Peripheral arterial disease (PAD)
Peripheral arterial disease is a narrowing of the arteries that carry blood to the legs. The cause is nearly always the same: cholesterol-rich plaques build…
On this page
- What happens in the legs
- Why the arteries narrow
- Leg pain that does not come from the arteries
- How the diagnosis is confirmed
- What lengthens the distance you can walk
- The medicines prescribed for the heart and brain
- Feet that need looking at every day
- When surgery is needed and when an ambulance is
- Online consultation
Medicines commonly prescribed for Peripheral arterial disease (PAD)
For informational purposes only. Always consult a doctor before using any medicine.
Dosage form: TABLET, 80 mgActive substance: atorvastatinManufacturer: Sun Pharmaceutical Industries (Europe) B.V.Prescription requiredDosage form: TABLET, 30 mgActive substance: atorvastatinManufacturer: Laboratorios Alter S.A.Prescription requiredDosage form: TABLET, 40 mgActive substance: atorvastatinManufacturer: Teva Pharma S.L.U.Prescription required
Peripheral arterial disease is a narrowing of the arteries that carry blood to the legs. The cause is nearly always the same: cholesterol-rich plaques build up over years inside the vessel wall, the channel narrows, and the muscles stop getting the blood that effort demands. Hence the main sign — pain in the calves on walking that eases as soon as you stop. But the condition has a second side that is less widely known: the same plaques are growing in the vessels of the heart and the brain, so a narrowing found in the legs is first and foremost a warning about heart attack and stroke. What follows is how PAD shows itself, what it gets confused with, how it is confirmed and what changes the outlook.
What happens in the legs
In some people the disease gives no sign for years and turns up by chance. When symptoms do appear, they are recognisable.
- Pain on walking. A dragging, gripping or cramping pain in the calf, less often in the thigh or buttock, which starts after roughly the same distance every time and clears within a few minutes of standing still. The name for it is intermittent claudication. A brisk pace and going uphill shorten the distance.
- Both legs are usually involved, although one hurts more.
- Skin and nails. Hair on the lower leg and foot thins out, the skin becomes thin and shiny, the nails grow slowly and crumble, the foot is cold to the touch and goes pale when the leg is raised.
- Wounds that will not heal, on the toes, the heel, the edge of the foot or wherever a shoe rubs.
- Numbness, weakness and wasting of the calf muscles; in men, sometimes erectile dysfunction, when the narrowing sits higher up, at the level of the pelvis.
There is also a trap the other way round: in people with diabetes and nerve damage there may be no pain at all. The first sign then is not a limp but an ulcer on the foot that went unnoticed. That is why in diabetes the feet are checked regularly, without waiting for symptoms.
Why the arteries narrow
Underneath it lies atherosclerosis: cholesterol and other material deposited in the vessel wall, gradually narrowing the channel. It develops over decades and shows up in the legs before the heart, simply because the leg muscles work hard and a shortfall of blood is easier to notice there.
- Smoking is the heaviest factor, and the only one that can be removed completely. In smokers the disease starts earlier, runs a worse course and responds less well to every treatment, surgery included.
- Diabetes of both types. It not only speeds up atherosclerosis but also damages the small arteries of the foot and, along with them, the nerves, so that the pain signal disappears.
- High blood pressure and raised cholesterol.
- Age, male sex and a family history of early heart attacks and strokes.
- Chronic kidney disease and an inactive way of life.
One thing is worth holding on to separately: narrowed leg arteries are almost never the only ones affected. A person with PAD is far more likely to have a heart attack or a stroke than to lose a leg, and that is exactly why treatment is aimed not only at walking but at the heart and the brain.
Leg pain that does not come from the arteries
Not every pain on walking is PAD, and the causes cannot be told apart by eye — though certain features point to where to look.
- Narrowing of the spinal canal in the lower back. The commonest lookalike. This pain also comes on with walking, but it travels down from the lower back, comes with numbness and weakness and, unlike arterial pain, does not settle simply by standing still: relief needs sitting down or leaning forward. Such a person finds cycling easier than walking; in PAD it tends to be the other way round.
- Arthritis of the hip or knee. The pain sits in the joint itself, builds up towards the end of the day and depends on position rather than on distance covered.
- Venous problems. In severe chronic venous insufficiency the leg also hurts on walking, but the pain is bursting, the leg is swollen, and raising it helps rather than merely standing still.
- Deep vein thrombosis. Swelling of one leg with bursting pain and redness that has come on over a day or two needs to be seen the same day.
- Muscles and tendons after unaccustomed effort, inflammation of the Achilles tendon, or a nerve injury.
A word about age: "my legs hurt because I'm over seventy" is not a diagnosis. Leg pain on walking always deserves working out rather than being put down to the years.
How the diagnosis is confirmed
It starts with an examination: the doctor compares the temperature and colour of the feet, feels for pulses at the foot and behind the knee, looks between the toes and at the heels, and asks after how many metres the pain comes on and how quickly it goes.
- The ankle-brachial pressure index is the main test. Blood pressure is measured at the arm and at the ankle and the second is divided by the first. Normally the readings are close; with narrowed arteries the ankle pressure is lower and the index falls. It is painless, takes a quarter of an hour and is done in a clinic.
- The same index after exercise. If it is normal at rest but the symptoms persist, the measurement is repeated after walking on a treadmill: a hidden narrowing shows itself precisely under load.
- Duplex ultrasound shows where the narrowing is and how tight it is.
- CT or MR angiography, when a procedure is under discussion and a map of the vessels is needed.
One important caveat is often forgotten: a normal ankle-brachial index does not always rule the diagnosis out. In long-standing diabetes and in kidney disease the artery walls calcify, become rigid and cannot be compressed by the cuff, so the index reads normal or even high while the vessels are genuinely narrowed. In that situation the pressure is measured at the toe instead, or an ultrasound is done straight away. If the symptoms are typical and the number looks "good", the assessment carries on.
What lengthens the distance you can walk
Two measures achieve more here than everything else put together, and both are free.
- Stopping smoking. No medicine and no operation delivers the same effect. Help with stopping — nicotine replacement, medication prescribed by a doctor, support — works considerably better than going it alone.
- Walking to a programme. This is treatment, not the advice to "move about more". It means walking until moderate pain appears, stopping, waiting for it to pass and setting off again — about half an hour of that in total, several times a week, for months. Supervised, it multiplies the distance covered: small vessels gradually open up around the narrowed stretch. The first weeks are unpleasant, a clear effect arrives at about six to eight weeks, and it is lost just as fast if the programme is dropped.
Medicines that increase walking distance do exist, but their effect is modest; they come up once the walking programme has been used and surgery has been ruled out. Plaques cannot be removed altogether, but in most people the situation settles and the distance covered grows.
The medicines prescribed for the heart and brain
This part of the treatment does nothing at all for the leg pain, and it is precisely the part most often abandoned on the grounds that it "isn't helping". It is taken for what may happen away from the leg.
- A statin is prescribed to almost everyone with this diagnosis, whatever the starting cholesterol: it stabilises the plaque and lowers the risk of heart attack and stroke. Muscle aches on a statin do occur, but more often have another cause; they are to be sorted out with a doctor rather than by stopping the drug on your own.
- Blood-thinning medicines. Usually this is an antiplatelet drug, which stops platelets clumping together. Sometimes a low-dose anticoagulant is added — a different group with a different mechanism — and that decision belongs to the doctor, weighing the bleeding risk. Stopping such medicines yourself, including before a dental extraction, is not acceptable: ask whoever prescribed them first.
- Blood pressure, blood sugar and weight. The targets are the same as in any disease of the blood vessels. The old worry that beta blockers cannot be taken in PAD has not held up: if the heart needs them, they are prescribed.
Feet that need looking at every day
When little blood reaches the foot, any small wound heals slowly and turns into an ulcer easily. Foot care in PAD is not cosmetic; it is amputation prevention, and it costs exactly five minutes a day.
- Check your feet daily, including between the toes and the heels; a mirror helps for the awkward places.
- Wash in warm rather than hot water and dry carefully between the toes; use cream to soften the skin, but not between the toes.
- Cut nails straight across without digging into the corners. Do not pare hard skin with a blade or use acid corn plasters — that is a job for a podiatrist.
- Choose soft, well-fitting shoes without inner seams, and do not walk barefoot.
- Do not warm your feet with a hot water bottle, by a heater or in a hot bath. Where sensation is impaired this is how people get burns they only find out about when the wound appears.
- Show a doctor any wound, crack, darkened patch or weeping area straight away, without waiting to see whether it clears on its own.
When surgery is needed and when an ambulance is
If despite treatment the pain makes life impossible, or the blood supply has become critically low, restoring the flow is considered. There are two routes. Angioplasty: a balloon is fed into the artery through a puncture, the narrowed stretch is widened and a stent is often left behind; it is minimally invasive and usually done under local anaesthetic. Bypass: the narrowing is routed around using the person's own vein or a graft; it is bigger surgery, but the result often lasts longer. The choice depends on where the narrowing is and how long it is, and on general fitness; both carry risks, discussed beforehand. Neither replaces stopping smoking or taking the medication: without those the repaired vessel closes again.
Separate from all this is the state in which the blood supply is inadequate even at rest. It shows itself as burning pain in the foot and toes at night, forcing the person to hang the leg out of bed or sleep sitting up, along with ulcers that will not close and tissue turning black. This is critical limb ischaemia, and it calls not for a routine appointment but for urgent referral to a vascular surgeon: the sooner the flow is restored, the better the chance of keeping the leg.
Call an ambulance — in Spain, Italy, Portugal, Poland and Ukraine the single number is 112 — if a leg has suddenly, over minutes or hours, become cold, pale or mottled, intensely painful, numb and unresponsive, with the pulse gone. That is how a sudden blockage of an artery by a clot presents. The clock runs in hours: the leg can be saved if help comes quickly. Do not warm it, do not rub it and do not wait for morning.
Online consultation
A leg that has suddenly gone cold and stopped working is not for an online conversation — that is an ambulance call. Everything around the diagnosis, though, is well suited to being discussed from home. A doctor can help you work out whether your symptoms look like intermittent claudication or point to the spine or a joint, and where to start the assessment; go through the ankle-brachial index and the ultrasound with you, including the case where the number is normal but the symptoms remain; explain what the statin is for when the legs do not improve on it, and what to do about muscle aches; help you build the walking programme and explain why pain is part of it; sort out your blood-thinning medicines before the dentist or an operation; teach you how to check your feet and which finding needs an appointment tomorrow and which one today. A reason of its own to write in: pain in the foot at night, and any wound on the leg that has gone more than two weeks without healing.
This material is for information only and does not replace medical advice.
Consult with a doctor about Peripheral arterial disease (PAD)
Discuss your symptoms and possible next steps with a doctor online.
Online doctors for Peripheral arterial disease (PAD)
Discuss your symptoms and possible next steps for Peripheral arterial disease (PAD) with a doctor online.
