Signs and Symptoms

• Pain in the calf / thigh / buttock on walking
• Resolves completely with 1-5 minutes of rest: recurs after further walking
• Worse on incline or hurrying

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)
• Diabetes / hypertension / renal impairment history
• Smoking history – smoking cessation advice/support should be offered
• Family history – especially for younger patients (e.g. less than 55 years)

Examination

• Evidence of arterial pulses on palpation or Doppler
• Blood Pressure
• ABPI:
  • The normal range for an ABPI is 0.8-1.3. ABPI of more than 1.0 with normal Doppler sounds makes claudication unlikely, but still a possibility in the presence of a good history (calcification of arteries may give false readings – especially in diabetics)
  • ABPI in patients with intermittent claudication is typically between 0.5 and 0.8)

• Distal ulceration or gangrene below the ankle (see Red Flags)

Differential Diagnoses

There are many other causes of leg pain – the symptoms bulleted above are the key to diagnosis.

If the patient has palpable distal pulses / ABPI greater than 0.8, consider alternative diagnoses e.g., musculoskeletal / spinal stenosis etc.

Leg weakness or numbness are not features of intermittent claudication. Weakness or heaviness on walking, with symptoms localised to a muscle group can be features of spinal pain. These symptoms are sometimes relieved by leaning forward.

Same Day Admission

• Patients with ulceration below the ankle AND infection

Urgent referral to Vascular Surgeon

• Nocturnal pain or Rest Pain
• Pain relieved by dependency
• IC symptoms AND an ABPI lower than 0.5
• Distal ulceration or gangrene, below the ankle

• Full Blood Count (FBC) - to check for anaemia or hyperviscosity
• Renal Function Tests (RFTs)
• Serum lipids
• HbA1c
• Blood Pressure
• ABPI

The mainstay of treatment for IC is managing risk factors in primary care.

Patients with mild symptoms / few limitations in lifestyle and ABPI 0.5-0.8

Assess Cardio-Vascular Risk and maximise tolerated treatment, including:

• Smoking Cessation
• Diabetes
• Blood Pressure
• Prescribe lipid-regulating drugs (even if cholesterol is not high)
• Prescribe anti-platelet drugs
• Avoid Betablockers if possible
• Advise regular exercise. Walking to the limit of tolerance is beneficial.

Monitor progress e.g., for 4 – 6 months

• If improvements in symptoms – continue
• If stable / adjusts lifestyle to symptoms – continue
• If symptoms deteriorate despite maximally tolerated risk factor modification, refer to the Vascular clinic

Please Note

a) Smoking Cessation

There is a strong expectation that the patient will have made all efforts to stop smoking prior to referral.

Patients who smoke, without evidence of critical limb ischaemia (see Red Flags), have a significantly higher risk of complications from surgical intervention. In those patients’, secondary care surgical interventions are unlikely to be offered, as surgical risks nearly always outweigh the benefits. Risk factor modification, especially smoking cessation, is the mainstay of treatment.

b) A low ABPI alone is NOT an indication for referral: referral should be based on the severity of symptoms and disability.

Same Day Admission

• Patients with ulceration below the ankle AND infection

Urgent Referral Criteria

• Nocturnal pain or Rest Pain
• Pain relieved by dependency
• IC symptoms AND an ABPI lower than 0.5
• Distal ulceration or gangrene, below the ankle

Routine Referral Criteria

• Patients with an ABPI between 0.5-0.8 and have moderate to severe symptoms (e.g., limiting lifestyle, walking distance (below 200m)), despite maximally tolerated risk factor modification – including smoking cessation ⃰.
  
  ⃰ Patients who smoke, without evidence of critical limb ischaemia (see Red Flags), have a significantly higher risk of complications from surgical intervention. In those patients’, secondary care surgical interventions are unlikely to be offered, as surgical risks nearly always outweigh the benefits. Risk factor modification, especially smoking cessation, is the mainstay of treatment.

• Patients with troublesome leg pain when there is doubt about the diagnosis and when confirmation of arterial disease would change management
  e.g., patients with a good history of claudication but have a normal ABPI

Referral Instructions

Referral to vascular specialist

• e-Referrals service selection:
  • Specialty: Surgery - Vascular
  • Clinic Type: Not otherwise specified
  • Service: DRSS-Western-Vascular- Devon ICB-15N

Referral Form

DRSS referral form

Pathway Group

This guideline has been signed off on behalf of NHS Devon.

Publication date: June 2015

Updated: November 2024