Intermittent claudication is cramping limb pain—most commonly in the legs—brought on by exercise and relieved within 1–2 minutes of rest. Pain may be acute or chronic. Acute pain may indicate arterial occlusion. Chronic intermittent claudication is most prevalent in men aged 50–60 with risk factors such as diabetes mellitus, hyperlipidemia, hypertension, or tobacco use. Without treatment, pain may progress to rest; however, limb loss is uncommon in chronic arterial occlusion due to collateral circulation development.

Pain is caused by inadequate blood supply in occlusive artery disease. Calf or foot pain typically indicates femoral or popliteal artery disease, whereas buttock and upper thigh pain indicates aortoiliac disease. During exercise, anaerobic metabolism in ischemic muscles produces lactic acid, causing pain; rest clears lactic acid and relieves pain. Neurogenic causes (narrowing of the vertebral column at the cauda equina) may also produce similar pain, which worsens with walking.

Physical findings

• Pallor on elevation

• Rubor on dependency (toes and soles)

• Loss of hair on toes

• Diminished arterial pulses

Emergency interventions

• Sudden claudication with severe or aching leg pain at rest may signal acute arterial occlusion.

• Examine leg temperature, color, pulses (femoral, popliteal, posterior tibial, dorsalis pedis), numbness, and tingling.

• Suspect occlusion if pulses are absent, leg is cold, pale, cyanotic, or mottled, and paresthesia/pain is present.

• Mark and frequently reassess affected areas.

• Do not elevate the leg; protect it from pressure.

• Prepare for preoperative blood tests, urinalysis, ECG, chest X-ray, Doppler studies, and angiography.

• Start IV line, administer anticoagulants and analgesics.

History and Physical Examination

• Assess walking distance before pain onset and rest duration for relief.

• Evaluate risk factors for atherosclerosis: smoking, diabetes, hypertension, hyperlipidemia.

• Ask about associated symptoms: paresthesia, color changes with cold, stress, or smoking; male impotence.

• Cardiovascular examination: palpate femoral, popliteal, dorsalis pedis, posterior tibial pulses; assess character, amplitude, and symmetry.

• Diminished/absent pulses suggest arterial disease location:

  • Absent popliteal/pedal pulses, femoral pulse present → femoral artery disease

  • Diminished femoral/distal pulses → terminal aorta/iliac branches

  • Absent pedal pulses, normal femoral/popliteal pulses → Buerger’s disease

• Auscultate for bruits over major arteries.

• Assess leg color and temperature, elevation pallor, time for color return when dependent.

• Check DTRs after exercise; examine feet, toes, and fingers for ulceration, nodules, erythema, nail quality, and hair.

• Inspect arms if symptomatic; palpate radial, ulnar, brachial, axillary, subclavian pulses.

Medical causes

Special considerations

• Encourage exercise to improve collateral circulation and venous return.

• Advise avoiding prolonged sitting, standing, or leg crossing.

• Diagnostic tests (Doppler flow studies, arteriography, digital subtraction angiography) may be required to assess occlusion location and severity.

Patient counseling

• Discuss risk factors: smoking, diabetes, hypertension, hyperlipidemia.

• Stress importance of inspecting legs and feet for ulcers.

• Teach protection of extremities from injury and environmental exposure.

• Educate on signs/symptoms that require urgent medical attention.

Pediatric pointers

• Rare in children; may occur with aortic coarctation, but collateral circulation usually prevents symptoms.

• Exercise-related muscle cramps or growing pains may mimic claudication.

References

1. Deeks, S. G. (2011). HIV infection, inflammation, immunosenescence, and aging. Annual Review of Medicine, 62, 141–155.

2. Mangili, A., Polak, J. F., Quach, L. A., Gerrior, J., & Wanke, C. A. (2011). Markers of atherosclerosis and inflammation and mortality in patients with HIV infection. Atherosclerosis, 214, 468–473.