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claudication claudication claudication claudication claudication claudication claudication claudication claudication claudication claudication claudication leg pain leg PAIN LEG pain leg pain leg pain leg pain leg pain leg pain leg pain leg pain leg pain leg pain leg pain leg pain What
is Claudication? The
term Claudication is derived from the Latin claudicatio, which means, ``to limp."
This refers, generally, to pain that develops in the legs upon walking. What
Causes Claudication? Intermittent
claudication is that condition in which pain develops in the legs usually, but not limited
to, the calf muscles due to inadequate circulation (arterial blood supply.) How
Does Poor Circulation Cause Claudication? Simply
stated, intermittent claudication is a problem of oxygen supply and demand. That is, the
supply of blood (actually, the oxygen carried by the blood) does not meet the demands of
the leg muscles. Oxygen is required of all muscles and organs in the body for them to
perform their function. The heart, brain, liver, kidney, etc. require oxygen and so do the
muscles of the legs. If the heart is derived of its oxygen (blood) supply, a ``heart
attack", ensues. Lack of blood supply, or oxygen, to a certain portion of the brain
results in a stroke. Likewise, poor blood supply to the leg muscles produces claudication. Why
Does Claudication Develop? All
muscles need oxygen, which is transported via the arterial circulation, and a lack of
oxygen will produce symptoms. When at rest that is, when a person is sitting-- the level
of oxygen required for the muscle cells to function is very low. As walking begins, that
requirement increases and continues to do so with more walking or more exertion. In a
``normal" person (one without artery disease), the body responds to this increased
need for blood by opening (dilating) the arteries up (much like a faucet will open) to
allow more blood to travel through. Therefore, in a person without arterial disease
(atherosclerosis), the increasing demand of exercise is met by an increasing supply of
blood (oxygen.) However,
in the person with ``hardening of the arteries" (atherosclerosis, arteriosclerosis)
or blockages in the arteries, this increasing demand for more oxygen cannot be met. The
arteries cannot dilate (open) to deliver more blood flow. Therefore, while the blood
supply may be adequate to meet the demands of the muscles when the muscles are at rest,
the increasing demand cannot be met once exercise (walking) begins. How
Do We Diagnose Claudication? The
diagnosis of claudication is made on the basis of a careful history and physical
examination. The pain of intermittent claudication is typically very consistent that is,
it occurs at a rather fixed distance in each person. There may be some variation in
distances related to the incline of the path being walked or the rate at which a person is
walking; however, the pain is usually reproducible at an exact distance. It is rare for
the pain to begin immediately upon standing and it does not usually radiate these are
signs of other causes of leg pain. Rest usually relieves the pain and this relief comes
within one minute of halting the walking exercise. The pain of intermittent claudication
is usually described as a ``cramp" in the calf, thigh or buttocks depending on where
the artery is blocked. Following
a good history, a thorough examination will usually identify those patients with a
circulation problem causing leg pain. The ability to feel for pulses at different points
in the leg is of utmost importance and a skill developed by an experienced examiner. The
Noninvasive Vascular Laboratory will provide objective
evidence of impaired arterial circulation. The use of special equipment (plethysmography)
will allow for the accurate diagnosis of arterial disease of the extremities (arms or
legs). This test is simple, pain-free and quick. It must, however, be performed by an
experienced technologist and interpreted by a vascular surgeon well versed in this
technology. What
is the Treatment of Claudication? A
large experience in our practice, and that in the medical literature, shows that most
patients (>75%) will improve with conservative therapy! It is very rare that
intervention is needed to adequately treat intermittent claudication. The use of a walking
exercise program AND the cessation of tobacco use will, if followed, improve arterial
circulation without the need for surgery or balloon angioplasty. The presence of
claudication does NOT imply that limb loss (need for amputation) will occur. Only very
rarely, will the person with intermittent claudication have their disease progress to the
point of gangrene or limb loss. A
walking exercise program simply means that for thirty (30) minutes each day, the person
must walk PAST THE POINT of claudication. For example, if one can walk 100 steps before
the calf cramping sets in, he should walk those 100 steps; when the cramping begins, that
person should bite his tongue and walk another ten (10) steps WITH THE PAIN and then stop.
Exercise tolerance is built up gradually and consistently. However, one must be diligent
at this and it MUST be accompanied by the cessation of smoking! If
the exercise tolerance does not improve with an honest 2-3 month effort on the part of the
patient AND if the intermittent claudication is truly prohibiting a person from conducting
his lifestyle in a manner that he can tolerate, intervention may be considered. However,
one must understand that once surgery or balloon angioplasty of arterial problems is
performed, the patient must be monitored for the remainder of his or her life. All
arterial procedures have a finite lifespan and, depending on the person's other medical
problems, may need to be repeated at a later date. There
is NO justification for performing any type of lower extremity procedure in a patient who
has no symptoms (asymptomatic) but does have a ``blockage." Persons whose
intermittent claudication does progress to either ``rest pain"
(leg or foot pain even without walking), gangrene (blackening of the
skin) or a nonhealing ulcer are at risk for losing their legs
and must be treated aggressively and appropriately.
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