Leg pain when walking: what is intermittent claudication
Pain or cramp in the calf that appears consistently while walking and subsides with a little rest is not simple tiredness or ageing. Very often it is the first, discreet sign that the arteries of the legs have begun to narrow.
Many people put it down to age: after walking a certain distance, the calf starts to hurt or to "tighten", forcing them to stop, and within one to two minutes of rest the pain passes. What is characteristic is that the pattern repeats: the pain appears at almost the same distance and goes away in almost the same way. This pattern has a name, intermittent claudication, and it is the classic symptom of a condition that progresses silently: peripheral arterial disease.
Theodosios Bisdas, Associate Professor of Vascular Surgery and Director of the 3rd Vascular Surgery Department of the Athens Medical Center, specialises in the diagnosis and in the minimally invasive, endovascular treatment of peripheral arterial disease and intermittent claudication.
Do your legs hurt when you walk?
A simple, painless examination by a vascular surgeon can show immediately whether the arteries are responsible. Do not put the pain down to age before the blood supply to your legs has been checked.
What is intermittent claudication?
Intermittent claudication is the pain, cramp or sensation of fatigue in the leg muscles that appears while walking and subsides with rest, usually within less than ten minutes. It is not a disease in itself but a symptom: it shows that the muscles, while you walk, are asking for more blood and oxygen, but the narrowed arteries cannot supply it in time. The word "intermittent" describes exactly this cycle: the pain comes with effort and disappears with rest.
Why do legs hurt when walking?
When you walk, the leg muscles work intensively and need several times more blood than at rest. In a healthy leg, the arteries cover this demand comfortably. When an artery has narrowed because of atherosclerotic plaque (the gradual build-up of fat and cholesterol in the vessel wall, that is, atherosclerosis), the flow is not enough during exertion. The muscles then work with an oxygen deficit and this translates into pain or cramp. As soon as you stop, demand falls, the available flow again covers the needs and the pain subsides. That is precisely why the pain is so predictable.
Where does the pain appear and what does its location indicate?
The pain is most often located in the calf, because narrowings in the superficial femoral artery are the most common. Depending on the level of the occlusion, however, it can also appear higher up: pain in the buttock or hip points to a narrowing higher up, at the level of the aorta and the iliac arteries, while pain in the thigh is related to the femoral region. As a general rule, the narrowing is one level higher than where you feel the pain. Two further features are characteristic: the pain comes on at a relatively constant distance and worsens uphill or at a fast pace, that is, when demand increases.
Is it always a sign of peripheral arterial disease?
Intermittent claudication is the classic symptom of peripheral arterial disease, but it is neither the only way the disease presents nor the most common. According to the international literature, only about 10% of patients with peripheral arterial disease show "classic" claudication. A large proportion have atypical complaints and about 40% have no symptoms at all in the early stages. This is why the condition often remains underdiagnosed.
At the same time, not every pain on walking is due to the arteries. Leg pain can also come from the lumbar spine (neurogenic claudication) or, more rarely, from conditions such as popliteal artery entrapment. That is why distinguishing between them requires examination by a specialist. Who is most at risk also matters: smoking, diabetes mellitus, age, hypertension, high cholesterol and family history are the main risk factors.
When should you be concerned?
Some signs should never be ignored, because they show that the blood supply has become critically inadequate (critical ischaemia). These are: pain in the leg even at rest, particularly at night, which is relieved when you hang the leg out of bed; wounds or ulcers that do not heal; and a cold, pale or blue toe. If these appear, immediate assessment by a vascular surgeon is needed, because without restoration of flow there is a real risk of progression to gangrene and amputation.
It is also important to remember that atherosclerosis in the legs is the same process as in the heart and the brain, so intermittent claudication also signals an increased risk of heart attack and stroke.
How is the diagnosis made?
The investigation starts from the history and a simple clinical examination, in which the doctor palpates the pulses in the legs. The most useful first tool is the ankle-brachial index (ABI), a painless measurement that compares the pressure at the ankle with the pressure in the arm. A value below 0.9 indicates arterial disease in the lower limbs. This is usually followed by colour duplex ultrasound of the arteries, which shows where and how much the vessels have narrowed. When a procedure is being planned, more detailed imaging with CT or MR angiography may be needed, or, more rarely, digital angiography.
Treatment and prevention
The basis of treatment, especially in the early stages, is not surgery but the control of the causes and exercise. Stopping smoking is the most decisive measure. At the same time, diabetes, blood pressure and cholesterol are brought under control. A structured walking programme helps significantly: although it sounds paradoxical, regular, controlled walking (typically in cycles of walking, resting and walking again, on most days of the week) trains the leg to develop collateral circulation and increases the pain-free distance. The doctor may also prescribe medication, such as antiplatelets and statins that protect the vessels, while in selected cases there are also drugs that specifically improve walking distance.
When the pain seriously limits daily life, or when there are signs of critical ischaemia, interventional solutions that restore flow are considered. Today most narrowings are treated endovascularly, that is in a minimally invasive way, with balloon angioplasty, stent placement or endoluminal removal of the atherosclerotic plaque (atherectomy). In certain cases surgical bypass is chosen. The choice is made individually, on the basis of the position and extent of the lesion.
Frequently asked questions
My legs hurt when I walk. Could it be the arteries?
Possibly, but not always. Pain on walking that subsides with rest is suspicious for arterial disease, but it can also be due to a problem in the spine. A visit to the vascular surgeon, with clinical examination and duplex ultrasound, usually answers the question easily.
Which tests are needed for intermittent claudication?
First the clinical examination and palpation of the pulses, then the ankle-brachial index (ABI) and colour duplex ultrasound of the arteries. If a procedure needs to be planned, CT, MR or digital angiography follows.
Do exercise and walking help?
Yes, and they are in fact a fundamental part of treatment in the early stages. An organised walking programme, ideally supervised, gradually increases the distance you can cover without pain, combined with stopping smoking and controlling the risk factors.
Are there medicines or vitamins for intermittent claudication?
There are medicines with proven benefit, such as antiplatelets and statins, as well as specific preparations that improve walking distance, always on prescription. There is, however, no vitamin or supplement that cures the condition. Treatment is determined by the doctor.
What is neurogenic intermittent claudication?
This is pain in the legs on walking that is not caused by the arteries but by pressure on the nerves in the lumbar spine (for example spinal canal stenosis). It is often relieved when you bend forward or sit down, unlike vascular claudication, which subsides simply by standing still. In addition, this type of condition causes symptoms when lying down or immediately on getting out of bed, as a sensation of pins and needles (numbness) in the leg and foot.
When does intermittent claudication become an emergency?
When pain appears in the leg at rest (particularly at night), a wound that does not heal, or a cold, pale or blue limb. These are signs of critical ischaemia and require immediate assessment by a vascular surgeon.
Where to turn
If you experience pain in the legs while walking or any of the signs described above, an examination by a vascular surgeon can quickly show whether the arteries are responsible. Associate Professor Dr. Theodosios Bisdas (MD, PhD, FACS), Director of the 3rd Vascular Surgery Department of the Athens Medical Center and Associate Professor of Vascular Surgery at the University Clinic of Munster, specialises in the minimally invasive, endovascular treatment of peripheral arterial disease.
Sources
- Mayo Clinic – Claudication (symptoms & causes): mayoclinic.org
- Mayo Clinic – Claudication (diagnosis & treatment): mayoclinic.org
- Cleveland Clinic – Intermittent Claudication: clevelandclinic.org
- British Heart Foundation – Intermittent claudication: bhf.org.uk
- StatPearls / NIH – Intermittent Claudication: ncbi.nlm.nih.gov
This article is for information only and does not replace individual medical assessment. If you experience pain in the legs while walking or any of the signs above, consult a vascular surgeon.
