Claudication

What is claudication?

Claudication refers to limping because of pain in the thigh, calf, and/or buttocks that occurs when walking. Claudication may be a symptom of peripheral arterial disease (PAD). PAD is caused by a narrowing or blockage of arteries in the legs and/or aorta (the largest artery in the body and the primary blood vessel leading from the heart to the body), which may cause decreased blood flow to the muscles of the calf, thigh, or buttocks. This decreased blood flow may cause claudication. The pain associated with claudication occurs with walking but disappears at rest.

Claudication may be a symptom of underlying systemic artery disease and is seen more often in persons who have blockages in other arteries, including the heart and brain. Because claudication is associated with an increased risk for heart attack or stroke, its presence signals the need for assessment and possible treatment.

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About 9 million Americans, about 12 percent of the population, experience occasional claudication. Of those who are age 70 or more, about 20 percent are affected. About 25 percent of people who have hardening of the arteries (arteriosclerosis) in the legs experience claudication.

Claudication generally occurs when walking the same distance. With progressive vessel disease, the initial claudication distance (that distance at which a person first experiences pain when walking) may decrease or the person may no longer be able to walk.

What causes claudication?

Blockage of an artery in the legs may cause intermittent claudication. Atherosclerosis (a build-up of plaque, which is a deposit of fatty substances, cholesterol, cellular waste products, calcium, and fibrin in the inner lining of an artery) is the most common cause of blockage of arteries.

Blockages in the leg are most common in the thigh and behind the knee but may also occur at other sites in the body including the aorta, groin, or abdomen. A person may have more than one blockage.

What are the risk factors for claudication?

As stated above, atherosclerosis is the most common cause of arterial blockage which can cause claudication. Risk factors for claudication are the same as those for atherosclerosis, and may include:

• smoking
• diabetes
• overweight or obesity
• sedentary lifestyle
• high cholesterol
• high blood pressure
• family history of atherosclerosis or claudication
• older age (55 for men, 60 for women)

A risk factor is anything that may increase a person's chance of developing a disease. It may be an activity, such as smoking, diet, family history, or many other things. Different diseases have different risk factors.

Although these risk factors increase a person's risk, they do not necessarily cause the disease. Some people with one or more risk factors never develop the disease, while others develop disease and have no known risk factors. Knowing your risk factors to any disease can help to guide you into the appropriate actions, including changing behaviors and being clinically monitored for the disease.

What are the symptoms related to claudication?

Claudication itself is a symptom of a narrowing or blockage of an artery. Pain, a burning feeling, or a tired sensation in the legs and buttocks while walking are symptoms of claudication. In some cases, the sound of blood moving through a blockage (a whooshing sound called a bruit), can be heard through a stethoscope.

The skin of the foot or leg may become shiny, hairless, mottled (blotchy) in appearance, or may ulcerate. The affected leg may become pale when elevated and reddened (rubor) when lowered. Additional symptoms that may be present in persons with claudication include cold feet, impotence in men, and leg pain that occurs at night when in bed. Pain that occurs at rest may be a sign of increasing severity of arterial disease in the leg(s).

The symptoms related to claudication may resemble other medical conditions or problems. Always consult your physician for a diagnosis.

How is claudication diagnosed?

In addition to a complete medical history and physical examination, diagnostic procedures for claudication may include any, or a combination, of the following:

• ankle-brachial index (ABI) - a test in which blood pressure is taken in the arms and in the legs. ABI is a comparison of the blood pressure in the ankle with the blood pressure in the arm using a regular blood pressure cuff and a Doppler ultrasound device. To determine the ABI, the systolic blood pressure (the top number of the blood pressure measurement) of the ankle is divided by the systolic blood pressure of the arm.
• auscultation - listening to the arteries of the legs with a stethoscope to determine if a bruit is present.
• Doppler ultrasound - a non-invasive test that can depict blood flow. A Doppler probe within the ultrasound transducer evaluates the velocity and direction of blood flow in the vessel by bouncing high-frequency sound waves off of red blood cells. The transducer picks up the reflected waves and sends them to an amplifier, which makes the ultrasonic sound waves audible. Absence or faintness of these sounds may indicate an obstruction to the blood flow.
• angiogram (also called an arteriogram) - an x-ray image of the blood vessels that may be performed to help determine the presence and extent of blockage. It is performed to evaluate various vascular conditions, such as an aneurysm (ballooning of a blood vessel), stenosis (narrowing of a blood vessel), or blockages. The procedure involves inserting a thin, flexible tube into an artery in the leg and injecting a contrast dye into the artery. The contrast dye makes the arteries and veins visible on the x-ray.

Treatment for claudication:

Specific treatment will be determined by your physician based on:

• your age, overall health, and medical history
• extent of the disease
• the location of the blockage
• your signs and symptoms
• your tolerance for specific medications, procedures, or therapies
• expectations for the course of the disease
• your opinion or preference

Claudication is usually treated conservatively, with the primary goal of treatment being modification of risk factors. Treatment for claudication may include one or more of the following:

• smoking cessation
• exercise, preferably a walking program
• treatment of related medical problems, such as high cholesterol, high blood pressure, and/or high blood sugar levels (glucose intolerance or type 2 diabetes). Treatment for these problems includes diet and exercise. In some cases, medication(s) may be prescribed.
• prevention of blood clots with antiplatelet medication, such as aspirin or other medications
• medications such as pentoxifylline or cilostazol, that may improve walking distances in some cases
• diet low in saturated fats

For advanced cases in which pain is severe and/or blood flow has been completely or almost completely blocked, an invasive procedure such as angioplasty (a catheter is used to create a larger opening in the vessel to increase blood flow), stent placement (a tiny coil is expanded inside the blocked artery to open the blocked area and is left in place to keep the artery open), or surgery may be needed to open the blocked artery.

In a small percentage of cases where all other treatments have not been effective, amputation of the affected limb may be necessary. Patients who smoke or who have diabetes are at increased risk for poor outcomes in treating claudication.

Prevention of claudication:

Because many persons who have claudication also have atherosclerotic disease such as peripheral arterial disease, coronary artery disease, and/or blockages of the carotid artery (carotid stenosis), aggressively modifying risk factors for atherosclerosis can help prevent claudication.

A prevention plan for claudication may also be used to prevent or lessen the progress of PAD associated with claudication once it has been diagnosed. Consult your physician for diagnosis and treatment.

Preventative measures may include:

• treating high blood pressure
• lowering low-density lipoprotein (LDL) as directed by your physician
• lowering triglycerides (fats in the blood)
• raising high-density lipoproteins (HDL) as directed by your physician
• maintaining normal weight
• increasing physical activity, especially walking 

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