Absent Dorsalis Pedis Pulse in Normal Peripheral Vasculature
An absent dorsalis pedis (DP) pulse occurs congenitally in approximately 1.8% of healthy individuals bilaterally and in an additional 1.1% unilaterally, making it a relatively uncommon but well-documented normal variant. 1
Prevalence in Healthy Populations
In a study of 547 young healthy subjects, the DP pulse was congenitally absent bilaterally in 9 subjects (1.8%) and unilaterally absent in 6 additional subjects (1.1%), for a total prevalence of approximately 2.9% having at least one absent DP pulse 1
The posterior tibial (PT) pulse is far less commonly absent congenitally, occurring in only 0.18% of healthy subjects 1
The low incidence of congenital absence makes the clinical finding of an absent pedal pulse in later life a significant marker of peripheral vascular disease rather than a benign variant 1
Clinical Significance and Diagnostic Implications
The American College of Cardiology recommends that the presence of normal femoral, popliteal, and pedal pulses reduces the likelihood of moderate to severe PAD, though this finding may be less reliable in persons with diabetes 2
The absence of pedal pulses suggests PAD, but pulse assessment alone is often unreliable, especially in persons with diabetes 2
When both pedal pulses (DP and PT) are present bilaterally and no femoral bruits are detected, the specificity is 98.3% and negative predictive value is 94.9% for excluding PAD 3
The American College of Cardiology recommends ankle-brachial index (ABI) testing as the initial test for patients with absent or diminished pedal pulses to objectively confirm or exclude PAD 4
Distinguishing Normal Variant from Pathology
If pulses are palpable on both feet, the prognosis for PAD progression is relatively good, with ankle indices consistently above 50% and toe systolic pressures above 40 mmHg 5
Patients lacking palpable pulses in both feet have ankle indices below 90%, indicating actual PAD rather than normal anatomic variation 5
The American College of Cardiology recommends checking the posterior tibial pulse immediately when DP is absent, as PT has greater diagnostic reliability 6
The American College of Cardiology suggests checking contralateral limb pulses, as bilateral absence may indicate chronic PAD rather than normal variant 6
Key Clinical Pitfalls to Avoid
Never assume PAD is absent based solely on palpable pulses, as even skilled examiners can detect pulses despite significant ischemia 7
Never assume an absent DP pulse is pathologic without checking the PT pulse and contralateral limb, as congenital absence occurs in approximately 3% of healthy individuals 1
The American College of Cardiology recommends obtaining ABI testing to confirm diagnosis when encountering absent pulses in asymptomatic patients or those with chronic presentation 6
In diabetic patients with absent pulses, never rely on ABI alone due to arterial calcification causing falsely elevated readings; always obtain toe-brachial index (TBI) or waveform analysis 7
When to Pursue Further Evaluation
The American College of Cardiology recommends immediate objective vascular assessment with ABI, TBI, and pedal Doppler waveform analysis when absent pedal pulses are accompanied by nonhealing wounds 7
Urgent vascular referral is indicated for nonhealing wounds with absent pulses, which may indicate critical limb ischemia 6
The American College of Radiology recommends immediate clinical context evaluation to determine urgency, specifically assessing for acute limb ischemia (sudden onset with pain) versus chronic PAD 6
In patients with absent DP pulse but present PT pulse, normal skin temperature, no bruits, and no symptoms, the likelihood of significant PAD is low and represents probable congenital absence 1, 5