How to describe atherosclerosis of the leg in a physical exam?

Physical Examination Findings for Lower Extremity Atherosclerosis (PAD)

The physical examination for atherosclerosis of the leg should systematically document pulse palpation using a standardized grading scale (0=absent, 1=diminished, 2=normal, 3=bounding) at four key sites, auscultate for vascular bruits, and inspect for specific ischemic skin changes. 1

Pulse Palpation - The Core Assessment

Grade and document all four lower extremity pulse sites bilaterally: 1

• Femoral artery (groin)
• Popliteal artery (behind knee)
• Dorsalis pedis artery (dorsum of foot)
• Posterior tibial artery (behind medial malleolus)

Use the standardized grading system: 0 (absent), 1 (diminished), 2 (normal), or 3 (bounding). 1 Absent or diminished pulses are abnormal findings that require confirmation with ankle-brachial index testing. 1

Auscultation for Bruits

Listen for vascular bruits in three locations: 1

• Epigastric region (abdominal aorta)
• Periumbilical area (aortoiliac vessels)
• Groin/femoral region (femoral arteries)

The presence of a femoral bruit has high specificity (98.3%) for detecting PAD when combined with absent pedal pulses. 2

Inspection for Ischemic Changes

Document the following skin and tissue findings suggestive of chronic ischemia: 1

• Asymmetric hair growth on lower legs (hair loss on affected side)
• Nail bed changes (thickened, dystrophic nails)
• Calf muscle atrophy (comparing both legs)
• Elevation pallor (foot becomes pale when elevated above heart level)
• Dependent rubor (dusky red discoloration when leg hangs down)
• Nonhealing wounds or ulcers (typically painful, located on toes, heels, or pressure points)
• Gangrene (tissue necrosis, indicating critical limb-threatening ischemia)

1

Additional Examination Components

Measure bilateral arm blood pressures at the initial assessment to identify the higher systolic pressure (required for accurate ankle-brachial index calculation) and detect subclavian stenosis (>15-20 mmHg difference is abnormal). 1

Assess for signs of severe ischemia in chronic limb-threatening ischemia: 1

• Ischemic rest pain (pain at rest, especially at night, relieved by dependency)
• Extended capillary refill time (>2 seconds after finger pressure on foot)
• Foot pallor when leg is at rest

Critical Clinical Pearls

Physical examination findings alone are insufficient for diagnosis - any abnormal finding must be confirmed with objective testing, starting with the ankle-brachial index. 1, 3 However, when both pedal pulses are present bilaterally and no femoral bruits are detected, the negative predictive value is 94.9%, making significant PAD unlikely. 2

The sensitivity of physical examination is only 58% for detecting PAD, but specificity is 98% when abnormalities are present, meaning abnormal findings are highly reliable but normal findings do not exclude disease. 2

In patients with diabetes or chronic kidney disease, medial arterial calcification may cause falsely normal or elevated ankle pressures despite significant disease, making toe-brachial index or other alternative testing necessary when clinical suspicion remains high despite normal pulses. 1