Peripheral Arterial Disease (PAD)

Poor circulation in the legs and feet

What is peripheral arterial disease?

Peripheral arterial disease (PAD) is a condition in which the arteries supplying blood to the legs and feet become narrowed or blocked.

The most common cause is atherosclerosis – a gradual build-up of fatty deposits within the walls of the arteries. As the arteries narrow, less oxygen-rich blood can reach the muscles and tissues of the legs and feet.

PAD is a form of cardiovascular disease. This means that identifying it is important not only for the health of your feet and legs, but also because people with PAD have an increased risk of heart attack and stroke.

What are the symptoms of PAD?

Some people with PAD have no obvious symptoms at all.

The most common symptom is intermittent claudication – an aching, cramping or painful sensation in the leg muscles which:

  • Develops when walking or exercising

  • Often occurs after a fairly predictable distance

  • May affect the calf, thigh or buttock

  • Improves after stopping and resting

  • Returns when walking resumes

PAD can affect one or both legs.

Other possible signs and symptoms include:

  • Feet that feel unusually cold

  • Numbness or weakness

  • Changes in skin colour

  • Shiny or thin-looking skin

  • Reduced hair growth on the feet and lower legs

  • Slow-growing or brittle toenails

  • Reduced muscle bulk in the legs

  • Wounds or ulcers which are slow to heal

  • Pain in the feet or legs while resting in more advanced disease

These features are not individually diagnostic of PAD. For example, hair loss and thickened toenails have many other causes. They need to be considered alongside your symptoms, medical history and vascular assessment.

Who is more at risk?

PAD becomes more common with increasing age.

Important risk factors include:

  • Smoking

  • Diabetes

  • High blood pressure

  • High cholesterol

  • Increasing age

  • Other cardiovascular disease

Smoking is a particularly important risk factor.

Having several risk factors does not mean that you definitely have PAD, and PAD can sometimes occur in people who do not appear to have the typical risk factors.

Is leg pain when walking just part of getting older?

No.

Recurring pain in the calf, thigh or buttock brought on by walking and relieved by rest should not simply be dismissed as ageing.

There are many possible causes of leg pain, including muscular, joint, nerve and spinal problems, but intermittent claudication is an important symptom of PAD and deserves assessment. The NHS recommends seeing your GP if you experience recurring leg pain during exercise.

How is PAD assessed?

Assessment involves more than simply feeling for a pulse in the foot.

A healthcare professional may consider:

  • Your symptoms and when they occur

  • Your medical and cardiovascular history

  • The appearance, temperature and condition of the legs and feet

  • Pulses within the legs and feet

  • Blood flow using a handheld Doppler

  • Ankle Brachial Pressure Index (ABPI)

NICE recommends ABPI as part of the assessment of suspected PAD.

What is an ABPI?

An Ankle Brachial Pressure Index compares the blood pressure measured at the ankle with the blood pressure measured at the arm.

You normally rest lying down before blood-pressure measurements are taken using a cuff and Doppler ultrasound.

The results from the ankle and arm are then compared. A reduced ankle pressure can indicate narrowing within the arteries supplying the lower limb.

Does a normal ABPI always mean the circulation is normal?

Not necessarily.

This is particularly important in people with diabetes. Arteries can sometimes become stiff or calcified, which may produce a normal or unusually high pressure reading despite arterial disease being present.

For this reason, NICE specifically states that PAD must not be excluded in someone with diabetes solely because their ABPI is normal or raised.

The result therefore needs to be interpreted alongside the rest of the vascular assessment.

Does having a pulse in my foot mean my circulation is fine?

Not necessarily.

Being able to feel a pulse is reassuring information, but it is only one part of a vascular examination.

The strength and character of pulses, Doppler findings, symptoms, skin changes and pressure measurements may all contribute to the overall picture.

This is particularly important when there is a non-healing wound, unexplained leg pain or symptoms that strongly suggest arterial disease.

Why does PAD matter to the feet?

Healthy skin and other tissues need an adequate blood supply to receive oxygen and nutrients.

When circulation is significantly reduced:

  • Small injuries may take longer to heal

  • Wounds can become difficult to heal

  • Infection may become more serious

  • Pressure damage may be less well tolerated

  • Severe arterial disease can threaten the viability of toes or the foot

This makes good preventative foot care particularly important for people with PAD.

Looking after your feet if you have poor circulation

Check your feet regularly and pay attention to small changes.

It is sensible to:

  • Wear well-fitting footwear

  • Avoid walking barefoot

  • Check inside shoes for anything that could cause injury

  • Moisturise dry skin, but not between the toes

  • Treat cuts and wounds promptly

  • Avoid attempting to cut out corns or callus yourself

  • Avoid over-the-counter corn plasters containing acids

  • Protect the feet from extremes of temperature

  • Seek professional advice if a wound is not healing normally

If your circulation is significantly reduced, even a seemingly minor injury deserves attention.

Can PAD be treated?

Yes.

PAD cannot always be completely reversed, but treatment can reduce symptoms, slow progression and importantly reduce the risk of heart attack and stroke.

Treatment may involve:

  • Stopping smoking

  • Regular exercise

  • Managing diabetes

  • Treating high blood pressure

  • Managing cholesterol

  • A healthy diet and weight management

  • Antiplatelet or other cardiovascular medication where indicated

  • Medication specifically for intermittent claudication in selected patients

Supervised exercise is an important first-line treatment for intermittent claudication and can improve walking ability and symptoms.

What if PAD is severe?

Where symptoms severely restrict everyday activities or the blood supply is significantly compromised, referral to a vascular specialist may be required.

Procedures to improve the blood supply can include:

Angioplasty – widening a narrowed artery, usually using a small balloon.

Bypass surgery – creating an alternative route for blood to travel around a severely narrowed or blocked artery.

The most appropriate treatment depends upon the location and severity of the disease and the person's overall health.

Pain at rest – an important warning sign

More severe PAD can reduce the blood supply so much that the tissues do not receive enough blood even while you are resting.

This can cause persistent burning or severe pain in the foot, particularly at night.

Some people find that hanging the leg over the side of the bed temporarily makes the pain feel better because gravity assists blood flow towards the foot.

Persistent rest pain, non-healing ulcers or tissue damage may indicate chronic limb-threatening ischaemia (also called critical limb ischaemia) and require urgent medical assessment.

When is poor circulation an emergency?

There is an important difference between PAD that develops gradually and a sudden loss of arterial blood supply.

Seek emergency medical attention if a leg or foot suddenly becomes:

  • Very painful

  • Cold

  • Pale, blue or unusually discoloured

  • Numb or tingling

  • Weak or difficult to move

A sudden blockage of an artery can cause acute limb ischaemia, which is a medical emergency because tissue can rapidly become permanently damaged.

Do not wait for a routine podiatry or GP appointment if a foot suddenly becomes cold, painful, pale or numb.

PAD and compression stockings

Compression can be extremely useful for certain venous conditions and swelling, but arterial circulation must be considered before significant compression is applied.

NICE specifically recommends assessing for PAD in people who need to use compression hosiery.

This is one reason why compression stockings should not simply be purchased and worn for unexplained leg swelling without first establishing whether they are appropriate.

Peripheral arterial disease and your podiatry assessment

At Blackfords Footcare, the circulation of the feet and lower limbs forms an important part of podiatric assessment.

Depending upon your symptoms and clinical findings, vascular assessment may include examination of the skin and temperature of the feet, palpation of pulses, Doppler assessment of arterial blood flow and, where clinically appropriate, an Ankle Brachial Pressure Index (ABPI).

Where findings suggest possible peripheral arterial disease, we can explain what has been identified and recommend appropriate onward investigation or medical assessment.

Podiatric care is also particularly valuable for people with established PAD because seemingly minor problems such as pressure, corns, callus, nail trauma or breaks in the skin may carry greater consequences when healing capacity is reduced.

A wound that is failing to heal, new persistent rest pain or a significant change in the colour or temperature of a foot should not be left until your next routine appointment.