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Presentation and Clinical Diagnosis

Classic signs to establish and indicate arterial ulceration:


The patient may experience pain particularly associated with walking and when their legs are elevated. This is called intermittent claudication, which is explained above. The pain will be relieved by rest and by hanging their legs down.

Appearance Of Leg

The patient’s leg may have a shiny, hairless appearance. The leg may feel cold to touch, and the toenails may thicken and appear opaque. The legs become white on elevation and a reddish/blue colour when dependent (Vuolo, 2009). Gangrene of the extremities may also occur (Grey et al., 2006; NICE, 2016).

Pedal Pulses

Examination of the arterial system may show a decreased or absent pulse in the dorsalis pedis and posterior tibial arteries (Grey et al., 2006).

Ulcer Position

Arterial ulceration typically occurs over the toes, heels, and bony prominences of the foot (Grey et al., 2006). However, ulceration can be found anywhere on the leg in addition to the foot. The most common places are on top of the foot, the front of the shin or the lateral malleolus.

Ulcer Appearance

An arterial ulcer often has a punched-out appearance and can be deep, involving muscles or tendons. Necrosis is often present.


Stasis oedema may be present if the patient is immobile (Dealey, 2005).


  • At tips of toes or between toes
  • Over phalangeal heads
  • Above lateral malleolus, over the metatarsal head, on the side or sole of the feet
  • Minimal/no hair
  • Thin, dry and shiny skin
  • Thickened toenails
  • Leg may be cool
  • Leg becomes pale when elevated
  • May have neuropathy
  • Nil or diminished leg and foot pulses
Commonly a history of:
  • Ageing
  • Diabetes
  • Arteriosclerosis
  • Smoking
  • Hypertension
  • Deep pale base
  • Well defined edges
  • Black or necrotic tissue
  • Very painful
  • Pain is reduced by lowering the leg to a dependent position

(Nurses for Nurses Network, 2015)