To Walk or To Limp: Time to Check

Posted on Jun 26, 2017

Clinicians encounter at least once in their practice, patients complaining of leg pain classically attributed to peripheral arterial disease (PAD). More often than not, patients with this condition may be totally asymptomatic or may simply be ignoring their symptoms until such time when the discomfort is already unbearable.


In my clinic, a 60-year-old male who was a smoker, hypertensive, diabetic and dyslipidemic (elevated cholesterol levels) sought consult due to recurrent leg pain when walking, and relieved with rest. He initially attributed his symptoms to aging or simply arthritis or muscle aches. Until recently, he also noticed that there was progression of the pain with reduced walking distance (leg pain felt on walking less than 200 meters). This is a typical example of “claudicant legs.”


Claudication, derived from the Latin word claudicare meaning “to limp,” is the classic symptom of PAD – a condition due to narrowing or blockage of blood vessels in the limb. Patients may also experience leg numbness, pallor, cold-to-touch extremities, poor nail or hair growth in the legs or, worse, presence of non-healing wounds. Once the vessels become narrowed, reduction in blood flow ensues, diminishing tissue perfusion and if completely occluded, can cause severe damage leading to gangrene formation necessitating amputation.


The most common cause of PAD is atherosclerosis, which refers to the buildup of cholesterol plaques in the walls of the arteries of the extremities, more often involving the legs.  Most patients with PAD have concomitant coronary artery disease (CAD) and/or cerebrovascular disease (CVD). The major risk factors for PAD include advanced age, smoking and comorbid conditions such as hypertension, diabetes mellitus and dyslipidemia. PAD may also occur in less than 50-year-old patients with diabetes and at least one additional risk factor. It is important to seek consult, for proper evaluation, if a patient already has the aforementioned risk factors, more so if with symptoms suggestive of PAD.


Diagnosis of PAD is based on history and physical examination, and confirmed with imaging studies. PAD screening includes ankle brachial index (ABI), a simple and readily available test. ABI compares your ankle blood pressure to that in your arms. Suspected PAD patients with an abnormal ABI screening are referred to vascular specialists for further evaluation and management. At St. Luke’s Medical Center, available diagnostic modalities include arterial duplex ultrasound, a noninvasive imaging study to visualize the arteries and blood flow, with segmental pressure measurements and toe-brachial indices. Noninvasive angiographic procedures include computed tomographic (CT) and magnetic resonance angiography (MRA), which can provide better image definition of the vascular anatomy to localize and determine severity of PAD.  For patients contemplated for revascularization, peripheral angiography is likewise available for preoperative evaluation.


Treatment of PAD would depend on the severity of the disease. Mild to moderate PAD cases require conservative medical measures to address major comorbid conditions or risk factors. In addition, essential lifestyle changes such as smoking cessation, proper diet and exercise should be instituted. Severe cases of PAD or those with critical limb disease may require specialized procedures such as angioplasty and/ or stenting or peripheral bypass surgery, aimed at improving blood circulation and symptomatic relief.


As an adjunct to the management of patients with severe PAD who are not candidates for peripheral intervention or surgical bypass procedure, the arterial assist device can be offered. It is an external compression device that massages the foot, ankle and calf with the purpose of opening collateral channels, improving blood flow and thereby, alleviating symptoms. This is under the guidance and recommendation of vascular specialists.  The ART Assist Package is available at the Section of Vascular Medicine, St. Luke’s Medical Center-Quezon City. Vascular rehabilitation with supervised treadmill exercise test for PAD patients to improve the functional capacity and increase pain free walking distance, is accessible at both St. Luke’s Medical Center Heart Institute Global City and Quezon City.


Given all these diagnostic and treatment modalities, early detection and treatment of risk factors can help maintain a good leg circulation. Patients should bear in mind that “claudicant legs” should not be ignored.  To walk or to limp? Time to have yourself checked for PAD.


In line with one of the advocacies of the Philippine Society of Vascular Medicine (PSVM) on intensifying public awareness on PAD #WalkToCirculate, the Section of Vascular Medicine of St. Luke’s Medical Center-Global City Heart Institute will be conducting a PAD lay forum which aims to educate and raise awareness of patients about this disease, especially those who are at risk of it. It will be held on July 20, 2017, from 8:00 AM - 5:00 PM at Conference Rooms 1& 2 of St. Luke’s Medical Center-Global City. There will free ankle brachial index (ABI) testing for participants from 1:00 PM - 3:00 PM. This is in commemoration of PAD Awareness Day which is held every third Sunday of July as declared through Presidential Proclamation No. 1321. For inquiries, you may contact the St. Luke’s Vascular Laboratory at Tel. no. 7897700 ext. 2001.




Dr. Marilou T. de Jesus earned her medical degree at Far Eastern University Nicanor Reyes Medical Foundation and had her cardiology and vascular research fellowship training at St. Luke’s Dr. HB Calleja Heart and Vascular Institute, Quezon City.  She is currently the Head of the Vascular Division of St. Luke’s-Global City Heart Institute and Section Head of Thrombosis at St. Luke’s-Quezon City Heart Institute. She is also one of the Board of Directors of the Philippine Society of Vascular Medicine and Chapter President of the Philippine College of Physicians, Rizal.