Physical Examination Findings for Peripheral Vascular Disease
The key physical examination findings for peripheral vascular disease (PVD) include abnormal pulse assessment, skin changes, temperature differences, bruits, and in advanced cases, tissue damage and gangrene.
Pulse Assessment
- Pulse evaluation is the cornerstone of PVD physical examination 1
- Pulses should be systematically assessed at all levels:
- Femoral
- Popliteal
- Dorsalis pedis
- Posterior tibial arteries
- Document pulse intensity using standardized scale 1:
- 0: Absent
- 1: Diminished
- 2: Normal
- 3: Bounding
- Reproducibility is better for detecting absent versus normal pulses than for diminished versus normal pulses 1
- Absence of posterior tibial pulse is more specific for PAD than absence of dorsalis pedis pulse (which can be congenitally absent in some healthy individuals) 1
Skin and Tissue Changes
- Inspect legs and feet with shoes and socks removed 1
- Look for:
- Pallor on elevation (elevation pallor)
- Dependent rubor (redness when legs are dependent)
- Asymmetric hair loss on legs and feet
- Trophic skin changes (thin, shiny skin)
- Hypertrophic nails
- Delayed capillary refill (>3 seconds)
- Cool skin temperature compared to proximal limb or contralateral limb
- Atrophy of calf muscles
Advanced Disease Findings
- Nonhealing wounds or ulcers (particularly on toes, foot, ankle)
- Gangrene
- Cyanosis in dependent position
- Sharp line of temperature transition
- Pain at rest (particularly when elevated)
Bruits
- Auscultate for bruits over:
- Femoral arteries
- Abdominal aorta
- Iliac arteries
- Presence of bruits suggests turbulent blood flow due to stenosis 1
Acute Limb Ischemia Assessment
For suspected acute limb ischemia, assess using the Rutherford classification 1:
- Class I (Viable): No sensory loss, no motor loss, audible arterial and venous Doppler signals
- Class IIa (Marginally threatened): Mild sensory loss limited to toes, no motor loss, often inaudible arterial but audible venous Doppler
- Class IIb (Immediately threatened): Sensory loss beyond toes, mild-moderate motor weakness, inaudible arterial but audible venous Doppler
- Class III (Irreversible): Complete sensory and motor loss, inaudible arterial and venous Doppler signals
Differential Diagnosis Assessment
- Compare symptoms with conditions that mimic PAD 1, 2:
- Hip/ankle arthritis (improved when not weight-bearing)
- Nerve root compression (sharp, lancinating pain)
- Spinal stenosis (relief with lumbar spine flexion)
- Venous claudication (relief with leg elevation)
- Chronic compartment syndrome (in muscular athletes)
Blood Pressure Measurement
- Measure blood pressure in both arms 1
- Inter-arm difference >15-20 mmHg suggests subclavian artery stenosis
- Identifies arm with highest systolic pressure for accurate ABI measurement 1
Pitfalls and Caveats
- Absence of dorsalis pedis pulse alone is not diagnostic (may be congenitally absent in healthy individuals) 1
- Cool skin and delayed capillary refill alone are not reliable for PAD diagnosis 1
- Many patients with PAD are asymptomatic or have atypical symptoms 1
- Pulse assessment has better reproducibility for absent versus normal than for diminished versus normal 1
- Multiple abnormal findings increase likelihood of confirmed PAD 1
Physical examination findings must be confirmed with objective diagnostic testing, primarily the ankle-brachial index (ABI), to establish the diagnosis of PAD 1.