How should I palpate the lower‑limb peripheral pulses in an adult, including the femoral, popliteal, posterior tibial, and dorsalis pedis arteries, especially in elderly or diabetic patients?

How to Palpate Lower Limb Peripheral Pulses

Remove the patient's shoes and socks, position them supine with legs fully exposed, and systematically palpate the femoral, popliteal, dorsalis pedis, and posterior tibial pulses bilaterally, grading each on a 0–3 scale (0=absent, 1=diminished, 2=normal, 3=bounding). 1, 2

Patient Preparation and Positioning

• Position the patient supine with both legs fully exposed from the groin to the toes to allow complete visualization and access to all pulse sites. 2

• Remove all lower garments, shoes, and socks before beginning the examination—failure to do so impairs adequate inspection and palpation. 1, 2

• Allow 5–10 minutes of rest in the supine position at constant room temperature before measuring pulses or performing hemodynamic assessments. 1

Systematic Pulse Palpation Technique

Femoral Pulse

• Palpate at the inguinal ligament, midway between the anterior superior iliac spine and the pubic symphysis, using firm pressure with your fingertips. 1, 2

• Auscultate both femoral arteries for bruits after palpation, as femoral bruits increase the likelihood of peripheral arterial disease. 1

Popliteal Pulse

• Flex the patient's knee slightly and palpate deeply in the popliteal fossa with both hands, using your fingers to compress the artery against the posterior tibia. 1, 2

• The popliteal pulse is the most difficult to palpate and may require the patient to be prone or the examiner to use bimanual technique with the knee flexed to 30–45 degrees. 2

Dorsalis Pedis Pulse

• Palpate on the dorsum of the foot, lateral to the extensor hallucis longus tendon, typically between the first and second metatarsal bones. 1, 2

• Note that the dorsalis pedis pulse may be congenitally absent in up to 10% of healthy individuals, so its absence alone does not confirm peripheral arterial disease. 2, 3

Posterior Tibial Pulse

• Palpate posterior and inferior to the medial malleolus, curving your fingers behind the ankle bone. 1, 2

• Absence of the posterior tibial pulse is more specific for peripheral arterial disease than absence of the dorsalis pedis pulse and should raise greater clinical concern. 2

Pulse Grading and Documentation

• Grade each pulse using the standardized 0–3 scale:

  • 0 = absent (no palpable pulse)
  • 1 = diminished (weak, barely palpable)
  • 2 = normal (easily palpable, not bounding)
  • 3 = bounding (very strong, easily palpable) 1, 2

• Document the grade for each pulse site bilaterally to allow comparison between limbs and serial monitoring over time. 1

• The presence of multiple pulse abnormalities markedly increases the likelihood of confirmed peripheral arterial disease, whereas normal pulses in all four sites bilaterally make the diagnosis less likely. 2, 3

Additional Vascular Examination Components

Bilateral Arm Blood Pressure

• Measure systolic blood pressure in both arms during the initial assessment, as an inter-arm difference >15–20 mmHg suggests subclavian or innominate artery stenosis. 1, 2

• Use the arm with the higher systolic pressure for subsequent ankle-brachial index calculations. 2

Skin and Tissue Inspection

• Inspect the feet for color, temperature, and skin integrity, looking for pallor, dependent rubor (redness when dependent), or cyanosis. 1

• Evaluate for trophic changes including asymmetric hair loss, shiny or taut skin, thickened or dystrophic nails, and skin atrophy—all signs of chronic ischemia. 1, 2

• Identify any non-healing wounds or ulcerations, particularly on the toes, heels, or pressure points, as these indicate advanced peripheral arterial disease. 1, 2

• Arterial ulcers typically appear on the toes or distal foot with well-demarcated borders and a "punched-out" appearance, distinguishing them from venous ulcers which occur near the medial malleolus. 1, 2

Special Considerations for Elderly and Diabetic Patients

Elderly Patients

• Elderly patients have higher rates of arterial calcification, which can make vessels non-compressible and falsely elevate ankle-brachial index measurements (>1.40). 1, 2

• In patients over 70 years, peripheral arterial disease prevalence is high (present in approximately 20% of this population), warranting thorough examination even in asymptomatic individuals. 1

• Popliteal artery aneurysms are more common in elderly men and may present as a pulsatile mass in the popliteal fossa rather than diminished pulses. 4

Diabetic Patients

• Diabetic patients often have distal vessel disease affecting the popliteal artery and below-knee vessels, making posterior tibial and dorsalis pedis pulse assessment particularly important. 1

• Medial arterial calcification is common in diabetes, leading to non-compressible vessels and falsely elevated ankle-brachial index; in these cases, toe-brachial index should be obtained. 1, 2

• Diabetic neuropathy may mask ischemic symptoms, so patients may have advanced peripheral arterial disease despite minimal complaints—making objective pulse examination even more critical. 1, 2

• Annual comprehensive foot examination is recommended for all diabetic patients, including pulse palpation, sensory testing, and inspection for ulceration. 1, 5

• Diminished or absent dorsalis pedis pulsation was found in 16% of diabetic adults aged 35–54 years and 24% of those aged 55–74 years in population studies. 1

Diagnostic Accuracy and Clinical Interpretation

• If both pedal pulses (dorsalis pedis and posterior tibial) are present bilaterally and no femoral bruits are detected, the specificity is 98.3% and negative predictive value is 94.9% for excluding peripheral arterial disease. 3

• The combination of absent or diminished pedal pulses plus femoral bruit has 93.8% overall accuracy for detecting peripheral arterial disease compared to ankle-brachial index. 3

• However, a normal pulse examination does not completely exclude peripheral arterial disease, as many patients have atypical or no symptoms despite significant disease. 2

• Any abnormal physical examination finding must be confirmed with ankle-brachial index testing to establish a definitive peripheral arterial disease diagnosis. 5, 2

Common Pitfalls to Avoid

• Do not rely solely on dorsalis pedis pulse assessment, as this pulse may be congenitally absent in healthy individuals; always assess the posterior tibial pulse as well. 2, 3

• Avoid assuming that cool skin or delayed capillary refill alone indicates peripheral arterial disease, as these findings are not reliable diagnostic markers. 2

• Do not skip bilateral arm blood pressure measurement, as this can lead to inaccurate ankle-brachial index calculations and missed subclavian stenosis. 2

• Never assume a normal examination excludes peripheral arterial disease in high-risk patients (elderly, diabetic, smokers), as subclinical disease is common and requires objective testing. 1, 2

• Failing to remove all lower garments prevents adequate inspection of the entire lower extremity for trophic changes and wounds. 2