Most Common Causes of Leg Pain in the Elderly
Peripheral arterial disease (PAD) is the most common cause of leg pain in the elderly, affecting approximately 50% of persons age 65 and older, with prevalence increasing to 85% in those 75 and older. 1
Peripheral Arterial Disease (PAD)
PAD is characterized by atherosclerotic blockages that restrict blood flow to the lower extremities. The prevalence of PAD increases exponentially with age, making it particularly concerning in the elderly population 2.
Key characteristics of PAD-related leg pain:
- Intermittent claudication (classic symptom): pain during exertion that resolves with rest
- Atypical presentations are actually more common than classic claudication 1
- Pain location varies based on blockage site:
- Iliac artery disease: hip, buttock, and thigh pain
- Femoral/popliteal artery disease: calf pain
- Tibial artery disease: calf pain or foot pain/numbness 1
Importantly, studies show that the majority of elderly PAD patients do not have classic claudication symptoms. In the PARTNERS survey, of those with newly diagnosed PAD, 48% were asymptomatic, 46% had atypical leg pain, and only 6% had typical claudication 1.
Osteoarthritis (OA)
Osteoarthritis is another extremely common cause of leg pain in the elderly, affecting about 50% of persons age 65 and older 1.
Key characteristics of OA-related leg pain:
- Pain typically worsens with activity and improves with rest
- Morning stiffness that improves with movement
- Pain often localized to specific joints (knees, hips)
- May be associated with joint swelling, crepitus, and reduced range of motion 3
Other Common Causes
Leg cramps: Affects approximately 50% of elderly outpatients, more common in females (56%) than males (40%), and strongly associated with peripheral vascular disease and arthritis 4.
Lumbar spine disorders: Including spinal stenosis, which can cause pseudoclaudication - leg pain that mimics vascular claudication but is caused by nerve compression 1, 5.
Venous insufficiency: Causes aching pain, heaviness, and swelling, typically worsening throughout the day.
Differential Diagnosis Algorithm
When evaluating leg pain in an elderly patient, consider:
Timing of pain:
- Pain during exertion relieved by rest → Consider PAD
- Pain at rest, especially at night → Consider severe PAD, neuropathy, or leg cramps
- Pain worse at night (62% of leg cramps occur at night) 4
Location of pain:
- Joint-specific pain → Consider OA
- Calf pain with walking → Consider PAD or spinal stenosis
- Diffuse leg pain → Consider neuropathy or vascular causes
Associated symptoms:
- Decreased pulses, cool extremities → PAD
- Joint swelling, crepitus → OA
- Back pain with leg symptoms → Spinal stenosis or radiculopathy
Diagnostic Approach
The ankle-brachial index (ABI) is the most effective and widely used screening tool for detecting PAD 2. An ABI less than 0.90 is diagnostic of PAD, though it was found in only 69% of those with claudication symptoms, highlighting the need for clinical judgment 1.
Common Pitfalls to Avoid
Assuming all exertional leg pain is PAD: Many elderly patients have atypical presentations or multiple concurrent conditions.
Dismissing leg pain as "normal aging": As the American Geriatrics Society notes, "An older man visits his doctor complaining of difficulty with getting out of a chair and walking because of persistent pain in one of his knees. The doctor replies, 'Well you're 75, this is just part of growing old.' The astute patient replies, 'My other knee is just as old and it doesn't hurt.'" 1
Missing critical limb ischemia: Severe PAD can progress to tissue loss if not identified and treated promptly 1.
Overlooking comorbidities: Many elderly patients have multiple conditions contributing to leg pain, including diabetes, neuropathy, and venous disease 6.
In conclusion, while PAD and osteoarthritis represent the most common causes of leg pain in the elderly, a systematic approach to diagnosis is essential to identify the specific etiology and implement appropriate treatment strategies.