystic disease . management of vascular insufficiency in young patients depends on the underlying pathogenesis . in adventitial cystic disease , symptoms may resolve spontaneously if cysts rupture ; however , recurrence is common . in congenital popliteal artery stenosis , vascular bypass is often required as with the 24-year - old gentleman under consideration here . in conclusion , this case emphasizes the importance of maintaining a broad differential diagnosis in young individuals presenting with persistent foot ulcers . in a young person with a persistent non healing ulcer , with unusual bacteriology and normal pulses , always consider a proximal vascular lesion . a prompt diagnosis of an unusual congenital vascular insufficiency can prevent complications and long - term morbidity for the patient .