All women with symptoms of PAD in the legs should have an examination and tests to diagnose PAD. The earlier you are diagnosed, the better your chances of avoiding serious complications of PAD including amputation, heart attack, and stroke. Prompt treatment can also slow the progression of the disease, relieve any symptoms you have, and prevent your symptoms from getting worse. Be sure you know how to recognize the symptoms of PAD and call your doctor immediately if you notice them. Common symptoms of PAD in the legs include:
- Cramping, aching, numbness, tiredness, or weakness in the buttock, thigh, calf, or foot that occurs when walking and goes away when you rest
- Skin wounds or ulcers on your legs or feet that heal slowly or not at all
- A feeling that the hip is “giving out” during walking
Even if you do not have any symptoms, women at high risk for PAD because they have characteristics and conditions that make them more likely to develop the disease (called risk factors) may benefit from screening to detect PAD early. See PAD screening to learn who should have a screening test to detect PAD, and to find a screening location near you.
A diagnostic evaluation for PAD consists of three main steps:
- A physical examination and medical history
- Functional blood flow tests to measure how much blood is flowing in your legs
- Imaging tests that produce detailed pictures of your leg arteries and blood flow through them
Medical History & Physical Examination
The first step in diagnosing PAD is a comprehensive medical history and physical examination.
A medical history includes a complete review of any medical conditions you have (especially PAD risk factors), surgeries and other procedures you’ve had in the past, and any medications you are taking (including prescription drugs, over-the-counter medications, and dietary supplements).
The medical history will also include a review of your PAD symptoms: when they started, what they feel like, how often you have them, and how much they limit your normal activities. Questions you may be asked include:1,2
- Do you have any pain or discomfort in your legs? How severe is it?
- What does the pain feel like and where is it located?
- Is the pain in your left or right leg, or both?
- When does the pain happen? Does it occur only during exercise, or while you are sitting or standing still?
- Does it occur when you are walking at a normal pace on level ground, or only when walking uphill, up stairs, or in a hurry?
- What is the longest distance you can walk without stopping to rest?
- How many flights of stairs can you climb without stopping to rest?
- After you rest, how long does it take the pain to go away?
- Does the pain go away or get worse when you are in certain positions (standing up or lying down)?
Next, your doctor will perform a physical examination to check for signs of PAD and other possible explanations for your symptoms. The exam may include:
- Measuring blood pressure in both arms, and noting if it is different between arms
- Checking the pulses in the femoral arteries in your groin, and listening with a stethoscope for a bruit (BROO-ee), a whooshing sound that may be caused by blood flow problems
- Checking your leg muscles for weakening or degeneration (atrophy)
- Feeling the pulses in your legs and feet (using the fingertips) to see if there is enough blood flowing
- Removing your shoes and socks to inspect the appearance of your legs and feet, including skin color and temperature
- Checking your legs and feet for slow or non-healing wounds
- Lifting your feet above your heart and looking to see if they become pale (a sign of decreased blood flow)
- Checking for other signs of PAD, such as hair loss on your legs, thickened nails, smooth and shiny skin, coolness, or paleness
You will also have blood tests to evaluate your general health and look for other conditions that could be causing your symptoms or affect the accuracy of diagnostic tests.
If your medical history and physical examination suggest your symptoms may be caused by PAD, you will have tests to examine the blood flow in your legs more closely.
The most commonly used test for diagnosing PAD is called the Ankle-Brachial Index, or ABI. This test uses blood pressure cuffs to compare the blood pressure in your ankles to that in your arms. If your ABI number is low (less blood flow in your legs than your arms), it is a sign that PAD is affecting your leg arteries.
In some women (particularly elderly women and women with longstanding diabetes or severe kidney disease), the ABI test may not produce an accurate result because of hardened arteries that cannot be closed off by the blood pressure cuff. These women may need further testing with a toe-brachial index, pulse volume recording, or ultrasound to diagnose PAD.
If your doctor still suspects PAD, even if your ABI is normal, you may have an exercise ABI test that examines how your arteries respond after exercise on a treadmill (when the leg muscles need more blood than usual). The exercise ABI also shows how much your PAD symptoms are affecting your walking ability. Women who are not able to exercise on a treadmill can have other tests that provide similar information, such as the toe-tip test or 6-minute walk test.
Other physiologic tests that may be used to provide information about blood flow in your legs and to narrow down the location of artery problems include segmental pressure measurement and pulse volume recording.
If the Ankle-Brachial Index and other initial tests indicate you have PAD, other imaging tests may be used to confirm the diagnosis, locate any narrowing or blockages, and help develop a treatment plan.3 These tests may also be used to get a closer look at the arteries when earlier tests did not provide enough information to diagnose PAD.
One commonly used initial imaging test to evaluate PAD is the duplex ultrasound, which combines normal ultrasound images of the arteries with measurement of the speed and direction of blood flow. A duplex ultrasound test can tell doctors how blood is flowing through your arteries, and determine the location and severity of any narrowing or blockages. It can also help with planning treatment.
The CT angiogram and MR angiogram are imaging tests that provide more detailed information than an ultrasound. However, because they take longer than an ultrasound test and involve a dye injection, they are mostly used in women who are considering a procedure to restore blood flow to arteries that have been narrowed by PAD, such as angioplasty and stents or lower extremity bypass surgery.
The contrast angiogram is the “gold standard” test for creating images of the arteries and blood flow though them. The contrast angiogram is the most accurate test for locating narrowed or blocked arteries and determining how PAD is affecting blood flow, but because it requires entering the body it is rarely used to diagnose PAD. Instead, it may be used when less-invasive imaging tests did not provide enough information to plan a procedure to restore blood flow.
PAD Testing Overview
What happens next?
If you have been diagnosed with PAD but do not have any symptoms, you will be started on a treatment plan that includes lifestyle changes and medications to control any PAD risk factors you have. Treatment of PAD in its early stages may slow the progression of the disease and even prevent symptoms altogether.
If you have been diagnosed with PAD that is causing symptoms, an exercise rehabilitation program and medication to treat leg pain can relieve your symptoms and improve your ability to exercise. Women with severe PAD may need to undergo a procedure to restore blood flow to narrowed or blocked arteries, such as angioplasty and stents or lower extremity bypass surgery.
To learn more about your treatment options for PAD, see our PAD Treatment Overview (coming soon). For tips on leading an active and fulfilling life after a diagnosis of PAD, see Living with PAD (coming soon).
References
- Leng GC, Fowkes FG. The Edinburgh Claudication Questionnaire: an improved version of the WHO/Rose Questionnaire for use in epidemiological surveys. J Clin Epidemiol. Oct 1992;45(10):1101-1109.
- Criqui MH, Denenberg JO, Bird CE, Fronek A, Klauber MR, Langer RD. The correlation between symptoms and non- invasive test results in patients referred for peripheral arterial disease testing. Vasc Med. 1996;1(1):65-71.
- Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. Circulation. Mar 21 2006;113(11)
