Leg Pain – Peripheral Artery Disease
As clinic director of a chiropractic and alternative functional medicine clinic, we treat a lot of patients with “leg pain.” We treat and have written about how to diagnose the variable cause of leg pain ranging from sciatica, to I band syndromes, to peripheral neuropathy, fibromyalgia, statin and vitamin D excess induced pains and more. But amazingly, very few patients have been screened for the possibility of peripheral artery disease (PAD).
The National Heart, Lung and Blood Institute estimates that about 50 percent (8-12 million) of the US adults older than 65 have lower extremity athrosclerosis, commonly knows as peripheral artery disease (PAD). Despite the high prevalence, many patients and clinicians do not immediately consider PAD as a potential cause of leg pain in older people. The disease occurs equally in men and post-menopausal women, but men are more likely to have symptoms. Once recognized, modification of risk factors and non-drug therapeutic interventions can reduce PAD progression and improve symptoms on functional status. I personally would argue that even non-symptomatic PAD warrants aggressive treatment to reduce cardiovascular risk factors because PAD can be a harbinger of other cardiovascular problems.
There are sophisticated exam procedures that can be very diagnostically accurate in the PAD evaluation. They are also very expensive and frequently deemed not medically necessary by the insurance industry. However, the simple in-office evaluation of the ankle pulse can rapidly focus the diagnostic evaluation. The taking of the pulses–all of the pulses–in all leg pain cases should be a standard procedure. The ABI test is the most commonly used and most useful diagnostic test for PAD. It’s a simple test that can be done in the office in less than five minutes. The ABI test compares blood pressure in the ankle with blood pressure in the arm. Other causes of leg pain should also be ruled out with a proper orthopedic exam for low back contributions and neurologic exam for peripheral neuropathy or fibromyalgia contributions also need to occur. A drug review and general symptoms exam should be performed to rule out drug side effects, nutritional deficiencies or other metabolic contributions. Anything short of the above referenced exam is insufficient and can result in a long road of misdiagnosis.
Want to know if you have PAD? Answer the following five questions:
1) Do you get pain or discomfort in your legs when you walk? Yes / No / I am unable to walk.
If you answered no, you don’t have PAD. If you answered yes to question one, please answer the following:
2) Does this pain ever begin when you are standing still or sitting? Yes / No
3) Do you get it if you walk uphill or hurry? Yes / No
4) Do you get it when you walk at ordinary pace on the level? Yes / No
5) What happens if you stand still?
a) Usually continues more than 10 minutes
b) Usually dissipates in 10 minutes or less
If you answer “Yes” to 1, “No” to 2, “Yes” to 3–you probably marked usually dissipates in 10 minutes or less in question number four, you have PAD. A Grade I PAD (mild to moderate) is if you answered “No” to number four, and a Grade II (moderate to severe) is if you said “Yes” to number four.
The Functional Medicine approach to treatment of PAD indicates lifestyle changes according to specifically targeted blood and specialty panels dictated by the patient history. These panels also allow for non-drug treatment evaluation of oxidative stress (the process that breaks down your arterial walls) and lipid/cholesterol problems. Non-drug blood pressure control and regulation. Non-drug balanced glucose blood sugar regulation. Assessing immune system dysfunction (maybe the most important and underappreciated aspect of PAD and coronary artery disease as this process also damages the arteries in legs and heart) and believe it or not, exercise.
Most PAD occurs in the calves and affects walking. But 50 percent may affect other areas of the legs and may not stop the patient from waling or be asymptomatic. The bottom line is if you have leg pain, get it checked. The functional medicine approach is a comprehensive diagnostic approach that fully assesses all potential aspects of leg pain, is patient-centered and treats the patient and not the diagnosis. Its non-drug approaches are safe and effective alternatives to more aggressive treatments that frequently carry with them significant side effects.
1. Inflammation and Atherosclerosis: From Vascular Biology to Biomarker Discovery and Risk Production, Rene S. Packard and Peter Libby, Clinical Chemistry 54:1 24-39 (2008)
2. The Role of Vascular Biology, Nutrition and Nutraceuticals in the Prevention and Treatment of Hypertension, CAD and PAD Mark C. Houston MC, SCH, FACP, FAHA, Supplement #1
For more info, or to schedule a free consultation with Dr. Rutherford or Dr. Gates, call (775) 329-4402, or visit online at www.PowerHealthReno.com.