Peripheral arterial disease differential diagnosis

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AHA/ACC Guidelines on Management of Lower Extremity PAD
Guidelines for Clinical Assessment of Lower Extremity PAD
Guidelines for Diagnostic Testing for suspected PAD
Guidelines for Screening for Atherosclerotic Disease in Other Vascular Beds in patients with Lower Extremity PAD
Guidelines for Medical Therapy for Lower Extremity PAD
Guidelines for Structured Exercise Therapy for Lower Extremity PAD
Guidelines for Minimizing Tissue Loss in Lower Extremity PAD
Guidelines for Revascularization of Claudication in Lower Extremity PAD
Guidelines for Management of CLI in Lower Extremity PAD
Guidelines for Management of Acute Limb Ischemial in Lower Extremity PAD
Guidelines for Longitudinal Follow-up for Lower Extremity PAD
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Editors-in-Chief: C. Michael Gibson, M.D., Beth Israel Deaconess Medical Center, Boston, MA; Robert G. Schwartz, M.D. [1], Piedmont Physical Medicine and Rehabilitation, P.A.; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Differentiating Peripheral arterial disease from other Diseases

• Intermittent claudication (IC) must be differentiated from lower extremity pain with nonvascular etiologies
• Many concomitant disease processes can complicate the diagnosis of PAD
• Both neurologic and musculoskeletal and venous pathology can cause leg pain or coexist with leg pain from PAD
• False-positive diagnosis rates of up to 44% and false-negative rates of up to 19% have been reported
• Calf claudication is commonly confused with pain from venous disease, nerve root compression or spinal cord stenosis
• Hip and buttock claudication is commonly confused with osteoarthritis of the hip or with spinal canal narrowing due to osteoarthritis
• Nonatherosclerotic conditions that mimic intermittent claudication:

  • Venous Claudication

    • Occurs in patients with chronic venous insufficiency and those who develop post-thrombotic syndrome after deep venous thrombosis
    • Baseline venous hypertension in the obstructed veins worsens with exercise and produces a tight bursting pressure in the limb, usually worse in the thigh and uncommonly in the calf
    • Usually associated with evidence of venous edema in the leg
    • Venous claudication tends to improve with cessation of exercise, but total resolution takes much longer than resolution of intermittent claudication (IC), and may require leg elevation

  • Chronic compartment syndrome

    • An uncommon cause of exercise-induced leg pain
    • Tends to occur in young athletes, who develop increased pressure within a fixed compartment, compromising perfusion and function of the tissues within that space
    • Results from thickened fascia, muscular hypertrophy or when external pressure is applied to the leg
    • Presentation is one of tight bursting pressure in the calf or foot following participation in endurance sports or other robust exercise
    • Pain subsides slowly with rest
    • Intracompartmental pressure testing before and after exercise is the diagnostic test of choice

  • Peripheral nerve pain

    • Generally attributable to nerve root compression by herniated disks or osteophytes and typically follows the dermatome of the affected root
    • Pain usually begins immediately upon walking and may be felt in the calf or lower leg
    • Pain is not quickly relieved by rest and may even be present at rest
    • A sensation of pain running down the back of the leg as well as a history of back problems may be present

  • Spinal chord compression from narrowing secondary to lumbar spine osteoarthritis

    • In patients with cauda equina syndrome, upright positioning aggravates the narrowing of the spinal canal, therefore causing symptoms.
    • Upright standing may produce pain, weakness or discomfort in the hips, thighs and buttocks, and sometimes a sensation of numbness and paresthesias, although symptoms are usually associated with walking.
    • Symptoms are alleviated by sitting or flexing the lumbar spine forward as opposed to standing, which alleviates pain caused by IC.

  • Hip and knee osteoarthritis

    • Osteoarthritis in joints is typically worse in the morning or at the initiation of movement
    • Degree of pain varies day to day, does not cease upon stopping exercise or standing
    • Pain improves after sitting, lying down, or leaning against an object to alleviate weight-bearing on the joint.
    • Pain may be affected by weather changes, and may be present at rest

  • Nonatherosclerotic etiologies of arterial disease:

    • Thromboangiitis obliterans
    • Popliteal artery entrapment syndrome
    • Cystic adventitial disease
    • Fibromuscular dysplasia
    • Exercise-induced endofibrosis of the iliac arteries
    • Other arterial causes of IC or critical limb ischemia

      • All of these conditions generally produce a decrease in the exercise or resting ABI
      • Usually differentiated from atherosclerotic etiologies by the history and physical examination

References

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