What are the symptoms of Peripheral Artery Disease (PAD)?

Symptoms of Peripheral Artery Disease (PAD)

PAD presents with a spectrum of symptoms ranging from no symptoms at all (in up to 50% of patients) to life-threatening limb ischemia, with classic claudication occurring in only about one-third of affected patients. 1

Classic Claudication (Most Recognized Pattern)

The hallmark symptom of PAD is intermittent claudication, which presents as: 1

• Pain, aching, cramping, or tired/fatigued feeling in the buttocks, thigh, calf, or foot 1
• Consistently induced by walking or exercise and does not start at rest 1
• Does not improve during continued walking 1
• Relieved within approximately 10 minutes of rest 1

Additional Symptom Descriptors

Beyond classic pain, patients may describe: 1, 2

• Tingling sensations 1
• Numbness 1
• Burning 1, 3
• Throbbing 1
• Shooting pain 1

Anatomic Correlation

The location of symptoms predicts the site of arterial stenosis: 4

• Iliac disease → hip, buttock, and thigh pain 4
• Femoral-popliteal disease → calf pain 4
• Tibial disease → calf or foot pain 4

Atypical Presentations (More Common Than Classic Claudication)

Most patients with PAD do not present with typical claudication. In the Walking and Leg Circulation Study: 1

• 19.8% had no exertional leg pain 1
• 28.5% had atypical leg pain 1
• Only 32.6% had classic intermittent claudication 1
• 19.1% had pain at rest 1

Some patients experience exertional leg symptoms that: 1

• Do not limit walking 1
• Take more than 10 minutes to resolve after rest 1

Chronic Limb-Threatening Ischemia (CLTI) - Advanced Disease

CLTI represents severe PAD and manifests as: 1, 2

• Ischemic rest pain (symptoms present for >2 weeks) 1
• Nonhealing wounds or ulcers 1
• Gangrene 1

Characteristic Positional Pain Pattern

Ischemic rest pain has a distinctive positional component: 1, 2

• Worsened by limb elevation (lying flat) - gravity no longer assists blood flow 1, 2
• Relieved by dependency (getting up, dangling legs) - gravity assists distal perfusion 1, 2
• Typically affects the forefoot 1

This positional pattern is critical for distinguishing CLTI from other causes of leg pain and indicates need for urgent revascularization evaluation. 2, 4

Acute Limb Ischemia (ALI) - Emergency Presentation

ALI presents with sudden onset (<2 weeks) of the "6 P's": 1

• Pain 1
• Pallor 1
• Pulselessness 1
• Poikilothermia (coolness) 1
• Paresthesias 1
• Paralysis (potential) 1

Asymptomatic Disease

Up to 50% of patients with objectively proven PAD have no leg symptoms at all. 1 This underscores why PAD is severely underdiagnosed, with over 70% of primary care providers in the PARTNERS study being unaware their patients had the disease. 1

Key Clinical Pitfalls

Do not wait for classic claudication symptoms to consider PAD - only about 10% to one-third of PAD patients present with typical claudication. 1, 5 The majority have atypical symptoms, no symptoms, or advanced disease at presentation. 1

Pain that worsens when lying flat and improves with dependency suggests CLTI, not simple claudication - this pattern indicates severe disease requiring urgent evaluation for revascularization. 2, 4 Historically, CLTI carries a 25-35% one-year mortality rate and up to 30% amputation rate. 1, 2