Is your leg pain actually PAD? Watch for these warning signs

Sometimes, aches and pains get dismissed as a normal part of getting older. In the case of peripheral artery disease, or PAD, those pains can be signs of a serious problem.

But while the consequences of PAD can be as severe as amputation, “it’s definitely underdiagnosed,” said Dr. Aaron Aday, a vascular medicine specialist and cardiologist at Vanderbilt University Medical Center in Nashville, Tennessee. An estimated 7 to 12 million people in the U.S. may have PAD, but that figure considers only symptomatic patients, according to a 2023 American Heart Association scientific statement.

Aday, who was lead writer on an article about the epidemiology of PAD that was published in the American Heart Association journal Circulation Research in 2021, said that medical professionals and patients alike need to be aware of what PAD feels like – and what to do about it.

What is PAD?

PAD (pronounced P-A-D) is the result of atherosclerosis – plaque that forms in arteries and blocks blood flow.

If blood flow is cut off to the heart, the result is a heart attack. In the brain, it’s a stroke. When blood flow is restricted to the legs or, less often, the arms, the result is PAD.

PAD shares many risk factors, such as high blood pressure, with the atherosclerosis that causes those problems. But while data specific to PAD is limited, Aday said, some distinctions have been found.

“The two overwhelmingly dominant risk factors for PAD are smoking and diabetes,” Aday said. “And smoking in particular, for reasons we don’t fully understand, seems to be a stronger risk factor for PAD than for other types of atherosclerosis.”

Other evidence suggests that plaque in the leg arteries differs from that in other arteries. It can be a little more calcified, Aday said, “and perhaps there’s more blood clotting involved than we necessarily see for atherosclerosis in other areas.”

What does PAD feel like?

Many people with PAD display no symptoms.

The classic symptom, Aday said, is leg pain that comes on while walking and is relieved with a little rest.

This pain is also described as cramping, aching, burning, heaviness or tightness in leg muscles that begins after exercising or while going uphill or climbing stairs.

The location of the pain is related to where blood flow is blocked, Aday said. It’s typically in the thigh, calf or buttocks.

One of the issues that makes PAD hard to diagnose, Aday said, is that patients sometimes mask their pain. “They may actually be subconsciously walking less and being more sedentary as a way to compensate.”

PAD is progressive, which means a problem might build quietly over time before a sudden new pain develops, Aday said.

Other symptoms can include leg or foot wounds that are slow to heal; discolored skin; or nails that grow slowly. “In severe cases,” Aday said, “there can be such poor blood flow that you can get ulcers or gangrene in your legs.”

But even those patients who don’t notice symptoms, Aday said, “are at a higher risk of bad things happening – heart attack, stroke, needing a procedure on their legs, or even an amputation.”

Who is at risk?

Age is a factor. “The older you are, the higher the risk you are of having it,” Aday said. And while some data conflict, “we think that overall men are at higher risk than women.”

Lifetime estimates of risk suggest that 30% of Black people and 20% of non-Hispanic white people will develop PAD. The risk of related amputations varies by geography, as shown in an interactive map posted by the American Heart Association, one of more than 25 organizations in a collaborative committed to advancing a PAD National Action Plan.

There’s no clear medical or biological explanation for the discrepancy, said Aday, an Association volunteer who is chair of the PAD Collaborative’s Population Health and Advocacy Committee.

What can someone do if they have symptoms of PAD?

“They should talk to their doctor, and they should have a thorough history and physical exam,” Aday said.

The “first-line test” in patients with suspected PAD is called the ankle-brachial index, Aday said. Basically, blood pressure is measured in a patient’s arms and legs, and the physician looks for a discrepancy when the readings are compared.

That might lead to more advanced tests, such as a duplex ultrasound, computed tomographic angiography (cta), magnetic resonance angiography (MRA), or invasive angiography to evaluate the arteries.

If tests reveal a blocked artery, it might be treated by procedures to improve blood flow, such as opening the clog with angioplasty, inserting a stent or routing around the blockage with bypass surgery.

If PAD isn’t treated, it can lead to a vicious cycle, Aday said, where pain leads people to become less active, which leads to them being more sedentary, which leads to more problems.

What can be done to prevent PAD?

Lifestyle changes are a part of treatment for people diagnosed with the disease.

“Yes, we want them to have a heart-healthy diet,” Aday said. “Beyond just exercise, we’re often prescribing formal exercise programs done at a medical facility to boost their walking function.”

Medications that prevent blood clots and reduce cholesterol also can be important parts of treatment, Aday said. So is managing conditions such as high blood pressure and diabetes.

Why do doctors and patients need to talk about PAD?

One of the reasons PAD is underdiagnosed, Aday said, is a general lack of awareness. “That’s a huge factor.”

Medical professionals, he said, should have “a high index of suspicion for patients who are coming and talking about leg symptoms.” But he acknowledged obstacles to making a diagnosis – even a simple check of blood pressure in the ankles takes time, which is at a premium during busy visits. And advanced screening tests aren’t always covered by insurance.

On the patient side, Aday said people need to understand that leg pain or needing to spend more time sitting isn’t always just part of aging.

“It’s always important for patients to advocate for their own health, and patients are the experts at their own body,” Aday said. So if they notice something is different about their legs, their health care team should be able to tell them, “Is this because you have some joint wear and tear? Is this because of muscle weakness? There needs to be a further explanation than just, ‘Well you’re getting older.’”

To learn more about peripheral artery disease, including patient support and resources, visit the American Heart Association’s PAD page.