Claudication

Contributors

  • Rohan Pinto

Claudication

Introduction

Claudication is pain that can be arterial, neurogenic or venous in aetiology. Arterial (intermittent) claudication is the most common of these. Intermittent claudication in the lower limb is very common in Peripheral Vascular Disease. The pain is associated with walking and is caused by atherosclerotic plaques, which can occlude the femoral artery to cause calf pain or the illiac arteries to cause thigh and buttock pain. Neurogenic claudication is normally caused by lumbar spinal stenosis causing leg pain due to compression of the spinal cord. Venous claudication is caused by venous outflow obstruction due to a Deep Vein Thrombosis.

Pathophysiology of Peripheral Vascular Disease

History

 

Presenting Complaint 

  • Leg Pain

 

History of Presenting Complaint

  • Use SOCRATES to elicit an accurate pain history
  • Find out how far they used to be able to walk and how far they can walk now before symptom onset
  • Ask questions such as "can you walk from your car to the hospital without stopping?" or "can you do your own grocery shopping?"
  • Find out if there is anything the patient can no longer do due to symptoms
  • Enquire about risk factors for atheroma such as smoking, hypercholesterolaemia, hypertension and diabetes mellitus
  • Ask specifically about osteoarthritis of the hip, angina or severe breathlessness to prevent vascular surgery, which will not improve the patient quality of life anyway
  • In buttock claudication in males, ask about erectile dysfunction

 

Past Medical History

  • Previous MI, stroke or TIA

 

Past Surgical History

  •  Previous Cardiothoracic Surgery
  • Previous Vascular Surgery

 

Medication History

  • Document all current medication
  • Ask about anti-coagulants pre-op
  • Ask about beta-blockers as these can precipitate claudication

 

Family History

  • Diabetes
  • Hypertension
  • Ischemic Heart Disease
  • Premature arterial disease 

 

Social History

  • Diet
  • Support at home post-op

 

    Examination of the Peripheral Vascular System

     

    In the general examination, look for signs of anaemia, cyanosis, heart failure and vascular disease. After the general examination, perform an examination of the peripheral pulses, which should be noted as normal, reduced or absent

     

    The Arms

    • Examine the radial, brachial and carotid pulses
    • Measure blood pressure in both arms

     

    Abdomen

    • Inspect for pulsation
    • Palpate and auscultate over abdominal aorta for a AAA

     

    Legs

    • Inspect and palpate for ischaemic changes (5Ps - Pale, Pulseless, Painful, Paralysed, Parasthetic and Perishing with cold) especially in between the toes
    • Inspect for surgical or non-surgical scars 
    • Note any ulceration 

     

    Lower Limb Pulses

    • Femoral pulse
    • Popliteal pulse
    • Posterior tibial pulse
    • Dorsalis pedis pulse
    • Buerger's Test

     

      Buerger's Test

      Buerger's Angle

      • The angle at which the patient's foot becomes pale
      • With patient supine, raise one leg 90 degrees to the bed
      • Normal leg - Toes stay pink
      • Ischaemic leg - Pallor is seen at 30 degrees or less when held for 60 seconds maximum. 

       

       

      Sunset Foot

      • After the establishing buerger's angle, hang the patients foot off the side of the bed
      • Foot will revert to normal pink colour and then to a more red colour as the arterioles dilate to remove metabolic waste

      Clinical Spectrum

      Investigations

      Intermittent Claudication 

      • FBC and ESR - Anemia 
      • U&E - Renal Function 
      • Blood Glucose - Diabetes
      • Serology - Connective Tissue disease 
      • Doppler Ultrasound - Assess blood flow through arteries
      • Angiography - Visualise the lumen of blood vessels

       

      Venous Claudication

      • FBC - platelet count prior to anti-coagulation therapy
      • U&E - Assess renal function 
      • D-dimer - Only useful if test is negative to indicate that a patient does not have a DVT
      • Doppler Ultrasound (Gold Standard) - Assess blood flow through veins

       

       

      References

      National Heart, Lung, and Blood Institute, USA.