LEG PAIN

Present as:
Claudication refers to leg pain while walking.  Derived from the Latin word “claudication”, it means “to limp.”  Intermittent claudication is a condition in which pain develops, usually in the calves, due to inadequate arterial circulation (arterial blood supply).

Simply stated, intermittent claudication is a problem of oxygen supply and demand. That is, the supply of blood (actually, the oxygen carried by the blood) does not meet the demands of the leg muscles. Oxygen is required for all muscles and organs, such as the heart, brain, liver, kidney and leg muscles, in the body to function correctly.  If the heart or brain are derived of their  oxygen (blood) supply, a “heart attack” or stroke, ensues.   Likewise, poor blood supply to the leg muscles produces claudication.

As mentioned above, all muscles need oxygen, which is transported via the arterial circulation.  A lack of oxygen will almost immediately produce symptoms in the patient.  When at rest, that is when a person is sitting, the level of oxygen required for the muscles  to function is very low.  As walking begins, that requirement increases and continues to do so with increasing exertion.  In a “normal” person (one without arterial disease), the body responds to this increased need for blood by dilating (opening)  the arteries (much like a faucet will open) to increase  bloodflow to the leg musculature. Therefore, in a person without arterial disease (atherosclerosis), the increasing demand of exercise is met by an increasing supply of blood (oxygen).

However, in a person with “hardening of the arteries" (atherosclerosis, arteriosclerosis) or blockages in the arteries, this increasing demand for more oxygen cannot be met.  The arteries cannot dilate to deliver more blood flow.  Therefore, while the blood supply may be adequate to meet the demands of the muscles when the muscles are at rest, the increasing demand cannot be met once exercise (i.e. walking) begins.

The diagnosis of PVD is based on a careful history and physical examination.  The pain of intermittent claudication is typically very consistent with each individual and will occur almost always at the same fixed distance.  There may be some variation in distances related to the incline of the path being walked or the rate at which a person is walking; however, the pain is usually reproducible at a similar  distance. It is rare for the pain to begin immediately upon standing and it does not usually radiate (these are generally signs of other causes of leg pain).  Rest usually relieves the pain and this relief comes within one minute of halting the walking exercise. The pain of intermittent claudication is usually described as a “cramp” in the calf, thigh or buttocks depending on where the artery is blocked.


Following a good history, a thorough examination will usually identify those patients with circulation problems causing leg pain.  The ability to feel for pulses at different points in the leg is a crucial skill developed over time.

Here at The Cardiovascular Care Group, our Noninvasive Vascular Laboratory will provide objective evidence of impaired arterial circulation.  The use of special equipment (plethysmography) will allow for the accurate diagnosis of arterial disease of the extremities (arms or legs). This test is simple, pain-free and quick.  It must, however, be performed by an experienced technologist and interpreted by a vascular specialist well- versed in this field.

When it comes to the treatment of claudication, our experience along with that of others,, shows that most patients will improve with conservative therapy.  It is rare that intervention is needed to adequately treat intermittent claudication.  The use of a walking exercise program and the cessation of tobacco use, if followed, will improve arterial circulation without the need for surgery or balloon angioplasty.  The presence of claudication does NOT necessarily mean limb loss or the need for amputation.  it is rare for a person with intermittent claudication to have their disease progress to the point of gangrene or limb loss.

An adequate walking exercise program for thirty minutes each day, will have the patient  walk PAST THE POINT of claudication.  For example, if one can walk 100 steps before the calf cramping sets in, he should walk those first 100 steps and when the cramping begins, continue to walk another ten steps with the pain, and then stop.  Exercise tolerance is built up gradually and consistently.  Every patient needs to be proactive by sticking to their daily exercise routine and MUST quit smoking in order for this conservative therapeutic approach to work.

If the exercise tolerance does not improve following a consistent 2-3 month effort on the part of the patient AND if the intermittent claudication is truly prohibiting a person from conducting his lifestyle in a manner that he can tolerate, intervention may be considered.  However, one must understand that once surgery or balloon angioplasty of arterial problems is performed, the patient must be monitored for the remainder of his or her life.  All arterial procedures have a defined lifespan and, depending on the patient’s overall medical status, it may need to be repeated at a later date.
There is rarely justification for performing any type of lower extremity procedure in a patient who has no symptoms (asymptomatic) but does have a “blockage.”  Conversely, persons whose intermittent claudication does progress to either “rest pain” (leg or foot pain even without walking), gangrene (blackening of the skin) or a non-healing ulcer are at risk for losing their legs and must be treated aggressively and appropriately.