What is the likelihood of peripheral arterial disease (PAD) in a person with palpable pedal pulses?

Likelihood of PAD with Palpable Pedal Pulses

The presence of palpable pedal pulses significantly reduces but does not eliminate the risk of peripheral arterial disease—approximately 5-6% of patients with all four pedal pulses palpable will still have PAD, while the absence of pulses increases the likelihood to approximately 50%. 1, 2

Understanding the Diagnostic Performance

When All Four Pedal Pulses Are Present

• The negative predictive value is approximately 95%, meaning that when both dorsalis pedis and posterior tibial pulses are palpable bilaterally, only about 5% of patients will have PAD (defined as ABI ≤0.9 or ≥1.4). 1

• In a large population-based screening study of over 18,000 men, the presence of four palpable pedal pulses was associated with only 5% false-negative PAD cases. 1

• When pedal pulses are present bilaterally, ankle indices are typically above 50% and toe systolic pressures above 40 mmHg—thresholds associated with relatively good prognosis for wound healing. 2

When Pulses Are Absent or Diminished

• If one or more pedal pulses are missing, the likelihood of PAD increases dramatically to approximately 50%—essentially a coin flip. 1

• Patients lacking palpable pulses in both feet have ankle indices below 90%, confirming the presence of PAD. 2

• The sensitivity of absent pulses for detecting PAD is only 71.7%, meaning that relying solely on pulse palpation will miss nearly 30% of PAD cases. 1

Critical Clinical Caveat: The Diabetic Patient Exception

Even skilled examiners can detect palpable pulses despite the presence of significant ischemia, particularly in patients with diabetes. 3, 4

• The International Working Group on the Diabetic Foot explicitly states that medical history and clinical examination sensitivity is too low to rule out PAD in diabetic patients with foot ulcers. 3

• In diabetic patients, palpable pulses may be present despite significant ischemia due to medial artery calcification (Mönckeberg sclerosis), which affects arterial compliance without necessarily causing stenosis. 3

• Up to 50% of patients with diabetic foot ulcers have coexisting PAD, making objective vascular assessment mandatory regardless of pulse findings. 3, 4

When Objective Testing Is Required

The presence of palpable pulses does NOT reliably rule out PAD in the following scenarios: 3, 4

• Any patient with diabetes presenting with a foot ulcer
• Patients with peripheral neuropathy (associated with arterial calcification)
• Patients with non-healing wounds despite optimal care
• Patients with risk factors: age ≥65 years, smoking history, hypertension, hyperlipidemia

Recommended Objective Assessment

When clinical suspicion exists despite palpable pulses, obtain: 3

• Ankle-brachial index (ABI): Values 0.9-1.3 largely exclude PAD, but values ≥1.3 indicate incompressible vessels requiring further testing
• Toe-brachial index (TBI): Values ≥0.75 make PAD unlikely; preferred when ABI is unreliable due to calcification
• Pedal Doppler arterial waveforms: Triphasic waveforms provide stronger evidence for absence of PAD than pulse palpation alone 3, 5

Practical Algorithm for Clinical Decision-Making

In non-diabetic patients without wounds: 6, 1

• Four palpable pedal pulses + no femoral bruits = 95% confidence PAD is absent
• Specificity 98.3%, negative predictive value 94.9%
• ABI measurement may be unnecessary in this low-risk scenario

In diabetic patients or those with wounds: 3, 4

• Palpable pulses are insufficient—always obtain objective vascular assessment
• Start with ABI and TBI
• If ABI ≥1.3 (incompressible), rely on TBI and Doppler waveforms
• Consider urgent vascular imaging if toe pressure <30 mmHg or TcPO₂ <25 mmHg