Peripheral arterial disease differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Rim Halaby

Overview

The most important disorder that peripheral arterial disease and the associated symptom of claudication must be distinguished from is pseudoclaudication caused by lumbar spinal stenosis.[1] Intermittent claudication (IC) must also be differentiated from lower extremity pain caused by non-vascular etiologies that may include neurologic, musculoskeletal and venous pathologies. Given the diversity in and the severity of symptoms among patients with peripheral arterial disease, there is a long list of disorders that peripheral arterial disease must be distinguished from. In fact, the false-positive diagnosis rates of peripheral arterial disease are estimated to be around 44% and the false-negative rates are estimated to be around 19%.

Differential Diagnosis

In Alphabetical Order[2]

Differential Diagnosis

By Organ System

Cardiovascular Arteritis (Takayasu, giant cell) • Aortic coarctationAortic dissection • Claudication due to venous congestion (Venous claudication) • Deep vein thrombosisCompartment SyndromeEmbolic diseaseFibromuscular dysplasiaThromboangiitis obliterans
Chemical / poisoning No underlying causes
Dermatologic No underlying causes
Drug Side Effect No underlying causes
Ear Nose Throat No underlying causes
Endocrine No underlying causes
Environmental No underlying causes
Gastroenterologic No underlying causes
Genetic Pseudoxanthoma elasticum
Hematologic No underlying causes
Iatrogenic No underlying causes
Infectious Disease No underlying causes
Musculoskeletal / Ortho ArthritisCompartment SyndromeBaker's cystDegenerative joint diseaseMyopathyPopliteal artery entrapment syndromePopliteal artery entrapment syndromeSpinal stenosis
Neurologic Compartment SyndromeSpinal stenosisSpondylolisthesis
Nutritional / Metabolic No underlying causes
Oncologic No underlying causes
Opthalmologic No underlying causes
Overdose / Toxicity No underlying causes
Psychiatric No underlying causes
Pulmonary No underlying causes
Renal / Electrolyte No underlying causes
Rheum / Immune / Allergy Arthritis
Trauma No underlying causes
Miscellaneous No underlying causes

The Characteristics of Claudication Pain

It is important to know the typical presentation of claudication so that it can be differentiated from the symptoms of other disorders.

Differentiating Signs and Symptoms of Claudication Pain

  • Claudication pain is a cramp- like pain that is always induced by exercise at a constant distance that the patient walks.
  • Claudication pain can be either unilateral or bilateral.
  • Claudication pain is relieved by rest.

Lumbar Spinal Stenosis

Claudication caused by the peripheral arterial disease must be differentiated from the pseudoclaudication caused by lumbar spinal stenosis.[1] Lumbar spinal stenosis is due to nerve root compression by herniated disks or osteophytes and the pain typically follows the dermatome of the affected root.

Differentiating Signs and Symptoms of Lumbar Spinal Stenosis

  • The pain usually begins immediately upon walking and may be felt in the calf or in the lower leg and it is associated sometimes with numbness and paresthesias.
  • The pain is not quickly relieved by rest and may even be present at rest.
  • A sensation of pain running down the back of the leg as well as a history of back problems may be present.
  • In patients with cauda equina syndrome, upright positioning aggravates the narrowing of the spinal canal and therefore causes the symptoms.
  • Symptoms are usually associated with walking; nevertheless, upright standing may produce pain, weakness or discomfort in the hips, thighs and buttocks.
  • Symptoms are alleviated by sitting or flexing the lumbar spine forward as opposed to standing, which alleviates pain caused by IC.

Venous Claudication

Venous claudication occurs in patients with chronic venous insufficiency and those who develop post-thrombotic syndrome after deep venous thrombosis. Baseline venous hypertension in the obstructed veins worsens with exercise.

Differentiating Signs and Symptoms of Venous Claudication

  • Venous claudication produces a tight bursting pressure in the limb following exercise, usually worse in the thigh and uncommonly in the calf.
  • It is usually associated with venous edema in the leg.
  • Venous claudication tends to improve with cessation of exercise but total resolution takes much longer time than the resolution of intermittent claudication (IC).
  • Leg elevation helps in relieving the symptoms.

Chronic Compartment Syndrome

Chronic compartment syndrome is an uncommon cause of exercise-induced leg pain. It results from thickened fascia, muscular hypertrophy or when external pressure is applied to the leg. It tends to occur in young athletes who develop increased pressure within a fixed compartment which compromises the perfusion and the function of the tissues within that space. Intracompartmental pressure testing before and after exercise is the diagnostic test of choice.

Differentiating Signs and Symptoms of Chronic Compartment Syndrome

  • Chronic compartment syndrome presents as tight bursting pressure in the calf or foot after endurance sports or other robust exercise.
  • Pain subsides slowly with rest.

Hip and Knee Osteoarthritis

Differentiating Signs and Symptoms of Hip and Knee Osteoarthritis

  • Osteoarthritis in joints is typically worse in the morning or at the initiation of movement.
  • The degree of pain varies day to day and does not cease upon stopping exercise or standing.
  • The pain improves after sitting, lying down, or leaning against an object to alleviate weight-bearing on the joint.
  • The pain may be affected by weather changes, and may be present at rest.

References

  1. 1.0 1.1 Spittel P. Chapter 44. Peripheral vascular Disease. In Murphy J, Lloyd M,Mayo Clinic Cardiology Concise Textbook. Fourth edition.Mayo clinic scientific press.2013
  2. Wennberg PW, Rooke TW. Chapter 109. Diagnosis and Management of Diseases of the Peripheral Arteries and Veins. In: Fuster V, Walsh RA, Harrington RA, eds. Hurst's The Heart. 13th ed. New York: McGraw-Hill; 2011.

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