Intermittent claudication, also known as vascular claudication, is a symptom that describes muscle pain on mild exertion (ache, cramp, numbness or sense of fatigue), classically in the

calf muscle The triceps surae consists of two muscles located at the calf – the two-headed gastrocnemius and the soleus. These muscles both insert into the calcaneus, the bone of the heel of the human foot, and form the major part of the muscle of the ...

, which occurs during exercise, such as walking, and is relieved by a short period of rest. It is classically associated with early-stage

peripheral artery disease Peripheral artery disease (PAD) is an abnormal narrowing of arteries other than those that supply the heart or brain. When narrowing occurs in the heart, it is called coronary artery disease, and in the brain, it is called cerebrovascular dis ...

, and can progress to critical limb ischemia unless treated or

risk factors In epidemiology, a risk factor or determinant is a variable associated with an increased risk of disease or infection. Due to a lack of harmonization across disciplines, determinant, in its more widely accepted scientific meaning, is often use ...

are modified and maintained. Claudication derives from the Latin verb ''claudicare'', "to limp".

Signs and symptoms

One of the hallmarks of arterial claudication is that it occurs intermittently. It disappears after a very brief rest and the patient can start walking again until the pain recurs. The following signs are general signs of atherosclerosis of the lower extremity arteries: * cyanosis * atrophic changes like loss of hair, shiny skin * decreased

temperature Temperature is a physical quantity that expresses quantitatively the perceptions of hotness and coldness. Temperature is measurement, measured with a thermometer. Thermometers are calibrated in various Conversion of units of temperature, temp ...

* decreased

pulse In medicine, a pulse represents the tactile arterial palpation of the cardiac cycle (heartbeat) by trained fingertips. The pulse may be palpated in any place that allows an artery to be compressed near the surface of the body, such as at the n ...

* redness when limb is returned to a "dependent" position (part of Buerger's test) The six "P"s of ischemia * Pain * Pallor (increased) * Pulse (decreased) * Perishing cold * Paraesthesia * Paralysis

Causes

Most commonly, intermittent (or vascular or arterial) claudication is due to

peripheral arterial disease Peripheral artery disease (PAD) is an abnormal narrowing of arteries other than those that supply the heart or brain. When narrowing occurs in the heart, it is called coronary artery disease, and in the brain, it is called cerebrovascular disea ...

which implies significant atherosclerotic blockages resulting in arterial insufficiency. Other uncommon causes are

coarctation of the aorta Coarctation of the aorta (CoA or CoAo), also called aortic narrowing, is a congenital condition whereby the aorta is narrow, usually in the area where the ductus arteriosus (ligamentum arteriosum after regression) inserts. The word ''coarctation' ...

, Trousseau disease and Beurger's disease (

Thromboangiitis obliterans Thromboangiitis obliterans, also known as Buerger disease (English ; ) or Winiwarter-Buerger disease, is a recurring progressive inflammation and thrombosis (clotting) of small and medium arteries and veins of the hands and feet. It is strongly a ...

), in which vasculitis occurs.

Raynaud's phenomenon Raynaud syndrome, also known as Raynaud's phenomenon, eponymously named after the physician Auguste Gabriel Maurice Raynaud, who first described it in his doctoral thesis in 1862, is a medical condition in which the spasm of small arteries cau ...

functional vasospasm. It is distinct from

neurogenic claudication Neurogenic claudication (NC), also known as pseudoclaudication, is the most common symptom of lumbar spinal stenosis (LSS) and describes intermittent leg pain from impingement of the nerves emanating from the spinal cord. ''Neurogenic'' means that ...

, which is associated with

lumbar spinal stenosis Lumbar spinal stenosis (LSS) is a medical condition in which the spinal canal narrows and compresses the nerves and blood vessels at the level of the lumbar vertebrae. Spinal stenosis may also affect the cervical or thoracic region, in which case ...

. It is strongly associated with smoking, hypertension, and diabetes.

Diagnosis

Intermittent claudication is a symptom and is by definition diagnosed by a patient reporting a history of leg pain with walking relieved by rest. However, as other conditions such as

sciatica Sciatica is pain going down the leg from the lower back. This pain may go down the back, outside, or front of the leg. Onset is often sudden following activities like heavy lifting, though gradual onset may also occur. The pain is often described ...

can mimic intermittent claudication, testing is often performed to confirm the diagnosis of

Magnetic resonance angiography Magnetic resonance angiography (MRA) is a group of techniques based on magnetic resonance imaging (MRI) to image blood vessels. Magnetic resonance angiography is used to generate images of arteries (and less commonly veins) in order to evaluate ...

and

duplex ultrasonography Doppler ultrasonography is medical ultrasonography that employs the Doppler effect to perform imaging of the movement of tissues and body fluids (usually blood), and their relative velocity to the probe. By calculating the frequency shift of a ...

appear to be slightly more cost-effective in diagnosing

among people with intermittent claudication than projectional

angiography Angiography or arteriography is a medical imaging technique used to visualize the inside, or lumen, of blood vessels and organs of the body, with particular interest in the arteries, veins, and the heart chambers. Modern angiography is perfor ...

Treatment

Exercise can improve symptoms, as can

revascularization In medical and surgical therapy, revascularization is the restoration of perfusion to a body part or organ that has had ischemia. It is typically accomplished by surgical means. Vascular bypass and angioplasty are the two primary means of rev ...

. Both together may be better than one intervention of its own. In people with stable leg pain, exercise, such as

strength training Strength training or resistance training involves the performance of physical exercises that are designed to improve strength and endurance. It is often associated with the lifting of weights. It can also incorporate a variety of training te ...

, polestriding and upper or lower limb exercises, compared to usual care or placebo improves maximum walking time, pain-free walking distance and maximum walking distance. Alternative exercise modes, such as

cycling Cycling, also, when on a two-wheeled bicycle, called bicycling or biking, is the use of cycles for transport, recreation, exercise or sport. People engaged in cycling are referred to as "cyclists", "bicyclists", or "bikers". Apart from t ...

and upper-arm ergometry compared to supervised walking programmes showed no difference in maximum walking distance or pain-free walking distance for people with intermittent claudication. Pharmacological options exist, as well. Medicines that control lipid profile,

diabetes Diabetes, also known as diabetes mellitus, is a group of metabolic disorders characterized by a high blood sugar level ( hyperglycemia) over a prolonged period of time. Symptoms often include frequent urination, increased thirst and increased ...

, and hypertension may increase blood flow to the affected muscles and allow for increased activity levels.

Angiotensin converting enzyme Angiotensin-converting enzyme (), or ACE, is a central component of the renin–angiotensin system (RAS), which controls blood pressure by regulating the volume of fluids in the body. It converts the hormone angiotensin I to the active vasoconstr ...

inhibitors,

adrenergic agents Adrenergic means "working on adrenaline (epinephrine) or noradrenaline (norepinephrine)" (or on their receptors). When not further qualified, it is usually used in the sense of enhancing or mimicking the effects of epinephrine and norepinephrine in ...

such as alpha-1 blockers and beta-blockers and alpha-2 agonists, antiplatelet agents (

aspirin Aspirin, also known as acetylsalicylic acid (ASA), is a nonsteroidal anti-inflammatory drug (NSAID) used to reduce pain, fever, and/or inflammation, and as an antithrombotic. Specific inflammatory conditions which aspirin is used to treat inc ...

and clopidogrel), naftidrofuryl, pentoxifylline, and

cilostazol Cilostazol, sold under the brand name Pletal among others, is a medication used to help the symptoms of intermittent claudication in peripheral vascular disease. If no improvement is seen after 3 months, stopping the medication is reasonable. It ...

(selective PDE3 inhibitor) are used for the treatment of intermittent claudication. However, medications will not remove the blockages from the body. Instead, they simply improve blood flow to the affected area.

Catheter In medicine, a catheter (/ˈkæθətər/) is a thin tubing (material), tube made from medical grade materials serving a broad range of functions. Catheters are medical devices that can be inserted in the body to treat diseases or perform a surgi ...

-based intervention is also an option.

Atherectomy Atherectomy is a minimally invasive technique for removing atherosclerosis from blood vessels within the body. It is an alternative to angioplasty for the treatment of peripheral artery disease, but the studies that exist are not adequate to determ ...

stent In medicine, a stent is a metal or plastic tube inserted into the lumen of an anatomic vessel or duct to keep the passageway open, and stenting is the placement of a stent. A wide variety of stents are used for different purposes, from expandab ...

ing, and

angioplasty Angioplasty, is also known as balloon angioplasty and percutaneous transluminal angioplasty (PTA), is a minimally invasive endovascular procedure used to widen narrowed or obstructed arteries or veins, typically to treat arterial atheroscle ...

to remove or push aside the arterial blockages are the most common procedures for catheter-based intervention. These procedures can be performed by interventional radiologists, interventional cardiologists, vascular surgeons, and thoracic surgeons, among others. Surgery is the last resort;

vascular surgeon Vascular surgery is a surgical subspecialty in which diseases of the vascular system, or arteries, veins and lymphatic circulation, are managed by medical therapy, minimally-invasive catheter procedures and surgical reconstruction. The specialty ...

s can perform either endarterectomies on arterial blockages or perform an

arterial bypass Bypass surgery refers to a class of surgery involving rerouting a tubular body part. Types include: * Vascular bypass surgery such as coronary artery bypass surgery, a heart operation * Cardiopulmonary bypass, a technique used in coronary arte ...

. However,

open surgery Minimally invasive procedures (also known as minimally invasive surgeries) encompass surgical techniques that limit the size of incisions needed, thereby reducing wound healing time, associated pain, and risk of infection. Surgery by definiti ...

poses a host of risks not present with catheter-based interventions.

Epidemiology

Atherosclerosis affects up to 10% of the Western population older than 65 years and for intermittent claudication this number is around 5%. Intermittent claudication most commonly manifests in men older than 50 years. One in five of the middle-aged (65–75 years) population of the United Kingdom have evidence of peripheral arterial disease on clinical examination, although only a quarter of them have symptoms. The most common symptom is muscle pain in the lower limbs on exercise—intermittent claudication.

References

External links

Cochrane Peripheral Vascular Diseases Review Group
{{DEFAULTSORT:Intermittent Claudication Symptoms and signs: Vascular Vascular diseases Diseases of arteries, arterioles and capillaries