What's the next step for a 56-year-old female with left leg pain radiating to the left foot and a negative ultrasound (ultrasound), considering potential vascular disease?

From the Guidelines

The next step for a 56-year-old female with left leg pain radiating to the foot and a negative ultrasound should be an MRI of the lumbar spine to evaluate for potential nerve compression, as suggested by the most recent guidelines 1. This presentation suggests radiculopathy, likely from a herniated disc or spinal stenosis, rather than vascular disease which has been ruled out by the negative ultrasound. The patient should be referred to a neurologist or orthopedic spine specialist for further evaluation. While awaiting specialist consultation, conservative management can include:

• NSAIDs such as ibuprofen 400-600mg three times daily with food for pain relief
• Physical therapy focusing on lumbar stabilization exercises
• Activity modification to avoid positions that worsen symptoms If pain is severe, a short course of oral steroids like prednisone 20mg daily for 5-7 days may help reduce inflammation. The radiating nature of the pain following a dermatomal pattern strongly suggests nerve root compression, and the negative ultrasound effectively rules out deep vein thrombosis or arterial insufficiency as the cause of symptoms, as outlined in the 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS guideline for the management of lower extremity peripheral artery disease 1. It's also important to consider other potential causes of leg pain, such as hip arthritis, foot/ankle arthritis, nerve root compression, spinal stenosis, symptomatic popliteal (Baker’s) cyst, venous claudication, and chronic compartment syndrome, as listed in the guideline 1. However, given the patient's symptoms and negative ultrasound, an MRI of the lumbar spine is the most appropriate next step, as it will help to determine if nerve compression is the cause of the patient's pain, as recommended by the American College of Cardiology/American Heart Association joint committee on clinical practice guidelines 1.

From the Research

Next Steps for Diagnosis

• The patient's negative ultrasound result does not rule out the possibility of peripheral arterial disease (PAD) 2, 3.
• Further diagnostic tests, such as an ankle-brachial index (ABI), pulse volume recordings, and post-exercise studies, may be necessary to confirm or rule out PAD 3.
• The ABI test may not be sufficient on its own, as it can produce false negative results, especially in patients with non-compressible arteries or those who are asymptomatic 3, 4.

Considerations for Patient Evaluation

• A comprehensive medical history, physical examination, and assessment of risk factors, such as smoking, hypertension, diabetes, and dyslipidemia, are essential in evaluating the patient's condition 5, 6.
• The patient's symptoms, such as leg pain radiating to the foot, should be taken into account, even if the ABI result is normal 3, 4.
• Exercise testing may be recommended to enhance the sensitivity of detection of PAD, especially in patients with symptoms of intermittent claudication 3.

Potential Treatment Options

• If PAD is confirmed, treatment options may include lifestyle modifications, such as smoking cessation, exercise therapy, and cholesterol reduction, as well as medications, such as antiplatelet therapy, statins, and cilostazol 2, 5, 6.
• Revascularization procedures, such as percutaneous transluminal angioplasty or bypass surgery, may be considered in severe cases or when lifestyle modifications and medications are ineffective 5, 6.