Claudication: Cramping of the Legs
Guest: Dr. Jay Robison – Surgery
Host: Dr. Linda Austin – Psychiatry
Dr. Linda Austin: I am Dr. Linda Austin. I am interview Dr. Jay Robison who is Professor of Surgery here at the Medical University of South Carolina. Dr. Robison, let’s talk about a very common complaint that patients have. A doctor would call it claudication, but a patient might describe it as pain in their legs when they exercise. Just what is at the root of this problem?
Dr. Jay Robison: Yes, Linda. That is a very common thing that people will present with to their primary physician and then, eventually, may make it over to see a vascular surgeon. It comes on with a little bit of walking. Sometimes it may take walking up to a block or two for a patient to have pain in their calf, most commonly. Sometimes the pain will actually go up into the buttock or the thigh muscle when they are walking that distance, then they can stop and stand and the pain goes away and then they can frequently go on and walk a similar distance. That is quite troublesome to a lot of patients. They cannot go out and do the walking that they would like to do, or cannot shop without stopping periodically and resting then going on to get their activities of daily living done. So, it is quite debilitating for a number of patients.
Dr. Linda Austin: How do you evaluate it when a patient comes to you with this complaint?
Dr. Jay Robison: In our practice, the two most important things that we do are, one, talk to the patient and see just how troublesome it is. Many older patients, for example, may have a little bit of trouble getting around but can actually do most of the things they need to do, so they are not really terribly troubled by it. Other patients may have a significant amount of trouble that keeps them from doing their work, or from doing some rehabilitation, or other activities that they really enjoy. So, that is the first thing that we need to decide from the patient’s history, how troubled they are by it.
The second thing is a good physical examination of their vasculature, feeling for their pulses, just to see exactly where there might be some restriction in their blood flow. We will often listen and see if there are any abnormal noises that tell us that there is some disturbance in blood flow.
Then, the third thing that we will often add to that is a vascular laboratory examination. That is where we actually take blood pressures of the circulation in the limb, usually in the legs, and we can determine just exactly how severe the restriction is.
Dr. Linda Austin: And, if there is a restriction, what is the treatment?
Dr. Jay Robison: There are several treatments and, mostly, the first line of defense is modifying those risk factors that predispose people to this problem to begin with. Most of the time, this is caused by a progressive problem with atherosclerosis, or hardening of the arteries. Those risk factors include, primarily, tobacco use, secondly, diabetes, occasionally hypertension, and high cholesterol can also contribute to the problem. So, those are the things that we can help the patient modify to improve their circulation. The other thing that we offer to patients is some kind of encouragement to exercise because, paradoxically, even though it hurts to walk, walking is one of the best things that patients can do to improve their exercise tolerance. There is one medication that does seem to be effective. It is called Cilostazol, or pletal. It is a very good medication but it does not help everybody. It does cost some money, about $1.00 a day. So, we will often have patients modify their risk factors initially and then if they still need additional help, we will offer them a medication to take in addition to that. There are some side effects with pletal. The only absolute contraindication is for those patients that have had congestive heart failure or fluid build up on their lungs.
Dr. Linda Austin: How about surgery for this problem?
Dr. Jay Robison: Surgery is generally reserved for those patients who remain significantly debilitated after modifying their risk factors, or would like to have something done to improve their symptoms. Surgery is one option. There are also the options of angioplasty, stent and some other types of intervention that are less invasive than surgery. Surgery can be performed in terms of cleaning out the arteries but, more commonly, some kind of bypass. It really depends on the level of the blockage as to which one of those interventions or therapies we might be able to offer for those patients. I think, as vascular surgeons who take care of only vascular surgery-type problems, we are in a position to kind of judge which one of those therapies is best for our patients. We offer all of those options. We cover the whole treatment spectrum of vascular disease. So, I think we can help the patient decide which one of those options, and interventions, is most appropriate for them or, maybe, if any intervention is necessary at all.
Dr. Linda Austin: Can this ever pose the threat of actually losing a limb?
Dr. Jay Robison: That is a good question, Linda. That is one of the things that patients are most concerned about when they first come in to see us with their leg claudication symptoms. As it turns out, very few patients with claudication symptoms who modify their risk factors and are followed by their physician will progress to lose a limb. Statistically, it is a very low risk. Maybe five to seven percent of all patients that present with these symptoms will be at risk for losing their limb, say, over a five-year period. So, does it happen? Yes, it does. Does it happen very frequently? No.
There is an additional number of patients, maybe one out of five patients, who may actually have progression of their symptoms to such an extent that they eventually need to have something done, or want to have something done, because they are more and more limited, they can walk only shorter and shorter distances which interferes with their lifestyle.
Dr. Linda Austin: Dr. Robison, what are some of the warning signs that a patient has claudication?
Dr. Jay Robison: Well, if somebody does have claudication and leg pain in their calf, say, when they are walking, some of the danger signs that they are heading for trouble and may be at risk for limb loss would be if they have an ulcer or sore on their foot or their extremity that develops and fails to heal promptly, within a few weeks of treatment. Or, should they have development of pain in their foot, usually it is in the furthest part of the extremity away from their heart, down in their toes, at night time that they have to wake up, say, hang their foot over the side of the bed to get relief then go back to sleep, we call that resting ischemic pain. That can be a sign of progressive poor circulation. Patients are at risk for limb loss when they develop those kinds of symptoms, an ulcer or non-healing sore, or resting ischemic pain that happens at night time.
Dr. Linda Austin: Dr. Robison, thank you so much.
Dr. Jay Robison: Thank you very much, Linda.
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