Leg pain when walking: is it claudication, and what can be done?

Pain in the legs on walking is one of the most common reasons people are referred to a vascular surgeon, and one of the most common reasons they are not. Many people put it down to age, arthritis or being unfit. Sometimes it is. But a very particular pattern of pain points to a narrowed artery, and that pattern is worth recognising because the treatment is different and, for most people, very effective.

What claudication feels like

The word comes from the Latin for limping. The classic description is a cramping, aching or tight pain in the calf that starts after a predictable distance, forces you to stop, and settles within two to five minutes of standing still. You can then walk a similar distance before it returns. Depending on where the artery is narrowed, the pain can be in the thigh or buttock rather than the calf, and it is often worse going uphill or walking quickly.

Two features help separate it from other causes of leg pain. First, it is brought on by walking rather than standing, and relieved by stopping rather than sitting or bending forward. Pain that eases when you sit down or lean on a trolley is more typical of nerve compression in the spine, which is called spinal claudication and needs a different approach. Second, the distance is consistent. Pain that is there at rest, at night or on the first step of the morning is usually something else.

Why it happens

The arteries that carry blood to the legs can narrow over time as fatty deposits (atherosclerosis) build up in their walls. At rest the leg muscles manage on the reduced flow. When you walk they need several times more blood than the narrowed artery can deliver, the muscle runs short of oxygen and it hurts. Stop, the demand falls, and the pain goes.

The risk factors are the familiar ones: smoking above all, diabetes, high blood pressure, high cholesterol and age. Intermittent claudication affects roughly 4% of people over 60.

Why it matters beyond the legs

For most people the leg symptoms themselves run a benign course. Studies that have followed patients over time show that symptoms stay stable or improve in the majority, and fewer than one in five progress to more serious circulation problems in the leg. Very few people with claudication are ever at risk of losing a leg.

The more important point is what claudication tells us about the rest of the arterial tree. Narrowed leg arteries almost always mean narrowed arteries elsewhere, including the coronary and carotid arteries. People with peripheral arterial disease have a clearly raised risk of heart attack and stroke. That is why treatment is never just about walking distance; it is about reducing that wider risk, and it is why NICE treats peripheral arterial disease as a cardiovascular condition in its own right.

How it is assessed

A consultation starts with the history, because the pattern of pain is so informative, and an examination of the pulses in the groin, behind the knee and at the ankle. The ankle-brachial pressure index (ABPI) compares the blood pressure at the ankle with the arm using a hand-held Doppler; a reduced ratio supports the diagnosis.

The key test is a duplex ultrasound scan of the leg arteries. It is painless, takes around half an hour and shows where the arteries are narrowed or blocked, how long the affected segment is and how good the arteries are above and below it. NICE recommends duplex ultrasound as the first-line imaging test for anyone in whom treatment of the artery itself is being considered. In my clinic the scan can often be arranged for the same visit, and if not it follows soon after. Only if an intervention is likely do we go on to a CT or MR angiogram to plan it.

Treatment: what the evidence supports

1. Reduce the risk to your heart and brain

This is the part people underestimate, and it matters most. Stopping smoking is the single most effective thing you can do, for the legs and for everything else. A statin and an antiplatelet medicine (usually clopidogrel or aspirin) are recommended for almost everyone with peripheral arterial disease, along with good control of blood pressure and diabetes. These reduce the chance of a heart attack or stroke, and they also slow the progression of disease in the legs.

2. Supervised exercise

Exercise is the first-line treatment for the symptom itself. NICE recommends that everyone with intermittent claudication is offered a supervised exercise programme, and suggests two hours of supervised exercise a week for three months, with people encouraged to walk to the point of maximal pain. That last part surprises patients: the instruction is to walk into the pain, rest until it settles, and go again.

It works. A Cochrane review summarised by the NIHR found that people who took part in structured exercise could walk around 80 metres further before pain came on, and around 120 metres further in total, compared with those who did not. The mechanism is partly the development of collateral vessels, the small arteries that enlarge to carry blood around a blockage, and partly improved muscle efficiency. Supervised programmes outperform simple advice to exercise, which is why they are specifically recommended, although a structured home walking plan is far better than nothing where a programme is not available.

3. Medication for the symptom

Naftidrofuryl oxalate is the one drug NICE supports for claudication symptoms, and only in a specific situation: when supervised exercise has not given a satisfactory improvement and the person would prefer not to have angioplasty or surgery. It is reviewed after three to six months and stopped if it has not helped. It is not a substitute for exercise.

4. Angioplasty, stenting or bypass

Treating the artery directly is considered when exercise and risk-factor treatment have not produced a satisfactory improvement, and the duplex scan shows a narrowing that is suitable. For short narrowings, angioplasty (stretching the artery with a balloon, sometimes with a stent) is a keyhole procedure done under local anaesthetic through a needle puncture in the groin. For long blockages, or where angioplasty has failed, a bypass operation using a vein or synthetic graft may be the better option.

Both can be very effective at relieving pain, but they are not without risk and treated arteries can narrow again, so the decision is a shared one that weighs how much the symptoms limit your life against the risks for your particular anatomy. The evidence is clear that exercise should come first; intervention is for those in whom it has not been enough.

When leg pain needs urgent attention

Claudication is a chronic, stable condition. The following are not, and need same-day assessment: pain in the foot at rest, particularly at night and relieved by hanging the foot out of bed; a wound or ulcer on the foot that will not heal; a toe or foot that has become pale, cold and numb; or a sudden onset of severe leg pain with a cold, white or mottled foot, which is an emergency.

What happens at a private consultation

You do not need a GP referral to see me privately. The appointment covers your history and an examination, with a duplex scan of the leg arteries often arranged for the same visit. You leave with a diagnosis, a written plan covering risk-factor treatment, exercise and whether any intervention is worth considering, and a letter to you and your GP. If an operation or angioplasty is needed it is carried out by me.

Frequently asked questions

What is intermittent claudication?

Intermittent claudication is a cramping, aching or tight pain in the muscles of the calf, thigh or buttock that comes on with walking and goes away within a few minutes of standing still. It is the most common symptom of peripheral arterial disease, where the arteries supplying the legs are narrowed by atherosclerosis.

How is claudication diagnosed?

Usually from the history and an examination of the pulses in the legs, supported by an ankle-brachial pressure index (ABPI). A duplex ultrasound scan then shows where the arteries are narrowed or blocked and how severely. NICE recommends duplex ultrasound as the first-line imaging test when treatment of the artery is being considered.

Is claudication dangerous?

For most people the leg symptoms stay stable or improve, and fewer than one in five progress to more serious circulation problems. The bigger issue is that narrowed leg arteries are a marker of arterial disease elsewhere, so the risk of heart attack and stroke is raised. Treatment is aimed at both the legs and that wider risk.

What is the first treatment for claudication?

NICE recommends a supervised exercise programme for everyone with intermittent claudication, typically two hours of supervised exercise a week for three months, walking to the point of maximal pain. Alongside this, stopping smoking, a statin and an antiplatelet medicine reduce the risk of heart attack and stroke.

When is angioplasty or bypass surgery considered?

When supervised exercise and risk factor treatment have not given a satisfactory improvement, and imaging shows a narrowing that is suitable to treat. Angioplasty and stenting, or bypass surgery, are then discussed with the risks and benefits for your particular pattern of disease.

Can I walk through the pain?

Yes. Walking into the pain, resting briefly and walking on again is the basis of exercise treatment. It encourages smaller collateral vessels to open up and improves walking distance. It does not damage the leg.