What is the appropriate work‑up for a patient presenting with leg heaviness?

Work-up for Leg Heaviness

Begin with a focused history to distinguish peripheral artery disease (PAD) from alternative diagnoses, followed by ankle-brachial index (ABI) measurement if PAD is suspected, as this is the recommended first-line diagnostic test. 1

Initial Clinical Assessment

The history should specifically characterize:

• Location and quality of symptoms: Leg heaviness in PAD typically affects the calf, thigh, or buttocks with aching or fatigue that is reproducible with exertion 1
• Exacerbating factors: Symptoms consistently triggered by walking a predictable distance suggest PAD, whereas variable exercise tolerance points toward alternative diagnoses 1
• Relieving factors: PAD symptoms resolve within 2-10 minutes of rest without position change, unlike spinal stenosis (requires sitting/spine flexion) or venous claudication (requires prolonged rest and leg elevation) 1
• Risk factors: Age ≥65 years, age 50-64 with atherosclerosis risk factors, diabetes with additional risk factors, smoking history, or known atherosclerotic disease elsewhere 1

Physical Examination

All lower extremity garments including shoes and socks must be removed for proper vascular examination. 1

Key examination components include:

• Pulse palpation: Assess femoral, popliteal, dorsalis pedis, and posterior tibial pulses bilaterally, grading as 0 (absent), 1 (diminished), 2 (normal), or 3 (bounding) 1. Presence of all four pedal pulses (bilateral dorsalis pedis and posterior tibial) makes PAD unlikely 1
• Auscultation: Listen for femoral and abdominal bruits 1
• Inspection: Look for elevation pallor, dependent rubor, asymmetric hair growth, calf muscle atrophy, and skin changes 1
• Neuropathy assessment: Particularly important in diabetic patients, as neuropathy can mask PAD symptoms ("masked LEAD") 1

Diagnostic Testing Algorithm

If PAD is Suspected (Based on History/Physical)

Resting ABI with or without segmental pressures and waveforms is the recommended initial diagnostic test. 1

ABI interpretation:

• ≤0.90: Abnormal, confirms PAD 1
• 0.91-0.99: Borderline 1
• 1.00-1.40: Normal 1
• >1.40: Non-compressible arteries (medial calcinosis, common in diabetes) 1

Additional Testing Based on ABI Results

For non-compressible arteries (ABI >1.40): Measure toe-brachial index (TBI) to establish PAD diagnosis 1

For normal/borderline ABI (>0.90 to ≤1.40) with persistent exertional leg symptoms: Perform exercise treadmill ABI testing to unmask PAD 1. This objectively measures functional limitation and can diagnose PAD when resting studies are normal 1

For confirmed PAD with symptoms severe enough to consider revascularization: Duplex ultrasound, CTA, or MRA to define anatomic location and severity of stenosis 1

Differential Diagnosis Considerations

The broad differential for leg heaviness includes 1:

• Spinal stenosis: Bilateral buttocks/posterior leg pain with standing/walking, relieved by lumbar flexion (sitting), often with back pain history 1
• Hip/foot arthritis: Aching after variable exercise, improved when not bearing weight, history of degenerative disease 1
• Venous claudication: Entire leg tightness/bursting pain, subsides slowly with rest, speeded by elevation, history of deep vein thrombosis with edema and venous stasis signs 1
• Nerve root compression: Sharp lancinating pain radiating down leg, induced by sitting/standing/walking variably, often present at rest 1
• Chronic compartment syndrome: Tight bursting calf pain after strenuous exercise in heavily muscled athletes, subsides very slowly 1

Critical Pitfalls to Avoid

• Do not rely on "atypical" symptoms to exclude PAD: Only one-third of PAD patients present with typical claudication; most have atypical exertional leg symptoms 1
• Identify "masked LEAD" patients: Elderly patients with multiple comorbidities, limited walking capacity, or neuropathy may have severe PAD without classic symptoms and can rapidly progress to critical limb-threatening ischemia after minor trauma 1, 2
• Do not perform anatomic imaging (CTA/MRA/angiography) in asymptomatic PAD patients: These studies are reserved for symptomatic patients considering revascularization 1
• Recognize that pulse examination alone has limitations: While helpful, reproducibility is better for detecting absent versus diminished pulses 1, 3