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Module 5.3: Lower Limb Ulcers
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Peripheral Arterial Disease (PAD)

Peripheral arterial disease is infrequent in younger people but increases with age. In population studies, there is evidence indicating that approximately 20% of people over 60 years of age have some level of peripheral arterial disease (NICE, 2022).

If the disease progresses, smaller arteries can also become affected. PAD increases the risk of having a heart attack or stroke. In general terms, it is the reduced circulation of blood to a body part - other than the brain or heart - due to a narrowed or blocked blood vessel. (Dealey, 2005; Vascular Society, 2017; NICE, 2022)

Modifiable risk factors for peripheral arterial disease include:

  • Smoking
  • Diabetes
  • Hyperlipidaemia
  • Hypertension
  • Known atherosclerotic disease elsewhere
  • Advanced age
  • Chronic kidney disease
  • Obesity
  • Decreased activity

(Grey et al., 2006; Vascular Society, 2017)

A major indicator of PAD is intermittent claudication (IC), described below.

The reduced blood flow to the limbs can cause the following physical changes:

  • Cool/cold feet to touch
  • Pain (described as burning or aching) in the legs while lying flat that is relieved when sitting – commonly in the toes and at night
  • Loss of pulses in legs or feet
  • Pale colour when legs are raised up
  • Redness when legs are in a hanging down position
  • Brittle, thin, or shiny skin on the legs and feet
  • Loss of hair on feet
  • Non-healing wounds or ulcers over pressure points, such as heels or ankles
  • Gangrene
  • Loss of muscle or fatty tissue
  • Numbness, weakness, or heaviness in muscles
  • Reddish-blue discolouration of the extremities
  • Restricted mobility
  • Severe pain
  • Thickened, opaque toenails (may have a fungal infection)

(British Heart Foundation, 2015)

Intermittent Claudication (IC)

Intermittent claudication (IC) is an important indicator of PAD. IC is a symptom related to a reduced perfusion through an artery caused by atheroma. During exercise, this reduced perfusion causes hypoxia in the muscle distal to the site of atheroma and a cramping pain is experienced, which is relieved by rest. Most commonly, the calf muscles are affected, but it can also affect the thigh, buttock and arm muscles (Vuolo, 2009; NICE, 2015).

It is important to assess:

  1. The distance a patient can walk prior to the onset of pain
  2. The ways in which patients find they can relieve the pain as these show the extent of the patient’s PAD

With regular exercise and lifestyle changes, IC symptoms can be resolved. Lifestyle changes will depend upon an individual’s circumstances, but they include smoking cessation, weight reduction, control of hyperlipidaemia, eating a healthy diet and foot care (Vuolo, 2009).

However, if PAD progresses, IC pain may become continuous and prevent the patient from sleeping. Patients find that their symptoms are relieved when their legs are dependant. Therefore, they may hang their leg down out of bed or sleep in a chair to relieve pain (Vuolo, 2009).

Rest Pain

Rest pain commonly occurs in the foot and can happen when the patient is asleep. Walking may provide some relief. However, lowering the limb can offer some respite. Gravity helps blood to flow into the foot and calf, thus reducing the oxygen deficit and relieving the discomfort (Vuolo, 2009).

Other causes for arterial ulceration include trauma that interrupts blood flow, vasculitis, Raynaud’s disease and cold injuries such as frostbite. Patients may also develop arterial ulcers due to acute events such as an arterial embolism or severe injury that disrupts blood flow (Moffatt, 2001).