Jump to content

Intermittent Claudication

(Redirected from Claudication)

Original Editor - Hetvi Gala

Top Contributors - Swati Singh, Jonathan Wong, Hetvi Gala, Lucinda hampton, Oyemi Sillo, Aminat Abolade and Alexandra Stead

Definition

Intermittent Claudication refers to an aching, tired, cramp-like and sometimes burning pain mainly in the legs unilaterally or bilaterally, which typically occurs with exercise and walking a certain distance for a certain amount of time and subsides with rest.[1] IC presents as a consequence of insufficient oxygen delivery to match the metabolic requirements of the skeletal muscles, most notably the lower limbs: IC commonly presents in the thigh, hip, buttock, and calf muscles.[2] The key feature of IC is that the pain is reproducible: provoked by walking and relieved by rest.[2]

Epidemiology

In the general population, over age 60, IC presents in 5% of men and 2.5% of women.

  • Only 10% to 35% present with “classic” intermittent claudication.
  • Patient groups have a higher incidence of IC include those aged greater than 70, people who smoke, patients with diabetes between the ages of 50-69, and those with other atherosclerotic cardiovascular diseases.[2]

Causes & Pathophysiology

Narrowing of artery
Narrowing of artery

Peripheral Arterial Disease (PAD) due to atherosclerosis or plaque formation is the most common cause of Intermittent Claudication[3]. This stenosis, or narrowing of arteries, makes it difficult for the oxygen-rich blood to reach the region it supplies. The ensuing imbalance between the demand and supply of oxygen, especially during activities which increase this demand, e.g., walking, results in pain. Pain severity sometimes correlates with the extent of stenosis/blockage in the arteries supplying the lower limb.[4][5][6]

Risk Factors

Risk factors for intermittent claudication (IC) are similar to risk factors for atherosclerosis:[2]

Modifiable risk factors:

Non-modifiable risk factors:

  • age
  • male gender
  • family history
  • Congenital predisposition

Diagnosis

The following tools can be used for the diagnosis of claudication[2]

Differential Diagnosis

Clinical features[2]

  • The patient usually complains of pain in one or both legs after walking for a particular distance, after which the patient needs to sit. The pain is usually burning or cramp-like, mainly in the calves and buttocks.[3] The site of pain is usually distal to the site of arterial occlusion.
  • Rest pain is due to severe occlusion. Pain is more severe at night.
  • Shiny, hairless skin of the legs
  • Pallor and absent pulse, mainly of the lower limbs, potentially ischemic leg
  • Reduced skin temperature - the affected limb may feel cool
  • Trophic changes of nails
  • The limb becomes pale on elevation.
  • Lack of exercise endurance
  • Prolonged wound healing
  • Impotence
  • Blue toe syndrome

Physical Exam

  • Observation:[8]
    • Dry skin
    • Muscle wasting
    • Reduced hair growth
  • Temperature of affected limb: may feel cool
  • Assessment of femoral, popliteal, dorsalis pedis, and posterior tibial artery pulses: In IC, there should be weakened or absent pulses. Generally, the presence of strong pedal pulses opposes an IC diagnosis.[2]
    • Patients with nonpalpable femoral pulses are more likely to have inflow or toiliac) disease, whereas patients with palpable femoral pulses, but nonpalpable popliteal and pedal pulses, are more likely to have outflow (femoropopliteal and/or tibial) disease.[8]
  • Should carefully eliminate other causes of leg pain, like:
    • neurogenic pseudoclaudication (spinal stenosis),
    • musculoskeletal pain, and
    • venous claudication

The video will help to have a better understanding of the concept:[9]

Grades for Classification of Claudication

According to the European Society of Cardiovascular Surgery, the symptoms of Claudication presented by the patient can help in determining the severity of occlusion.

Fontaine classification[10]

Grade Symptoms
Stage I Asymptomatic, incomplete blood vessel obstruction
Stage II Mild claudication pain in limb
Stage IIA Claudication at a distance > 200 m
Stage IIB Claudication at a distance < 200 m
Stage III Rest pain, mostly in the feet
Stage IV Necrosis and/or gangrene of the limb

20% to 30% of persons with IC will experience progressive claudication, with 1%–3% of all patients with IC progressing to chronic limb-threatening ischemia.[8] 5-year mortality in patients with IC presents as high as 15%, with another 20% of patients experiencing a stroke or myocardial infarction in as many years. [8]

Assessment of Claudication Distance

This is mainly done to assess the severity of occlusion and to monitor the improvement of the patient after surgical or Non-Surgical Intervention. [11][12]

The patient is asked to walk on a treadmill. The Distance at which the patient starts feeling pain is marked. This distance is termed the Initial Claudication Distance. However, the patient can walk further for a certain distance, after which the pain is maximum, interfering with the patient's ability to walk. This distance is termed the Maximum Claudication distance.

The difference in the Initial claudication distance and the Maximum Claudication distance is due to the formation of collateral blood vessels, which compensate for the occluded blood vessel. However, with increased demand on further walking, these collateral vessels become incompetent, leading to cessation of walking.

For more details, refer to Peripheral arterial disease

Management

The modern view on managing intermittent claudication emphasises a comprehensive, patient-centred approach:

  1. Exercise therapy remains the cornerstone of treatment:
    • Supervised exercise therapy (SET) programs are now considered first-line therapy[13][14] and structured walking programs increase pain-free walking distance better than pharmacological treatment alone.[2] The CLEVER (Claudication: Exercise Vs Endoluminal Revascularisation) trial found that supervised exercise programs were superior to endovascular revascularisation for improving treadmill walking performance, for patients with aortoiliac disease[15]
    • Exercise program guidelines:[16]
      • At least three times per week
      • Each should last a minimum of 30 minutes, ideally 30-60 minutes[8]
      • The program should last a minimum of 3 months, with greater results at 6 months[17]
    • Exercise program outline:
      1. Begin with exercise sufficiently intense as to provoke claudication.[8] Generally, the consensus is that patients should walk until moderate-high pain is provoked (2-3 on a scale of 0 to 4).[17][18] However, some trials have found success adopting a low or no pain approach.[19] As claudication pain can be an exercise barrier, it is possible to trial a low pain approach for patients for whom pain may be a barrier.[16] That said, the highest quality evidence still exists for exercising to the point of moderate to high pain.[18] [17]
        • Aim to reach this moderate amount of pain within 5 to 10 minutes of walking.[20] As they progress, they will need to walk uphill or faster, or both, to evoke pain within this timeframe.
        • Although walking is usually the first choice, aerobic arm exercise or total body recumbent stepping may be used if walking is unsafe for the patient or the patient is not progressing with walking.[13][18]
          • When performing these alternative modes of exercise and experiencing claudication, progression should mimic that of walking exercise. If no pain is experienced, exercise progression would be based on the rating of perceived exertion and target heart rate.[21]
      2. Stop and rest until the pain subsides.
        • Resting time should be around 2-5 mins as symptoms usually dissipate in that time[20][22]
      3. Start walking again:[15] Patient should then continue walking for at least 30 to 60 minutes, following the same pattern of walking and resting.[8] Over time, this should increase the total distance walked and the total distance before symptom onset.[8]
        • These intermittent periods of rest and exercise are thought to improve oxygen extraction by muscles[23]
        • Initially aiming for an intermittent exercise duration of 30-60 minutes, and progressing to a total walking duration of 30-60 minutes.
      4. Progression should happen every 1-2 weeks or greater[20]
    • Although high-quality evidence exists suggesting that supervised exercise programs have a greater benefit in treadmill walking distance compared with home-based exercise therapy and walking advice, any exercise program is preferable to no walking program.[8]
  2. Risk factor modification is crucial:
    • Aggressive management of cardiovascular risk factors[8]
    • Smoking cessation programs
      • Continued smoking during walking programs restricts improvement[2]
      • Education: cessation may reduce symptoms and decrease the risk and number of future vascular interventions.[8]
      • Pharmacology: Bupropion and varenicline[8]
    • Dietary interventions and weight management
  3. Pharmacological interventions:[8]
    • Antiplatelet therapy (e.g., aspirin) for all patients
    • Cilostazol is still recommended for symptom relief.
    • Statins are used not just for lipid lowering, but for their pleiotropic effects.
  4. Endovascular interventions:
    • Increasing use of minimally invasive procedures
    • Angioplasty and stenting are considered earlier in treatment algorithms.
    • New technologies like drug-coated balloons and stents show promise.
  5. Surgical interventions:
    • Current professional guidelines suggest patients trial conservative approaches such as supervised exercise for a minimum of 3 to 6 months before considering revascularisation [8]
    • Reserved for severe cases or when endovascular options are not suitable
    • Hybrid procedures combining open and endovascular techniques are more common.
    • After revascularisation, performing supervised exercise therapy leads to superior functional benefits versus revascularisation or SET alone[24]
  6. Personalised treatment plans:
    • Tailoring interventions based on individual patient characteristics, preferences, and disease patterns
  7. Multidisciplinary approach:
    • Involving vascular specialists, physiotherapists, and other healthcare professionals
  8. Quality of life focus:
    • Emphasis on improving functional capacity and overall well-being, not just symptom relief

Note: Ankle Brachial Indexes should not be expected to improve after conservative PAD management; however, noting significant decreases in ABI or worsening symptomatology may be useful as it suggests the PAD progression[8]

This modern approach aims to improve outcomes, reduce invasive interventions where possible, and enhance patients' overall quality of life. [2]

References

  1. ↑ Medical Definition of Intermittent Claudication [Internet]. Medicinenet.com. [cited 2021 Nov 28]. Available from: https://www.medicinenet.com/intermittent_claudication/definition.htm
  2. ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 Patel SK, Surowiec SM. Intermittent claudication. InStatPearls [Internet] 2023 Jul 10. StatPearls Publishing.Available: https://www.ncbi.nlm.nih.gov/books/NBK430778/(accessed 26.2.2025)
  3. ↑ 3.0 3.1 Claudication [Internet]. Hopkinsmedicine.org. [cited 2021 Nov 28]. Available from: https://www.hopkinsmedicine.org/health/conditions-and-diseases/claudication
  4. ↑ Abaraogu U, Ezenwankwo E, Dall P, Tew G, Stuart W, Brittenden J, Seenan C. Barriers and enablers to walking in individuals with intermittent claudication: A systematic review to conceptualise a relevant and patient-centred program. PLoS One. 2018 Jul 26;13(7):e0201095. doi: 10.1371/journal.pone.0201095. PMID: 30048501; PMCID: PMC6062088.
  5. ↑ Golledge J, Maarij K, Moxon JV, Beard JD, Girold S, Wrang H, Morris DR. Systematic Review and Meta-analysis of Clinical Trials Examining the Benefit of Exercise Programmes Using Nordic Walking in Patients With Peripheral Artery Disease. Eur J Vasc Endovasc Surg. 2018 Oct;56(4):534-543. doi: 10.1016/j.ejvs.2018.05.026. Epub 2018 Jul 13. PMID: 30017508.
  6. ↑ Skórkowska-Telichowska K, Kropielnicka K, Bulińska K, Pilch U, Woźniewski M, Szuba A, Jasiński R. Insufficient modification of atherosclerosis risk factors in PAD patients. Adv Clin Exp Med. 2018 Jun;27(6):819-826. doi: 10.17219/acem/68983. PMID: 30059197.
  7. ↑ Sutcliffe JB 3rd, Bui-Mansfield LT. AJR Teaching File: intermittent claudication of the lower extremity in a young patient. AJR Am J Roentgenol. 2007;189(3 Suppl):S17-20.
  8. ↑ 8.00 8.01 8.02 8.03 8.04 8.05 8.06 8.07 8.08 8.09 8.10 8.11 8.12 8.13 8.14 Stonko DP, Hicks CW. Current Management of Intermittent Claudication. Adv Surg. 2023 Sep;57(1):103-113. doi: 10.1016/j.yasu.2023.04.009. Epub 2023 May 29. PMID: 37536847; PMCID: PMC10773527.
  9. ↑ 1. Prof Walsh's Vascular Survival Guide. Intermittent Claudication [Internet]. YouTube. 2021 [cited 2025 Jul 9]. Available from: https://www.youtube.com/watch?v=45Algcuy92s ‌
  10. ↑ Hardman RL, Jazaeri O, Yi J, Smith M, Gupta R. Overview of classification systems in peripheral artery disease. Semin Intervent Radiol. 2014;31(4):378–88.
  11. ↑ Labs KH, Nehler MR, Roessner M, Jaeger KA, Hiatt WR. Reliability of treadmill testing in peripheral arterial disease: a comparison of a constant load with a graded load treadmill protocol. Vascular Medicine. 1999 Nov;4(4):239-46.
  12. ↑ Kruidenier LM, Nicolaï SPA, Willigendael EM, de Bie RA, Prins MH, Teijink JAW. Functional claudication distance: a reliable and valid measurement to assess functional limitation in patients with intermittent claudication. BMC Cardiovasc Disord. 2009;9(1):9.
  13. ↑ 13.0 13.1 Lane R, Harwood A, Watson L, Leng GC. Exercise for intermittent claudication. Cochrane Database of Systematic Reviews. 2017(12).
  14. ↑ Gerhard-Herman MD, Gornik HL, Barrett C, et al. 2016 AHA/ACC Guideline on the management of patients with lower extremity peripheral artery disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2017;69(11):e71–e126. doi:10.1016/j.jacc.2016.11.007. Erratum in: J Am Coll Cardiol. 2017;69(11):152
  15. ↑ 15.0 15.1 Murphy TP, Cutlip DE, Regensteiner JG, Mohler ER, Cohen DJ, Reynolds MR, Massaro JM, Lewis BA, Cerezo J, Oldenburg NC, Thum CC. Supervised exercise versus primary stenting for claudication resulting from aortoiliac peripheral artery disease: six-month outcomes from the claudication: exercise versus endoluminal revascularisation (CLEVER) study. Circulation. 2012 Jan 3;125(1):130-9.
  16. ↑ 16.0 16.1 Mazzolai L, Belch J, Venermo M, Aboyans V, Brodmann M, Bura-Rivière A, Debus S, Espinola-Klein C, Harwood AE, Hawley JA, Lanzi S, Madarič J, Mahé G, Malatesta D, Schlager O, Schmidt-Trucksäss A, Seenan C, Sillesen H, Tew GA, Visonà A. Exercise therapy for chronic symptomatic peripheral artery disease. Eur Heart J. 2024 Apr 14;45(15):1303-1321. doi: 10.1093/eurheartj/ehad734. PMID: 38461405.
  17. ↑ 17.0 17.1 17.2 Gardner AW, Poehlman ET. Exercise rehabilitation programs for the treatment of claudication pain: a meta-analysis. Jama. 1995 Sep 27;274(12):975-80.
  18. ↑ 18.0 18.1 18.2 Salisbury DL, Swanson K, Brown RJ, Treat-Jacobson D. Total body recumbent stepping vs treadmill walking in supervised exercise therapy: a pilot study. Vasc Med. 2022;27(2):150–157.
  19. ↑ Parmenter BJ, Raymond J, Dinnen P, Singh MA. A systematic review of randomised controlled trials: walking versus alternative exercise prescription as treatment for intermittent claudication. Atherosclerosis. 2011 Sep 1;218(1):1-2.
  20. ↑ 20.0 20.1 20.2 Ehrman JK, Gardner AW, Salisbury D, Lui K, Treat-Jacobson D. Supervised Exercise Therapy for Symptomatic Peripheral Artery Disease: A REVIEW OF CURRENT EXPERIENCE AND PRACTICE-BASED RECOMMENDATIONS. J Cardiopulm Rehabil Prev. 2023 Jan 1;43(1):15-21. doi: 10.1097/HCR.0000000000000723. Epub 2022 Sep 16. PMID: 36114638.
  21. ↑ Treat-Jacobson D, McDermott MM, Beckman JA, et al. Implementation of supervised exercise therapy for patients with symptomatic peripheral artery disease: a science advisory from the American Heart Association. Circulation. 2019;140(13):e700–e710.
  22. ↑ Rose GA. The diagnosis of ischaemic heart pain and intermittent claudication in field surveys. Bulletin of the World Health Organisation. 1962;27(6):645.
  23. ↑ Stewart KJ, Hiatt WR, Regensteiner JG, Hirsch AT. Exercise training for claudication. N Engl J Med. 2002 Dec 12;347(24):1941-51. doi: 10.1056/NEJMra021135. PMID: 12477945.
  24. ↑ Saratzis A, Paraskevopoulos I, Patel S, et al. Supervised exercise therapy and revascularisation for intermittent claudication: network meta-analysis of randomised controlled trials. JACC Cardiovasc Interv. 2019;12(12):1125–1136.
Retrieved from "https://www.physio-pedia.com/w/index.php?title=Intermittent_Claudication&oldid=373339"