Peripheral arterial disease differential diagnosis: Difference between revisions
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[[Image:Home_logo1.png|right|250px|link=http://www.wikidoc.org/index.php/Peripheral_arterial_disease]] | |||
{{CMG}}; '''Associate Editor-In-Chief:''' {{CZ}}; [[User:Rim Halaby|Rim Halaby]] | {{CMG}}; '''Associate Editor-In-Chief:''' {{CZ}}; [[User:Rim Halaby|Rim Halaby]] | ||
==Overview== | ==Overview== | ||
The most important disorder that peripheral arterial disease and the associated symptom of | 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. [[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<ref>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.</ref>=== | |||
*[[Arteritis]] (Takayasu, giant cell) | *[[Arteritis]] (Takayasu, giant cell) | ||
*[[Aortic coarctation]] | *[[Aortic coarctation]] | ||
| Line 27: | Line 27: | ||
*[[Venous claudication]] | *[[Venous claudication]] | ||
== | ==Differential Diagnosis== | ||
By | ===By Organ System=== | ||
{|style="width:60%; height:100px" border="1" | {|style="width:60%; height:100px" border="1" | ||
|style="height:100px"; style="width:25%" border="1" bgcolor="LightSteelBlue" | '''Cardiovascular''' | |style="height:100px"; style="width:25%" border="1" bgcolor="LightSteelBlue" | '''Cardiovascular''' | ||
|style="height:100px"; style="width:75%" border="1" bgcolor="Beige" | Claudication due to [[venous congestion]] ([[Venous claudication]]) • [[Deep vein thrombosis]] • [[Compartment Syndrome]] | |style="height:100px"; style="width:75%" border="1" bgcolor="Beige" | [[Arteritis]] (Takayasu, giant cell) • [[Aortic coarctation]] • [[Aortic dissection]] • Claudication due to [[venous congestion]] ([[Venous claudication]]) • [[Deep vein thrombosis]] • [[Compartment Syndrome]] • [[Embolic disease]] • [[Fibromuscular dysplasia]] • [[Thromboangiitis obliterans]] | ||
|- | |- | ||
|-bgcolor="LightSteelBlue" | |-bgcolor="LightSteelBlue" | ||
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|-bgcolor="LightSteelBlue" | |-bgcolor="LightSteelBlue" | ||
| '''Musculoskeletal / Ortho''' | | '''Musculoskeletal / Ortho''' | ||
|bgcolor="Beige"| [[Arthritis]] • [[Compartment Syndrome]] • | |bgcolor="Beige"| [[Arthritis]] • [[Compartment Syndrome]] • [[Baker's cyst]] • [[Degenerative joint disease]] • [[Myopathy]] • [[Popliteal artery entrapment syndrome]] • [[Popliteal artery entrapment syndrome]] • [[Spinal stenosis]] | ||
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|-bgcolor="LightSteelBlue" | |-bgcolor="LightSteelBlue" | ||
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|-bgcolor="LightSteelBlue" | |-bgcolor="LightSteelBlue" | ||
| '''Rheum / Immune / Allergy''' | | '''Rheum / Immune / Allergy''' | ||
|bgcolor="Beige"| [[Arthritis]] | |bgcolor="Beige"| [[Arthritis]] | ||
|- | |- | ||
|-bgcolor="LightSteelBlue" | |-bgcolor="LightSteelBlue" | ||
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|} | |} | ||
==The Characteristics of Claudication Pain | ===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 | It is important to know the typical presentation of [[claudication]] so that it can be differentiated from the symptoms of other disorders. | ||
===Signs and Symptoms of Claudication Pain=== | ====Differentiating Signs and Symptoms of Claudication Pain==== | ||
*Claudication pain is a cramp- like pain is always induced by exercise at a constant distance that the patient walks. | *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 can be either unilateral or bilateral. | ||
*Claudication pain is relieved by rest. | *Claudication pain is relieved by rest. | ||
==Lumbar Spinal Stenosis== | ===Lumbar Spinal Stenosis=== | ||
[[Claudication]] caused by the peripheral arterial disease must be differentiated from the pseudoclaudication caused by [[lumbar spinal stenosis]].<ref name="Spittel">Spittel P. Chapter 44. Peripheral vascular Disease. In Murphy J, Lloyd M,Mayo Clinic Cardiology Concise Textbook. Fourth edition.Mayo clinic scientific press.2013</ref> [[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=== | ====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 | *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. | *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. | *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. | *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 | *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. | *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=== | ||
[[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. | [[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=== | ====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. | *[[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]]. | *It is usually associated with venous [[edema in the leg]]. | ||
| Line 152: | Line 152: | ||
*Leg elevation helps in relieving the symptoms. | *Leg elevation helps in relieving the symptoms. | ||
==Chronic Compartment Syndrome== | ===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. | 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=== | ====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. | *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. | *[[Pain]] subsides slowly with rest. | ||
==Hip and Knee Osteoarthritis== | ===Hip and Knee Osteoarthritis=== | ||
===Differentiating Signs and Symptoms of 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. | *[[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 degree of pain varies day to day and does not cease upon stopping exercise or standing. | ||
Latest revision as of 18:32, 6 October 2020
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. 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[1]
- Arteritis (Takayasu, giant cell)
- Aortic coarctation
- Aortic dissection
- Baker's cyst
- Chronic compartment syndrome
- Cystic adventitial disease
- Deconditioning
- Degenerative joint disease (hip, back, knee)
- Embolic disease
- Fibromuscular dysplasia
- Myopathy
- Popliteal artery entrapment syndrome
- Popliteal vein compression
- Retroperitoneal fibrosis
- Spinal stenosis
- Thromboangiitis obliterans
- Venous claudication
Differential Diagnosis
By Organ System
| Cardiovascular | Arteritis (Takayasu, giant cell) • Aortic coarctation • Aortic dissection • Claudication due to venous congestion (Venous claudication) • Deep vein thrombosis • Compartment Syndrome • Embolic disease • Fibromuscular dysplasia • Thromboangiitis 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 | Arthritis • Compartment Syndrome • Baker's cyst • Degenerative joint disease • Myopathy • Popliteal artery entrapment syndrome • Popliteal artery entrapment syndrome • Spinal stenosis |
| Neurologic | Compartment Syndrome • Spinal stenosis • Spondylolisthesis |
| 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.[2] 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
- ↑ 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.
- ↑ Spittel P. Chapter 44. Peripheral vascular Disease. In Murphy J, Lloyd M,Mayo Clinic Cardiology Concise Textbook. Fourth edition.Mayo clinic scientific press.2013