Intermittent Claudication

  • People with intermittent claudication do not normally need referral
  • Control of risk factors is fundamental

Assessment

Signs and Symptoms

  • Pain in the calf on walking (+thigh/ buttock)
  • Never at rest or standing/weight bearing
  • Resolves completely with 1-5 minutes of rest: recurs after further walking
  • Worse hurrying and uphill

History and Examination

History
  • Details of symptoms (see above) to differentiate from other cause of leg pain
  • Ask about other symptoms which limit walking (e.g. dyspnoea, arthritis)
  • Smoking history
  • Family history – especially for younger patients (e.g. less than 55 years)
Examination
  • Pulse palpation and Doppler examination help to confirm the diagnosis
  • Ankle brachial pressure index is usually less than 1.0 (typically between 0.5 and 1.0) ABPI of more than 1.0 with normal Doppler sounds makes claudication unlikely, but still a possibility in the presence of a good history

Differential Diagnoses

  • Many other causes of leg pain – the symptoms bulleted above are the key to diagnosis

Red Flags

None.

Pain in the calf at night is not characteristic of ischaemic rest pain

Investigations

  • Full blood count to check for anaemia or hyperviscosity
  • Serum lipids
  • Screen for diabetes

Management

  • Advice and help to stop smoking is of the greatest importance
  • Prescribe an antithrombotic (usually clopidogrel) See section 2.9 Antiplatelet drugs
  • Prescribe a statin (even if cholesterol is not high) See section 2.12 Lipid regulating drugs
  • Ensure good control of diabetes and hypertension, if present
  • Advise regular exercise. Walking to the limit of tolerance is beneficial

Referral

Referral Criteria

  • Referral is only indicated for patients whose symptoms have become a persistent and significant disability
  • Do not refer patients who are still smoking
  • Ensure good risk factor control before referral
  • It is reasonable to refer patients with troublesome leg pain when there is doubt about the diagnosis and when confirmation of arterial disease would change management
  • A low ABPI is not an indication for referral: referral should be based on the severity of symptoms and disability
  • A good history of claudication with a normal ABPI may be a reason for referral, for specialist advice to establish the diagnosis

Referral Instructions

Referral to vascular specialist

  • e-Referrals service selection:
    • Specialty: Surgery - Vascular
    • Clinic Type: Not otherwise specified
    • Service: DRSS-South Devon & Torbay-Surgery Vascular- Devon CCG -15N

Referral Forms

DRSS referral form

Torbay and South Devon seeking advice form

Supporting Information

Pathway Group

This guideline has been signed off by Alex Rowe on behalf of South Devon and Torbay CCG.

Publication date: May 2015

 

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