Intermittent Claudication

Intermittent claudication is muscle pain in your legs that happens when you’re active and goes away when you rest. This pain is a sign that your muscles aren’t getting enough oxygen because of blood flow problems. With proper treatment and lifestyle changes, most people can prevent the condition from getting worse and maintain an active life.

Table of contents

• What is intermittent claudication?
• Symptoms and how it feels
• What causes intermittent claudication
• Risk factors
• Diagnosis and medical tests
• Treatment options
• Possible complications
• When to contact your doctor

What is intermittent claudication?

Intermittent claudication is muscle pain that appears during physical activity and disappears when you rest. The word “intermittent” means it happens only some of the time, and “claudication” comes from a Latin word meaning “to limp”^[1]. This condition most commonly affects the legs, particularly the calf muscles, but can also affect the thighs, buttocks, and hips^[2].

Intermittent claudication itself is actually a symptom of a more serious condition called peripheral artery disease (PAD). PAD occurs when arteries in your legs become narrowed or blocked due to a buildup of fatty deposits called plaque. This process is known as atherosclerosis^[1]. When your arteries are narrowed, your leg muscles cannot get enough oxygen-rich blood during exercise, which causes the pain.

Between 10% and 35% of all patients with peripheral artery disease experience classic intermittent claudication^[3]. In the general population over age 60, intermittent claudication is present in about 5% of men and 2.5% of women^[3].

Symptoms and how it feels

The pain from claudication is usually described as dull and aching. It may also feel like your muscles are tiring out, cramping, or experiencing a spasm. Some people compare it to a “Charley horse”^[1]. Others describe it as a tight, aching, or squeezing pain, or simply a sensation of heaviness and fatigue in the leg muscles^[2][4].

One of the key features of intermittent claudication is that the pain is reproducible and predictable. The pain typically appears after the same amount of exercise each time. For example, you might notice pain after walking a certain distance or climbing a certain number of stairs^[3]. The amount of activity needed to bring on the pain depends on factors like your walking speed and whether you are walking uphill or downhill^[6].

The pain usually stops within a few minutes—or even less—once you stop and rest^[1]. This quick relief with rest is what makes claudication different from other types of leg pain. In some cases, you may also feel numbness in your legs because the nearby nerves don’t have enough blood flow^[1].

Additional symptoms that may appear include:

• An aching or burning feeling in the legs
• Cold feet
• Skin on the leg or foot that becomes shiny, hairless, or has a blotchy appearance
• The affected leg becoming pale when elevated and reddened when lowered
• Sores on the feet or legs that are slow to heal
• In men, impotence
• Leg pain that occurs at night when in bed^[4][7]

Intermittent claudication can range from mild to severe. As the condition progresses, the pain may come on earlier and become more frequent. With treatment, however, more than 70% of people can keep the condition from getting worse for at least five years^[1].

What causes intermittent claudication

Intermittent claudication happens because of ischemia (pronounced “iss-key-me-uh”), which means a part of your body doesn’t have enough blood flow. When blood flow is reduced, the affected areas don’t receive enough oxygen^[1]. During physical activity, your muscle cells work harder and need more oxygen than your blood can deliver. When you’re resting, those cells don’t need as much oxygen, so there’s enough supply to meet the demand.

The main cause of intermittent claudication is peripheral artery disease (PAD). PAD develops when atherosclerosis causes plaque to build up on the inside of your arteries. This plaque is made up of fatty substances, cholesterol, cellular waste products, calcium, and other materials^[9]. As the buildup gets worse, there’s less room for blood to flow through those arteries. Think of it like a closed lane on a road that causes traffic to slow down and back up^[1].

The blockage in the leg arteries is most common in the thigh and behind the knee, but may also occur at other sites including the aorta, groin, or abdomen. A person may have more than one blockage^[9].

While PAD is by far the most common cause, other uncommon causes of intermittent claudication include coarctation of the aorta, Buerger’s disease (a condition where blood vessels become inflamed), and Raynaud’s phenomenon^[5].

Risk factors

The risk factors for developing intermittent claudication are similar to those for atherosclerosis and heart disease. These risk factors can be divided into two groups: those you can change and those you cannot.

Modifiable risk factors (those you can change) include:

• Smoking—this is one of the most important risk factors
• High blood pressure (hypertension)
• High cholesterol and other blood fat problems (dyslipidemias)
• Diabetes mellitus
• Being overweight or obese
• Metabolic syndrome
• Not exercising regularly^[3][7]

Non-modifiable risk factors (those you cannot change) include:

• Age—being a man over age 55 or a woman over age 60
• Male gender
• Family history of claudication or certain kinds of heart disease, such as atherosclerosis or peripheral artery disease^[3][7]

Besides smoking, poor kidney function is also considered a high-risk factor for the development of intermittent claudication^[3]. The condition is strongly associated with smoking, hypertension, and diabetes^[5].

Diagnosis and medical tests

Intermittent claudication may go undiagnosed because many people think the pain is just a normal part of aging. Some people simply reduce their activity level to avoid the pain^[13]. However, it’s important to see a doctor if you experience leg pain with walking that goes away with rest.

A diagnosis starts with a review of your symptoms, medical history, and lifestyle factors. Your doctor will perform a physical exam that includes checking the pulses in your legs and feet. If the pulses in your legs or feet are weaker than normal or impossible to feel or hear, it may indicate claudication^[1]. The doctor will also evaluate the skin on your limbs for signs of arterial insufficiency, such as prolonged wound healing, cool limbs, shiny or hairless skin, and changes in skin color^[1].

Common diagnostic tests include:

Ankle-brachial index (ABI) test: This test measures and compares the blood pressure in your ankle with the blood pressure in your arm. A large difference between the two may mean you have claudication. This is a simple, non-invasive test that is often the first step in diagnosis^[1][13].

Doppler ultrasound: This test uses sound waves to see the flow of blood through your vessels. It can help identify areas where blood flow is reduced or blocked^[13].

Segmental blood pressure measurement: This involves taking a series of blood pressure measurements at different areas on the arm or leg to help determine the amount and location of damage to the arteries^[13].

Exercise testing: This determines the maximum distance you can walk or the maximum exertion you can tolerate without pain. The “walk-rest-walk” pattern helps doctors understand how severe your claudication is^[13].

Imaging tests: Magnetic resonance angiography (MRA), computed tomography angiography (CTA), or standard angiography may be used to create pictures of your blood vessels. These images show whether there’s a blockage and, if so, how large it is^[7][13]. Research suggests that magnetic resonance angiography and duplex ultrasonography may be slightly more cost-effective in diagnosing peripheral artery disease among people with intermittent claudication than standard angiography^[5].

Treatment options

The goals of treating intermittent claudication are to reduce pain, improve your ability to walk and be active, and manage the risk factors that contribute to cardiovascular disease. Treatment usually starts with lifestyle changes and may include medications. In some cases, surgical procedures may be needed.

Lifestyle changes

Exercise: Exercise is one of the most important treatments for intermittent claudication. Regular exercise helps reduce the severity and frequency of symptoms, improves blood flow to the legs, and reduces the risk of developing other cardiovascular problems^[14][19].

Supervised exercise programs are recommended as one of the first steps for managing the condition. These programs usually involve two hours of supervised exercise a week for three months, often in group sessions led by a trainer^[14][19]. Walking is typically the best exercise. The recommended approach is:

• Walk until you feel moderate pain or as far as you can
• Rest to relieve the pain
• Walk again until the pain returns
• Repeat this walk-rest-walk cycle for 30 to 45 minutes
• Do this three or more days a week^[13][20]

Supervised exercise improves maximum walking distance and pain-free walking distance more than home-based exercise alone. However, when monitoring is included in home-based exercise programs, similar improvements can be achieved^[5]. Alternative exercise modes such as cycling, strength training, pole-striding, and upper-arm exercises have also been studied, though supervised walking remains the best-validated approach^[5][23].

Stop smoking: Stopping smoking is crucial. It will reduce your risk of PAD getting worse and lower your chance of developing other serious cardiovascular diseases. Research shows that people who continue to smoke after diagnosis are much more likely to have a heart attack and die from heart disease complications than people who quit^[14][19].

Other lifestyle changes: Additional important changes include eating a balanced, heart-healthy diet, managing your weight, and cutting down on alcohol^[14][19].

Medications

Different medicines can help treat the underlying causes of peripheral artery disease and reduce your risk of cardiovascular problems:

Antiplatelet medications: Medicines such as aspirin help prevent blood clots from forming in narrowed arteries^[10].

Statins: If you have high levels of LDL cholesterol (sometimes called “bad cholesterol”), you may be prescribed a statin. Statins help reduce cholesterol production by your liver^[14][19].

Blood pressure medications: If you have high blood pressure, you may need antihypertensive medications. A common type is an ACE inhibitor, which helps lower blood pressure^[14][19].

Medications to improve walking: Two medications are approved specifically to help with intermittent claudication symptoms. Cilostazol is a medication that can improve walking distances by helping blood flow more easily and reducing platelet clumping. Studies show that people taking cilostazol can walk farther before pain starts compared to those taking a placebo. The most common side effects include headache, diarrhea, dizziness, and palpitations^[16]. Pentoxifylline is another option, though it is generally less effective than cilostazol^[15][16].

Diabetes management: If you have diabetes, it’s important to control your blood sugar levels properly. Poorly controlled diabetes can make PAD symptoms worse and increase your chances of developing other forms of cardiovascular disease^[14][19].

Surgical and interventional procedures

For advanced cases where pain is severe or blood flow has been significantly reduced, your doctor may recommend a procedure to open the blocked artery:

• Angioplasty: A catheter is used to create a larger opening in the vessel to increase blood flow
• Stent placement: A tiny coil is expanded inside the blocked artery to open the blocked area and is left in place to keep the artery open
• Bypass surgery: In more severe cases, surgery may be needed to create a new path for blood to flow around the blocked artery^[10]

Research shows that combining exercise therapy with surgical procedures may provide better results than either treatment alone^[5].

Possible complications

Intermittent claudication is an important warning sign of cardiovascular disease throughout your body. Because it’s caused by atherosclerosis, having claudication means you have an increased risk of serious health problems^[1].

Most people with intermittent claudication (more than 70%) remain stable for at least five years with proper treatment^[1][12]. However, 20% to 30% of people will experience progressive worsening of their claudication symptoms^[12].

The five-year mortality rate in people with intermittent claudication can be as high as 15%, and another 20% of patients may experience a stroke or heart attack within five years^[3][12]. This is because the same atherosclerosis process that affects the leg arteries often also affects the arteries of the heart and brain.

In a small percentage of cases (1% to 3% of all patients with claudication), the condition may progress to critical limb ischemia. This is the most severe form of peripheral artery disease, characterized by continuous pain in the foot even at rest, especially at night, black toes (gangrene), and ulceration. When critical limb ischemia develops, the leg is at serious risk of amputation^[3][8][12].

Over time, if the condition worsens, you may start to feel pain in your legs even when you’re not exercising. Cuts and sores on your legs might not heal properly, and if they become infected, this could lead to gangrene and potentially result in losing a leg^[7].

When to contact your doctor

You should contact your doctor if you experience leg pain that occurs with walking and goes away with rest. Don’t assume this pain is just a normal part of aging^[13].

Seek immediate medical attention if you develop:

• Severe, constant pain in your legs or feet that doesn’t go away with rest
• Pain that progresses to numbness
• Cool, pale, or bluish skin on your legs or feet
• Sores or ulcers on your feet or legs that don’t heal
• Black areas on your toes (signs of tissue death)^[2]

Early diagnosis and treatment are important. Having peripheral artery disease means your blood vessels are unhealthy, and proper treatment can reduce your risk of heart attack, stroke, and other serious complications^[1][14][19].