What are the possible causes of leg pains in older adults or individuals with a history of cardiovascular disease?

Causes of Leg Pain in Older Adults and Those with Cardiovascular Disease

In older adults and individuals with cardiovascular disease, leg pain is most commonly caused by peripheral arterial disease (PAD), which affects approximately 20% of adults over age 70, though the majority present with atypical symptoms rather than classic claudication. 1

Vascular Causes (Most Critical in This Population)

Peripheral Arterial Disease

• PAD is the primary vascular cause and presents across a spectrum from asymptomatic disease to critical limb-threatening ischemia. 1, 2
• Only 6-13% of patients with PAD present with typical claudication (reproducible leg pain during exercise that resolves with rest within 10 minutes). 1
• The majority (46-62%) experience atypical leg pain, while 26-48% are completely asymptomatic despite having functional impairment. 1
• Pain location correlates with arterial involvement: hip/buttock/thigh pain indicates iliac artery disease, calf pain suggests femoral/popliteal disease, and calf/foot pain indicates tibial artery disease. 2, 3

Critical Limb-Threatening Ischemia

• Represents severe PAD with chronic ischemic rest pain, non-healing ulcers, or gangrene. 2
• This is a limb-threatening emergency requiring urgent vascular evaluation. 1

Neurological Causes

Lumbar Radiculopathy and Spinal Stenosis

• Burning, tingling, numbness, or sharp lancinating pain radiating down the leg from the tailbone suggests nerve root compression rather than vascular disease. 4
• Pain present at rest that worsens with sitting or standing points toward spinal stenosis, with relief occurring with lumbar spine flexion. 4
• Peripheral neuropathy, radiculopathies, and lumbar canal stenosis are common neurological associations with leg pain in this population. 2, 3

Distinguishing Features

• Pseudoclaudication from spinal stenosis can mimic vascular claudication but typically improves with forward flexion and worsens with extension. 2
• Straight leg raise testing and neurologic examination checking motor weakness, sensory deficits, and reflex changes help identify radiculopathy. 4

Musculoskeletal Causes

• Osteoarthritis and inflammatory muscle diseases can cause leg pain in older adults. 2
• Statin-induced myalgias are a common iatrogenic cause of lower extremity discomfort in patients with cardiovascular disease. 5

Other Conditions to Differentiate

Restless Legs Syndrome

• Characterized by unpleasant sensations with urge to move, symptoms beginning or worsening during rest, relief with movement, and symptoms worse in evening/night. 2, 3
• This is distinct from leg cramps or claudication. 3

Venous Disease and Chronic Compartment Syndrome

• These conditions can cause exertional leg symptoms but have different clinical presentations than arterial disease. 2

Diagnostic Approach

Physical Examination Priorities

• Check for diminished or absent dorsalis pedis and posterior tibial pulses—absence of both strongly suggests PAD. 2, 5
• Auscultate for bruits over femoral arteries. 2, 3
• Perform neurologic examination including straight leg raise, motor strength, sensation, and reflexes. 4

Objective Testing

• Ankle-brachial index (ABI) ≤0.90 confirms PAD diagnosis and is an independent predictor of increased cardiovascular mortality. 1
• ABI values of 0.91-0.99 (low-normal) and ≥1.40 (high-normal, suggesting arterial stiffness) are also associated with higher rates of exertional leg pain. 6
• Lumbar spine MRI is indicated if radiculopathy is suspected based on examination findings. 4
• Electromyography and nerve conduction studies are necessary for confirmed neurologic involvement. 4

Critical Clinical Pitfalls

• Do not rely on the presence or absence of classic claudication to rule in or out PAD—over 70% of patients with PAD have either atypical symptoms or no leg symptoms at all. 1
• Even "asymptomatic" PAD patients demonstrate objectively impaired lower extremity function with slower walking velocity, poorer balance, and reduced activity levels. 1
• PAD patients have 3.1 times greater all-cause mortality and 5.9 times greater cardiovascular mortality compared to those without PAD, regardless of symptom status. 1
• Comorbid conditions (diabetes, spinal stenosis, neuropathy) frequently coexist and contribute to the complexity of leg pain presentations in PAD patients. 7