A Family Doctor's Tale - INTERMITTENT CLAUDICATION

DOC I HAVE INTERMITTENT PAIN IN MY CALVES WHEN WALKING

The most important complaint is the pain in one or both calves when walking for some distance with or without numbness or pins and needles in the feet. The main cause is poor arterial blood circulation to the legs as a result of smoking, high cholesterol, obesity or blood clots formed in the arteries of the legs. No smoking, no fatty food, loss of weight and adequate exercise are best for the condition together with blood thinners like aspirin.

Intermittent claudication is a symptom of ischemic muscle pain usually in the calf muscles due to inadequate blood supply during exercise.
It is usually relieved by rest.


It is common in people:
1.Age older than 65 years


2.men older than 50 years affected more than women.


3.smoking


The causes of intermittent claudication are:


1.vascular intermittent claudication caused by peripheral arterial disease(atherosclerosis)- most common cause


2.Neurogenic intermittent claudication caused by spinal canal stenosis.


The symptoms and signs are:


1.Pain in the leg especially when walking a certain distance, disappear after rest, recur again after walking


2.Paraesthesia or numbness of the leg


3.Decrease in Pulse in the leg arteries(dorsalis pedis or posterior tibial arteries)


4.Decreased in temperature due to poorer blood flow


5.Pallor of the skin of leg when leg is raised upwards to 60 degrees


6.Redness of the skin when limb is placed downwards


7.Cyanosis if blood supply to the leg is compromised


8.Bruits may be heard where the arteries are narrowed


The type, size, location and depth of the arterial narrowing in the legs can be determined:


1.Ultrasound (non-invasive)


2.Arteriography where a dye is injected into the artery to determine the areas of narrowing.


Most patients with intermittent claudication can be treated.
1.In patients who smoke, smoking cessation is the most effective treatment.
2.Exercise can improve symptoms  
3.Surgery is only indicated in severe cases with limb-threatening ischemia or lifestyle-limiting claudication.


Medical treatment:
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medication to control the


1.lipid profile - reduction of fats will reduce arteriosclerosis eg. statins


2.diabetes - reduction of blood sugar to normal reduce the risk of diabetic arteriosclerosis


3.hypertension - hypertensive drugs has been found particularly useful in the treatmeent of hypertension and intermittent claudication:
 Angiotensin converting enzyme (ACE) inhibitors,
 beta-blockers,


4.blood clotting
 antiplatelet agents (ASA and clopidogrel), 
 
5.vasodilators
 pentoxifylline
 cilostazol ( PDE3 inhibitor)


Surgical treatment:
---------------------------


1.endarterectomy of leg arteries


2.arterial bypass of localised areas of obstruction


3.Sympathectomy may help in some resistant cases.


Prevention is by living a healthy lifestyle:
1. Stop smoking in smokers.


2. Reduce weight in the obese


3. Exercise to improve blood flow can improve symptoms


4. Foot hygiene and appropriate chiropody


5.Put your feet up when sitting


If treated early, prognosis is fair.


Surgical treatment is only needed if progressive gangrene develops.