How do you check a pedal pulse?

How to Check Pedal Pulses

To check pedal pulses, place your index and middle fingers over the dorsalis pedis artery on the dorsum of the foot (approximately 1 cm lateral to the extensor hallucis longus tendon or about 1 cm from the dorsal most prominence of the navicular bone) and the posterior tibial artery (behind the medial malleolus in the groove between the malleolus and Achilles tendon), applying gentle pressure to detect pulsations. 1

Proper Technique for Pedal Pulse Assessment

Dorsalis Pedis Pulse

• Position: Have the patient's foot relaxed in slight plantar flexion
• Location: On the dorsum of the foot between the first and second metatarsal bones
  • Approximately 1 cm lateral to the extensor hallucis longus tendon
  • About 1 cm from the dorsal most prominence of the navicular bone 2
• Technique: Use the pads of your index and middle fingers to apply gentle pressure
• Anatomical landmark: The dorsalis pedis artery is the direct continuation of the anterior tibial artery 3

Posterior Tibial Pulse

• Position: Have the patient's foot relaxed in slight dorsiflexion
• Location: Behind the medial malleolus in the groove between the malleolus and the Achilles tendon
• Technique: Use the pads of your index and middle fingers to apply gentle pressure

Documentation and Grading

Pulse intensity should be assessed and recorded numerically as follows 1:

• 0: Absent
• 1: Diminished
• 2: Normal
• 3: Bounding

Important Considerations

• Remove all lower extremity garments, including shoes and socks, for proper examination 1
• Ensure the patient is relaxed and comfortable
• Use adequate lighting for visual inspection
• Apply only gentle pressure; excessive pressure can obliterate the pulse
• Take your time and don't rush the examination 4
• If pulses are difficult to locate, use a handheld Doppler device to confirm presence 1
• The absence of the dorsalis pedis pulse is less accurate for diagnosis of PAD than absence of the posterior tibial pulse, as the dorsalis pedis can be naturally absent in some healthy individuals 1

Clinical Significance

• Palpable pedal pulses generally indicate ankle indices above 50% and toe systolic pressures above 40 mmHg 5
• The presence of all four pedal pulses (bilateral dorsalis pedis and posterior tibial) is associated with a low likelihood of peripheral arterial disease (PAD) 1
• Absence of pulses should prompt further evaluation with ankle-brachial index (ABI) testing 1
• Four palpable pulses are associated with only 5% false-negative PAD cases, while no palpable pulses are associated with a 50% chance of ABI-verified PAD 6

Pitfalls to Avoid

• Rushing the examination in busy clinical settings significantly reduces accuracy 4
• Relying solely on pulse palpation for diagnosis of PAD without objective measurements like ABI when ischemia is suspected 4
• Attributing leg symptoms solely to arthritis or neuropathy without proper vascular assessment 7
• Failing to consider that reproducibility of pulse assessment is better for detection of normal versus absent pulse than for normal versus diminished pulse 1

Remember that pedal pulse palpation is a reliable initial screening tool for PAD, but should be followed by ABI measurement in patients with fewer than four palpable pedal pulses to confirm diagnosis and initiate appropriate cardiovascular preventive actions 6.