Clinical features

The patient usually complains of a cramping, muscular pain in the back of the calf. It is brought on by exercise and relieved only by resting for a few minutes. Often, one leg is affected. A limp is usual.

Typically, the distance walked before the onset of symptoms, is remarkably constant. This is termed the claudication distance or exercise tolerance. It may be used as an index of the severity of the patient's disease, and to monitor it's progress.

The calf is most often affected but the pain may also ascend into the thigh or buttock indicating obstruction to arteries above the inguinal ligament. If there is also impotence, the condition is referred to as Leriche syndrome.

Intermittent claudication usually develops insidiously. It most commonly affects male smokers (or ex-smokers), beyond middle age. There may be a history of ischaemic heart disease or other manifestations of atherosclerosis. Symptoms may have been precipitated by polycythaemia, or beta-blockers used to control essential hypertension.

On examination, the distal peripheral pulses are usually absent i.e. dorsalis pedis, posterior tibial, and popliteal. The femoral pulse is absent in 25% of cases. Other features of atherosclerosis may be noted.

There are 4 increasing stages of severity: (1)

Stage I: asymptomatic

Stage IIa: mild claudication

Stage IIb: moderate to severe claudication

Stage III: ischaemia rest pain

Stage IV: ulceration or gangrene

Reference:

1. Aboyans V, Ricco JB, Bartelink MEL, et al. 2017 ESC guidelines on the diagnosis and treatment of peripheral arterial diseases, in collaboration with the European Society for Vascular Surgery (ESVS): document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries. Eur Heart J. 2018 Mar 1;39(9):763-816.