Intermittent claudication
Most common in the legs, intermittent claudication is cramping limb pain brought on by exercise and relieved by 1 to 2 minutes of rest. This pain may be acute or chronic; when acute, it may signal acute arterial occlusion. Intermittent claudication is most common in men ages 50 to 60 with a history of diabetes mellitus, hyperlipidemia, hypertension, or tobacco use. Without treatment, it may progress to pain at rest. With chronic arterial occlusion, limb loss is uncommon because collateral circulation usually develops.
With occlusive artery disease, intermittent claudication results from an inadequate blood supply. Pain in the calf (the most common area) or foot indicates disease of the femoral or popliteal arteries; pain in the buttocks and upper thigh, disease of the aortoiliac arteries. During exercise, the pain typically results from the release of lactic acid due to anaerobic metabolism in the ischemic segment, secondary to obstruction. When exercise stops, the lactic acid clears and the pain subsides.
Intermittent claudication may also have a neurologic cause: narrowing of the vertebral column at the level of the cauda equina. This condition creates pressure on the nerve roots to the lower extremities. Walking stimulates circulation to the cauda equina, causing increased pressure on those nerves and resultant pain.
Physical findings include pallor on elevation, rubor on dependency (especially the toes and soles), loss of hair on the toes, and diminished arterial pulses.
Emergency Interventions
If the patient has sudden intermittent claudication with severe or aching leg pain at rest, check the leg’s temperature and color and palpate femoral, popliteal, posterior tibial, and dorsalis pedis pulses. Ask about numbness and tingling. Suspect acute arterial occlusion if pulses are absent; if the leg feels cold and looks pale, cyanotic, or mottled; and if paresthesia and pain are present. Mark the area of pallor, cyanosis, or mottling, and reassess it frequently, noting an increase in the area.
Don’t elevate the leg. Protect it, allowing nothing to press on it. Prepare the patient for preoperative blood tests, urinalysis, electrocardiography, chest X-rays, lower-extremity Doppler studies, and angiography. Start an I.V. line, and administer an anticoagulant and analgesics.
History and physical examination
If the patient has chronic intermittent claudication, gather history data first. Ask how far he can walk before pain occurs and how long he must rest before it subsides. Can he walk less far now than before, or does he need to rest longer? Does the pain-rest pattern vary? Has this symptom affected his lifestyle?
Obtain a history of risk factors for atherosclerosis, such as smoking, diabetes, hypertension, and hyperlipidemia. Next, ask about associated signs and symptoms, such as paresthesia in the affected limb and visible changes in the color of the fingers (white to blue to pink) when he’s smoking, exposed to cold, or under stress. If the patient is male, does he experience impotence?
Focus the physical examination on the cardiovascular system. Palpate for femoral, popliteal, dorsalis pedis, and posterior tibial pulses. Note character, amplitude, and bilateral equality. Diminished or absent popliteal and pedal pulses with the femoral pulse present may indicate atherosclerotic disease of the femoral artery. Diminished femoral and distal pulses may indicate disease of the terminal aorta or iliac branches. Absent pedal pulses with normal femoral and popliteal pulses may indicate Buerger’s disease.
Listen for bruits over the major arteries. Note color and temperature differences between his legs or compared with his arms; also note where on his leg the changes in temperature and color occur. Elevate the affected leg for 2 minutes; if it becomes pale or white, blood flow is severely decreased. When the leg hangs down, how long does it take for color to return? (Thirty seconds or longer indicates severe disease.) If possible, check the patient’s deep tendon reflexes after exercise; note if they’re diminished in his lower extremities.
Examine his feet, toes, and fingers for ulceration, and inspect his hands and lower legs for small, tender nodules and erythema along blood vessels. Note the quality of his nails and the amount of hair on his fingers and toes.
If the patient has arm pain, inspect his arms for a change in color (to white) on elevation. Next, palpate for changes in temperature, muscle wasting, and a pulsating mass in the subclavian area. Palpate and compare the radial, ulnar, brachial, axillary, and subclavian pulses to identify obstructed areas.
Medical causes
Aortic arteriosclerotic occlusive disease
With this disorder, intermittent claudication occurs in the buttock, hip, thigh, and calf, along with absent or diminished femoral pulses. Bruits can be auscultated over the femoral and iliac arteries. Examination reveals pallor of the affected limb on elevation and profound limb weakness. The leg may be cool to the touch.
Arterial occlusion (acute)
This disorder produces intense intermittent claudication. A saddle embolus may affect both legs. Associated findings include paresthesia, paresis, and a sensation of cold in the affected limb. The limb is cool, pale, and cyanotic (mottled) with absent pulses below the occlusion. Capillary refill time is increased.
Arteriosclerosis obliterans
This disorder usually affects the femoral and popliteal arteries, causing intermittent claudication (the most common symptom) in the calf. Typical associated findings include diminished or absent popliteal and pedal pulses, coolness in the affected limb, pallor on elevation, and profound limb weakness with continuing exercise. Other possible findings include numbness, paresthesia and, in severe disease, pain in the toes or foot while at rest, ulceration, and gangrene.
Buerger’s disease
This disorder typically produces intermittent claudication of the instep. Men are affected more than women; most of the affected men smoke and are between ages 20 and 40. It’s common in the Orient, southeast Asia, India, and the Middle East and is rare in Blacks. Early signs include migratory superficial nodules and erythema along extremity blood vessels (nodular phlebitis) as well as migratory venous phlebitis. With exposure to cold, the feet initially become cold, cyanotic, and numb; later, they redden, become hot, and tingle. Occasionally, Buerger’s disease also affects the hands and can cause painful ulcerations on the fingertips. Other characteristic findings include impaired peripheral pulses, paresthesia of the hands and feet, and migratory superficial thrombophlebitis.
Cauda equina syndrome
Spinal stenosis causes pressure on nerve roots resulting in symptoms of claudication from the hip down as with Leriche’s syndrome. Diagnosis can be determined by noninvasive exercise studies. With cauda equina syndrome, the pressure doesn’t drop when the patient exercises on the treadmill.
Leriche’s syndrome
Arterial occlusion causes intermittent claudication of the hip, thigh, buttocks, and calf as well as impotence in men. Examination reveals bruits, global atrophy, absent or diminished pulses, and gangrene of the toes. The leg becomes cool and pale when elevated.
Neurogenic claudication
Neurospinal disease causes pain from neurogenic intermittent claudication that requires a longer rest time than the 2 to 3 minutes needed in vascular claudication. Associated findings include paresthesia, weakness and clumsiness when walking, and hypoactive deep tendon reflexes after walking. Pulses are unaffected.
Thoracic outlet syndrome
Activity that requires raising the hands above the shoulders, lifting a weight, or abducting the arm can cause intermittent pain along the ulnar distribution of the arm and forearm along with paresthesia and weakness. The pain isn’t true claudication pain because it’s related to position, not exercise. Signs and symptoms disappear when the arm is lowered. Other features include asymmetrical blood pressure and cool, pale skin.
Special considerations
Encourage the patient to exercise to improve collateral circulation and increase venous return, and advise him to avoid prolonged sitting or standing as well as crossing his legs at the knees. (See Improving circulation in your legs.) If intermittent claudication interferes with the patient’s lifestyle, he may require diagnostic tests (Doppler flow studies, arteriography, and digital subtraction angiography) to determine the location and degree of occlusion.
Pediatric pointers
Intermittent claudication rarely occurs in children. Although it sometimes develops in patients with coarctation of the aorta, extensive compensatory collateral circulation typically prevents manifestation of this sign. Muscle cramps from exercise and growing pains may be mistaken for intermittent claudication in children.
Patient counseling
Counsel the patient with intermittent claudication about risk factors. Encourage him to stop smoking, and refer him to a support group, if appropriate. Teach him to inspect his legs and feet for ulcers; to keep his extremities warm, clean, and dry; and to avoid injury.
Urge the patient to immediately report skin breakdown that doesn’t heal. Also urge him to report any chest discomfort when circulation is restored to his legs. Increased exercise tolerance may lead to angina if the patient has coronary artery disease that was previously asymptomatic because of exercise limitations.
Pictures
Book Source Details
- Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.
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Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2008 Williams & Wilkins.
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