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A 58 year old smoker presented with a six month history of pain in the left calf during walking.
Ask about key symptoms of peripheral arterial disease, including walking distance before onset. In peripheral arterial disease, pain in the hip, thigh, and calf (rarely foot) is not present at rest, on weight bearing, or when starting to walk but occurs after a distance that is predictable (and shorter going uphill). The pain is felt in the muscle, not the bone or joint, and is relieved rapidly with rest or reduction of walking pace. Pain occurring before 200 m reflects Fontaine stage Ia peripheral arterial disease; pain at or beyond 200 m reflects stage IIa.
Spinal claudication manifests as weakness not pain and starts soon after standing up, with relief on sitting or bending (lumbar spine flexion). Radiculopathy relates mainly to back problems, radiates down the leg, is not relieved by resting, and may diminish by changing position. With hip arthritis, pain starts with weight bearing and is related to activity. In arthritic and inflammatory conditions, pain is continuous and intensified by weight bearing, with tenderness, swelling, and hyperthermia. With a Baker's cyst the pain is aggravated with activity, not relieved by resting, and may have tenderness and swelling behind the knee.
Record risk factors, family history, other cardiovascular symptoms or events, and previous peripheral vascular interventions. Pay attention to drug treatment, such as β blockers, 5-HT receptor agonists, and ergot derivatives—these can worsen existing peripheral arterial disease.
Burns P, Gough S, Bradbury AW. Management of peripheral arterial disease in primary care. BMJ 2003;326:584-88.
British Cardiac Society, British Hypertension Society, Diabetes UK, HEART UK, Primary Care Cardiovascular Society, Stroke Association. JBS2: Joint British societies' guidelines on prevention of cardiovascular disease in clinical practice. Heart 2005;91(suppl 5):v1-52.
Hiatt WR. Medical treatment of peripheral arterial disease and claudication. N Engl J Med 2001;344:1608-21.
Patient information sheet is available from the Vascular Society of Great Britain and Ireland (www.vascularsociety.org.uk/patient/int_claud.html)