Claudication

Definition

Claudication refers to an excruciating pain like and sometimes burning sensation primarily in the leg unilaterally or bilaterally which usually occurs with exercise and walking for a certain distance and subsides with rescue the breath.[1]This is called intermittent claudication. Breathing pain may also occur in severe cases and may interfere with the patient’s activities of daily living.

Claudication is a major manifestation of a neurologic or neurological disorder. Decreases an individual’s Functional ability. It is therefore necessary to classify the pain as claudication so that one can come to a definite judgment and treat it accordingly.

Causes & Pathophysiology

Peripheral Arterial Disease (PAD) caused by atherosclerosis or plaque formation is the most common cause of Intermittent Claudication[2].This narrowing of arteries makes it difficult for oxygen-rich blood to reach the donor site. As a result, there is an imbalance between demand and supply of oxygen and nutrients especially in activities that increase this demand e.g. walking alters aerobic muscle metabolism resulting in pain.

Clinical features

The patient often complains of pain in one or both legs after walking a certain distance where the patient has to sit. The pain is usually burning or blister-like especially in the calves and buttocks.[2]The location of the pain is usually distal to the site of nerve blockage.
Pain at rest is due to severe occlusion. The pain is worse at night.
Shiny, hairless skin of the legs
Absent pulse mainly of the lower limbs
Pallor
Reduced skin temperature of the region
Trophic changes of nails
The limb becomes pale on elevation
Classification of lameness

According to the European Society of Cardiovascular Surgery, Claudication signs given by the patient can help determine the severity of the occlusion

Fontaine classification[3]

GradeSymptomsStage IAsymptomatic incomplete blood vessel obstructionStage IIMild claudication pain in limbStage IIAClaudication at a distance > 200 mStage IIBClaudication at a distance < 200 mStage IIIRest most pain in the legsStage IVNecrosis and/or gangrene of limb

Diagnosis

The following tools can be used to diagnose claudication

Ankle-Brachial Index
Doppler Ultrasound
Angiogram
Palpation of peripheral pulses
Differential Diagnosis

Delayed onset of muscle soreness
Osseous lesions compressing a peripheral nerve[4].
Muscle strain
Arthritis
Assessment of Claudication Distance

This is primarily done to assess the severity of the occlusion and monitor the Postoperative or Nonoperative improvement of the patient. [5][6] .

The patient is asked to walk on a treadmill. The Circle where the patient begins to feel pain is marked. This distance is called the Initial Claudication Distance. But the patient can walk further and further after which the pain is maximum interfering with the patients ability to walk. This distance is called the Maximum Claudication distance.

The difference between Initial claudication distance and Maximum Claudication distance is due to collateral blood vessel formation compensating for the blocked blood vessels. But with increased demand in the ongoing foot traffic, these containers become ineffective in releasing them involving walking.

Physiotherapy Management

Treadmill exercise 30-60 minutes per day 3 times per day for at least 3 months.[7]
Bicycle training
Upper extremity exercises- e.g. Biceps curls to increase the endurance
Plantar flexion resistance exercises[8]
For more information, see Peripheral arterial disease