Lower Extremity Pulse Examination
In the legs, you should check four pulses: femoral, popliteal, dorsalis pedis, and posterior tibial. 1
The Four Essential Pulses
Proximal Pulses
- Femoral pulse: Palpated in the groin, just below the inguinal ligament 1
- Popliteal pulse: Palpated behind the knee in the popliteal fossa 1
Distal (Pedal) Pulses
- Dorsalis pedis pulse: Palpated on the dorsum of the foot, approximately 10-11 mm from the dorsal prominence of the navicular bone 1, 2
- Posterior tibial pulse: Palpated in the groove between the medial malleolus and Achilles tendon 1
Pulse Grading System
Rate each pulse using this standardized scale 1:
- 0: Absent
- 1: Diminished
- 2: Normal
- 3: Bounding
Clinical Context and Technique
Remove shoes, socks, and lower garments completely before examination to ensure thorough assessment 1, 3. This seemingly obvious step is frequently omitted but critical for detecting subtle findings.
Key Technical Points
- Posterior tibial pulse has greater diagnostic reliability than dorsalis pedis because the dorsalis pedis can be congenitally absent in 10-20% of healthy individuals 4, 5, 6
- The dorsalis pedis pulse is absent in approximately 22% of normal patients, making its absence alone less specific for peripheral artery disease 1
- Palpation of femoral and popliteal pulses has only moderate interobserver agreement (kappa 0.52-0.53), highlighting the importance of confirming abnormal findings with objective testing 7
Additional Examination Components
Beyond pulse palpation, the complete lower extremity vascular examination includes 1:
- Auscultation for femoral bruits (increases likelihood of PAD when present)
- Inspection of legs and feet for elevation pallor, dependent rubor, asymmetric hair growth, trophic nail changes, and nonhealing wounds
- Assessment of skin temperature and capillary refill (though these have limited diagnostic accuracy)
When Abnormal Pulses Require Immediate Action
If you detect absent pulses with acute onset symptoms (hours to days), this represents a vascular emergency requiring immediate heparin anticoagulation and urgent vascular consultation 4, 5. Look for the "6 P's" of acute limb ischemia: pain, pallor, pulselessness, paresthesias, paralysis, and poikilothermia (coolness) 4, 5.
Diagnostic Accuracy
When both pedal pulses are present bilaterally and no femoral bruits are detected, the specificity is 98.3% and negative predictive value is 94.9% for excluding significant PAD 6. However, abnormal pulse findings must be confirmed with ankle-brachial index (ABI) testing before establishing a diagnosis of PAD 1.
Common Pitfall to Avoid
Never rely solely on dorsalis pedis pulse assessment 4, 5. Always check the posterior tibial pulse as well, since the dorsalis pedis can be congenitally absent. Missing this distinction can lead to false-positive findings and unnecessary testing, or worse, missing true vascular disease when the posterior tibial pulse is also abnormal.