What causes leg pain when walking?

Leg Pain with Walking: Causes and Clinical Approach

Leg pain with walking is most commonly caused by peripheral artery disease (PAD), which affects approximately 8.5 million people in the US, though the majority present with atypical symptoms rather than classic claudication. 1

Primary Vascular Cause: Peripheral Artery Disease

PAD is the leading cause of exertional leg pain and should be the primary diagnostic consideration in patients over 50 years with walking-related leg symptoms. 2, 1

Classic Claudication Presentation

• Pain, aching, cramping, or fatigue in the buttocks, thigh, calf, or foot that occurs during walking and does not start at rest 3, 4
• Symptoms resolve within approximately 10 minutes of rest 3, 4
• Pain increases with progressive exercise intensity and is quickly relieved by rest 3
• The anatomic location of arterial stenosis predicts symptom location: iliac disease causes hip, buttock, and thigh pain; femoral-popliteal disease causes calf pain; tibial disease causes calf or foot pain 2

Atypical PAD Presentations (More Common)

Critically, 70-90% of people with PAD either report no exertional leg symptoms or have leg symptoms that are not consistent with classic claudication. 1

• Burning, tingling, numbness, throbbing, or shooting sensations are legitimate PAD symptom descriptors 3, 4
• Leg pain on both exertion AND rest represents a distinct and more severe PAD subtype with worse functional impairment than classic claudication 5, 6
• Patients with pain on exertion and rest have higher rates of neuropathy (mean score 5.6 vs 3.5), diabetes (48.9% vs 26.7%), and spinal stenosis (20.8% vs 7.2%) compared to those with classic claudication 5

Advanced PAD: Chronic Limb-Threatening Ischemia (CLTI)

• Ischemic rest pain affecting the forefoot that worsens with limb elevation (lying flat) and improves with dependency (getting up, dangling legs) is pathognomonic for CLTI 3
• This positional pattern occurs because gravity assists blood flow to ischemic tissues when legs are dependent 3
• CLTI occurs in 11-20% of patients with known PAD and carries a 25-35% one-year mortality rate 3
• Associated with nonhealing wounds, ulcers, or gangrene present for >2 weeks 3

Critical Differential Diagnoses ("Pseudoclaudication")

Lumbar Spinal Stenosis

• Bilateral buttock and posterior leg pain that mimics claudication 2, 4
• Takes longer to recover than vascular claudication (>10 minutes) 4
• Key distinguishing feature: relieved by lumbar spine flexion (bending forward), not simply by stopping walking 2, 4

Nerve Root Compression/Radiculopathy

• Sharp, lancinating pain radiating down the leg 4, 7
• Often present at rest (unlike vascular claudication) 4
• Improves with position changes rather than specifically with rest 4

Hip Osteoarthritis

• Aching discomfort in lateral hip/thigh 4
• Not quickly relieved with rest 4
• Improves when not bearing weight 4

Venous Claudication

• Tight, bursting pain affecting the entire leg (worse in calf) 2, 4
• Subsides slowly (not within 10 minutes) 4
• Opposite positional pattern from arterial disease: relieved by leg elevation 4, 8

Chronic Compartment Syndrome

• Typically occurs in athletes after strenuous exercise 3
• Subsides very slowly 3

Diagnostic Algorithm

Step 1: History - Pain Characteristics

• Onset pattern: Does pain start at rest or only with walking? 3, 4
• Relief pattern: Does pain resolve within 10 minutes of rest? 3, 4
• Positional factors: Does lying flat worsen pain (suggests CLTI) or improve it (suggests venous)? 3, 8
• Quality descriptors: Cramping, burning, aching, fatigue, or sharp/shooting? 3, 4

Step 2: Physical Examination

• Palpate femoral, popliteal, posterior tibial, and dorsalis pedis pulses bilaterally 2
• Absence of both dorsalis pedis AND posterior tibial pulses strongly suggests PAD 7
• Presence of either pulse makes PAD less likely 7
• Auscultate for femoral, carotid, and renal bruits as signs of systemic atherosclerosis 2
• Inspect feet for tissue loss, ulcers, or gangrene 2

Step 3: Objective Testing

• Ankle-brachial index (ABI) is the primary diagnostic test when claudication is suspected 4, 1
• ABI <0.90 is 57-79% sensitive and 83-99% specific for arterial stenosis ≥50% 1
• If ABI is normal but claudication is still suspected, perform exercise ABI testing 4

Common Pitfalls to Avoid

• Do not assume asymptomatic patients lack significant PAD: Approximately 75% of PAD patients report no change in leg symptoms over time because they restrict walking activity or slow walking speed to avoid symptoms 1
• Do not dismiss atypical symptoms: Only about one-third of PAD patients present with typical claudication 4
• Do not use compression stockings in PAD patients: This can worsen arterial insufficiency, especially with ABI <0.5 8
• Do not overlook coexisting conditions: Patients with PAD and atypical symptoms often have concurrent diabetes, neuropathy, or spinal stenosis that contribute to functional impairment 5, 6
• Recognize medication-induced myalgias: Statins are a common cause of lower extremity myalgias 7

Risk Stratification for Urgent Evaluation

Patients with rest pain that worsens when lying flat require expedited evaluation for potential revascularization, as this indicates CLTI with high amputation and mortality risk. 3

• ABI <0.4 in non-diabetics or any diabetic with known PAD warrants regular foot inspection 2
• Patients with prior CLTI or successful CLTI treatment should be evaluated at least twice annually by a vascular specialist 2