Many people assume that aching legs when walking are just part of getting older. Sometimes they are a sign of peripheral artery disease, or PAD, a condition in which narrowed arteries reduce blood flow to the legs. PAD affects millions of Americans, and many do not know they have it. It matters not only for your legs: people with PAD have a much higher risk of heart attack and stroke.
What PAD is
PAD is caused by atherosclerosis, the same buildup of fatty plaque that narrows the arteries of the heart. When it affects the arteries to the legs, muscles do not get enough oxygen-rich blood, especially during activity. Having PAD is a strong sign that arteries elsewhere in the body, including those supplying the heart and brain, are also affected.
Warning signs
The classic symptom is claudication: cramping, aching, tiredness or heaviness in the calves, thighs or buttocks that comes on with walking and eases within a few minutes of rest. It tends to start at a predictable distance, such as after one block.
Other signs include:
- Leg pain at night or at rest, often in the feet or toes, that improves when you hang your legs over the side of the bed
- Sores or wounds on the feet, toes or legs that heal slowly or not at all
- Coldness in one leg or foot compared with the other
- Shiny skin, hair loss on the legs or feet, or slow toenail growth
- A weak or absent pulse in the feet
- Color changes in the skin of the legs or feet
- Erectile dysfunction in men
Many people with PAD have no symptoms, or have mild symptoms they put down to arthritis or age.
Who is at risk
- Smoking, the strongest risk factor for PAD
- Diabetes, which also raises the risk of foot ulcers and amputation
- Age over 65, or over 50 with other risk factors
- High blood pressure
- High LDL cholesterol
- Chronic kidney disease
- A history of heart disease or stroke
- Family history of vascular disease
How PAD is diagnosed
The key test is simple and painless. The ankle-brachial index (ABI) compares blood pressure at the ankle with blood pressure in the arm using a regular cuff and a small ultrasound device.
| ABI result | What it suggests |
|---|---|
| 1.00 to 1.40 | Normal |
| 0.91 to 0.99 | Borderline |
| 0.90 or lower | PAD |
| Above 1.40 | Stiff, calcified arteries (common in diabetes and kidney disease); further testing needed |
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If PAD is found, doctors may use a Doppler ultrasound, CT angiography or MR angiography to map the blockages, especially if a procedure is being considered.
Treatment: protecting your legs and your heart
Lifestyle changes
Stop smoking. This is the single most important step. It slows the disease, improves walking distance and reduces the risk of amputation, heart attack and stroke.
Supervised exercise therapy. A structured walking program, usually three sessions a week for 12 weeks, is one of the most effective treatments for claudication. You walk until moderate pain develops, rest, then repeat. Over time, the muscles become more efficient and new small blood vessels develop, and many people can walk much farther. Medicare and many insurers cover supervised exercise therapy for symptomatic PAD.
Healthy eating and weight control.
Medicines
- Statins to lower cholesterol and reduce heart attack and stroke risk
- Antiplatelet medicines, such as aspirin or clopidogrel, to reduce clotting
- Low-dose rivaroxaban with aspirin, which has been shown to reduce major heart and limb events in some patients with PAD
- Blood pressure and diabetes control
- Cilostazol, which can improve walking distance in some people with claudication (it is not suitable for people with heart failure)
Procedures
If symptoms remain severe despite exercise and medicines, or if blood flow is critically reduced, options include:
- Angioplasty and stenting: a balloon opens the narrowed artery through a catheter, often with a stent to keep it open
- Atherectomy: removal of plaque with a catheter device
- Bypass surgery: a vein or synthetic graft routes blood around the blockage
Critical limb ischemia: an emergency
The most severe form of PAD, called chronic limb-threatening ischemia, causes pain at rest, non-healing wounds or gangrene. It needs urgent specialist care to save the limb. Sudden severe pain, coldness, paleness, numbness or weakness in a leg can mean a complete blockage from a clot and is an emergency. Call 911.
Foot care with PAD
- Check your feet daily for cuts, blisters, color changes or sores
- Wash and dry feet carefully, especially between the toes
- Wear well-fitting shoes and never walk barefoot
- See a podiatrist for nail and callus care if you have diabetes
- Report any wound that is not healing promptly
The bottom line
Leg pain that comes on with walking and eases with rest is not just a sign of age. It can be PAD, a warning that your arteries are narrowing throughout the body. A quick ankle-brachial index test can diagnose it. Stopping smoking, a structured walking program and the right medicines protect both your legs and your heart.
This article is for general information and does not replace medical advice.