Musculoskeletal Science and Practice 61 (2022) 102611

Contents lists available at ScienceDirect

Musculoskeletal Science and Practice

journal homepage: www.elsevier.com/locate/msksp

Original article

Identifying peripheral arterial diseases or flow limitations of the lower

limb: Important aspects for cardiovascular screening for referral
in physiotherapy
Daniel Feller a, Andrea Giudice b, Agostino Faletra c, Mattia Salomon d, e, Erasmo Galeno f, g, h,
Giacomo Rossettini i, Fabrizio Brindisino j, h, Filippo Maselli k, l, Nathan Hutting m, *,
Firas Mourad n, o
a
Centre of Higher Education for Health Sciences, Trento, Italy
b
Department of Physical Therapy, Poliambulatorio Physio Power, Brescia, Italy
c
Queen Elizabeth Hospital, Clinical Support & Screening Service, Gateshead, United Kingdom
d
Department of Clinical Science and Translational Medicine, University of Roma “Tor Vergata”, Roma, Italy
e
CST Centro Sanitario Trento s.r.l., 30121, Trento, Italy
f
Polimedico Specialistico STEMA Fisiolab, Latina, Italy
g
Dip. Scienze mediche, chirurgiche e neuroscienze Università degli studi di Siena, Italy
h
Department of clinical science and translation medicine, University of Rome Tor Vergata, Roma, Italy
i
School of Physiotherapy, University of Verona, Verona, Italy
j
Department of Medicine and Health Science “Vincenzo Tiberio”, University of Molise c/o Cardarelli Hospital, Campobasso, Italy
k
Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Campus of Savona, University of Genoa, Savona, Italy
l
Sovrintendenza Sanitaria Regionale Puglia INAIL, Bari, Italy
m
Department of Occupation and Health, School of Organisation and Development, HAN University of Applied Sciences, Nijmegen, the Netherlands
n
Department of Physiotherapy, LUNEX International University of Health, Exercise and Sports, 4671, Differdange, Luxembourg
o
Luxembourg Health & Sport Sciences Research Institute A.s.b.l., 50, Avenue du Parc des Sports, 4671, Differdange, Luxembourg

A R T I C L E I N F O A B S T R A C T

Keywords: Many conditions could potentially cause pain in the lower limbs. One of these is peripheral arterial disease
Differential diagnosis (PAD). PAD is often a real challenge to be recognized for clinicians due to symptoms that commonly mimic
Ankle brachial index musculoskeletal conditions. PAD is defined as a total or partial blockage of the vessels that supply blood from the
Claudication
heart to the periphery. Its prevalence is around 7 percent in subjects between 55 and 59, reaching almost 25% in
Sciatica
Rehabilitation
individuals between 95 and 99 years old. The most dominant symptom of PAD is lower limb pain. Also, PAD can
produce other symptoms such as discoloration, altered skin temperature, and, when arterial blood flow is
insufficient to meet the metabolic demands of resting muscle or tissue, focal areas of ischemia. In our view,
physical therapists should be capable of triaging for PAD in a direct access setting. Therefore, in this Professional
Issue, we present the main characteristics of PAD and the physiotherapy role in its management. A supple­
mentary step-by-step guide will provide further resources for testing PAD.

1. Introduction limbs. Despite its frequency, PAD recognition is challenging due to its
presentations: it may mimic or be comorbid with other neuro-
Many conditions could potentially cause pain in the lower limb. musculoskeletal conditions, such as lumbosacral radiculopathy (LSR).
Therefore, identifying the source of the patient’s complaints is a com­
plex process for primary care clinicians. Peripheral arterial disease
(PAD) is a common and potentially serious cause of pain in the lower

* Corresponding author.
E-mail addresses: danielfeller.ft@gmail.com (D. Feller), a.giudice@physiopower.it (A. Giudice), agostino.faletra@nhs.net (A. Faletra), salomon.mattia@gmail.
com (M. Salomon), eragal@me.com (E. Galeno), giacomo.rossettini@gmail.com (G. Rossettini), fabrindi@gmail.com (F. Brindisino), masellifilippo76@gmail.com
(F. Maselli), Nathan.Hutting@han.nl (N. Hutting), firas.mourad@me.com (F. Mourad).

https://doi.org/10.1016/j.msksp.2022.102611
Received 2 February 2022; Received in revised form 8 June 2022; Accepted 16 June 2022
Available online 22 June 2022
2468-7812/© 2022 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
D. Feller et al.
2. Peripheral arterial disease
PAD is defined as a total or partial blockage of the vessels that supply
blood from the heart to the periphery (Fig. 1). This pathological process
is often caused by arteriosclerosis, an hardening of an artery due to an
atheromatous plaque (Firnhaber and Powell, 2019). PAD is most com­
mon in the lower limbs, with a prevalence of 7% in subjects between 55
and 59 years. This prevalence increases during the lifespan, reaching
almost 25% in individuals between 95 and 99 years old (Fowkes et al.,
2013). Notably, in 20–50% of all cases, PAD is asymptomatic. However,
if the blood supply is insufficient to satisfy the metabolic requirements,
symptoms occur (Norgren et al., 2007).
3. Patient interview
Clues that may raise the level of suspicion of PAD can be found
primarily during the patient interview. PAD is a progressive multifac­
torial disorder and is associated with at least one cardiovascular risk
factor (Joosten et al., 2012; Selvin and Erlinger, 2004), most commonly
atherosclerosis (Crawford et al., 2016). Diabetes and smoking have also
been identified to increase the likelihood of developing PAD (Selvin
et al., 2004, 2006; Willigendael et al., 2004). Other risk factors are: male
gender, hypertension, dyslipidemia, hyperhomocysteinemia, c-reactive
protein levels, and renal insufficiency (Norgren et al., 2007). The
"American College of Cardiology/American Heart Association (ACC/AHA)"
guidelines consider the following individuals at risk for lower limbs
PAD: age ≥65 years, age 50–64 years with risk factors for atherosclerosis
or a family history of PAD, age <50 with diabetes and another risk factor
for atherosclerosis, and all the individuals with known atherosclerotic
disease in other sites (e.g., coronary and carotid) (Gerhard-Herman
et al., 2017).
Many patients with PAD are asymptomatic (Alahdab et al., 2015;
Crawford et al., 2016). If symptoms are present, the most prevalent is
lower limb pain with three different patterns: claudication, ischemic,
and atypical pain. Ten to thirty-five percent of the cases report claudi­
cation. Claudication can be unilateral or bilateral and is described as
fatigue, or aching, cramping, and burning pain in the lower limb mus­
cles. The pain location depends on the occlusion site: occlusion at the
level of the aorta is likely to provide bilateral claudication of the
buttock, thigh, and calf. Occlusion at the common iliac, common
femoral, and superficial femoral arteries provide unilateral claudication
of the buttock, the thigh, and the calf respectively (Morley et al., 2018).
Claudication is consistently induced by exercise and relieved by rest
within 10 min (Hamburg and Creager, 2017). In the event of a severe
decrease in limb perfusion, patients may report ischemic pain that is
continuous and present even at rest. Ischemic pain is frequently local­
ized at the forefoot. Notably, for the differential diagnosis purpose,
ischemic rest pain is worsened by elevation of the lower limbs and is
Fig. 1. Peripheral arterial disease: total and partial blockage of blood supply in a peripheral vessel.
2
Musculoskeletal Science and Practice 61 (2022) 102611
often difficult to be distinguished from neuropathy (Gerhard-Herman
et al., 2017). Acute ischemia typically presents with the sudden/acute
onset of one or more of the so-called “six Ps” (i.e., pain, pallor, pulseless,
paraesthesia, paralysis, “perishingly” cold), which are a warning sign for
the risk of limb amputation (Morley et al., 2018). Lastly, due to
comorbidities and alterations in pain perception, pain can also be
"atypical" with a mixed manifestation (Hamburg and Creager, 2017).
Atypical symptoms may differ from classic descriptors of claudication
from a qualitative (e.g., patients may describe calf discomfort as tight)
and localisation (e.g., burn in the quadriceps) point of view (Schorr
et al., 2015). Notably, atypical symptoms may be more common than
classic claudication, making recognition difficult for less experienced
clinicians (Collins et al., 2003; Hirsch et al., 2001). That is, although
atypical symptoms restrict walking ability, there is still little evidence
supporting its reporting, and further research is needed to validate the
correspondence of atypical symptoms with ischemic changes during
exercise (Hamburg and Creager, 2017; Schorr et al., 2015). For an
overview of the main symptoms of PAD, we suggest readers to consult
the infographic proposed by Morley et al. (2018). The risk profile and
the specific symptoms identified during the interview will highlight the
need for further specific questioning and a direct physical examination.
4. Physical examination
For a comprehensive overview, readers are invited to refer to the
step-by-step guide on how to objectively assess a patient at risk of PAD in
Appendix 1. The examination should include an inspection of the skin,
nails, and limb temperatures. In fact, patients with PAD have thinner
skin, hypertrophic and ridged nails, and a reduced lower limb temper­
ature (Gerhard-Herman et al., 2017). Discoloration and hair loss could
also be observed (Boyko et al., 1997; Khan et al., 2006). When arterial
blood flow is insufficient to meet the metabolic demands of resting
muscle or tissue, PAD can also produce focal areas of ischemia with
full-thickness skin necrosis (Conte and Vale, 2018).
Although frequently used, the capillary refill testing has limited
diagnostic accuracy (Boyko et al., 1997; Khan et al., 2006). At the same
time, pulse palpation of the femoral, popliteal, dorsalis pedis, and pos­
terior tibial arteries is the most sensitive sign (Boyko et al., 1997; Ger­
hard-Herman et al., 2017; Khan et al., 2006). The examination should
comprise vital signs measurements, including blood pressure, on both
upper limbs, and heart rate, to screen the cardiovascular profile (Ger­
hard-Herman et al., 2017). Also, clinical practice guidelines recommend
that measurement of the ankle-brachial index (ABI) at rest should al­
ways be done. The ABI consists of the ratio between the ankle systolic
blood pressure divided by the systolic brachial pressure. Using arteri­
ography as the reference standard, an ABI inferior to 0.90 has been
demonstrated to have a high degree of sensitivity and specificity for
PAD. Moreover, the ABI has been associated with disease severity: an
D. Feller et al.
index between 0.5 and 0.9 is correlated with claudication, an index
between 0.2 and 0.5 is correlated with rest pain, and an index between
0 and 0.2 is correlated with tissues loss (Gerhard-Herman et al., 2017; Ko
and Bandyk, 2013).
5. Clinical reasoning
All relevant items collected during the patient interview and physical
examination can lead the physiotherapist in increasing or decreasing the
suspicion for PAD. Although the ABI is not considered within physio­
therapy common practice, its knowledge and findings interpretation
remain relevant for interdisciplinary communication and management
purposes (see Appendix 1). Notably, as patients with PAD commonly
present with comorbid conditions (e.g., cardiovascular and neuro­
musculoskeletal), its diagnosis does not imply this as the source of a
patient’s symptoms; however, early recognition is essential for under­
standing the symptoms and help in prioritizing the following manage­
ment pathway (Morley et al., 2018). Thus, differential diagnosis is
required to establish the relative contribution of all pathologies to the
presence of leg pain. Particularly, in those patients at risk (e.g., di­
abetics), monofilament testing to identify peripheral neuropathy should
be performed (Morley et al., 2018). Also, a peripheral neurological ex­
amination (e.g., reduced deep tendon reflexes, and motor and sensory
changes) and nerve mechano-sensitivity testing (e.g., straight leg raise
or SLUMP testing) for LSR, or lumbar stenosis prodromes screening (i.e.,
typically bilateral symptoms, leg numbness and weakness, foot loss of
sensation and weakness, symptoms relief in lumbar flexion) should be
useful, especially when a low back pain related neuropathic pain is
suspected (Kreiner et al., 2014; Schmid et al., 2018).
6. Physiotherapy scope in PAD
Patients with diagnosed or undiagnosed PAD may be encountered in
daily practice. The respective physiotherapy multi-professional role in
assessing and managing PAD is a professional responsibility. Firstly, as
physiotherapy practice advances to a more independent care model
(World Confederation for Physical Therapy, 2019), its role in the pri­
mary recognition of features that raise the suspicion for previously un­
recognized PAD, become of paramount importance to ensure patient
safety and effective medical management (Gerhard-Herman et al., 2017;
Morley et al., 2018). Patients presenting known risk factors for PAD, and
one of the following: sudden onset of the “six Ps”, rest pain in the foot for
more than two weeks, non-healing wounds, or gangrene, should be ur­
gently referred to vascular specialists. Individuals presenting with a
reduced pulse, atypical pain symptoms, or claudication should be
referred for primary/community care (Gerhard-Herman et al., 2017;
Morley et al., 2018). Secondly, the physiotherapist’s vigilance in
ensuring early detection and timely referral for medical review is even
more relevant when the patient’s condition deteriorates (Gerhard-Her­
man et al., 2017; Morley et al., 2018). Thirdly, physiotherapists are the
professionals in charge of the treatment and exercise prescription
required for patients with PAD (Morley et al., 2018). The table and the
flow chart in Appendix 1 provide insight on the decision-making process
relevant for physiotherapists’ scope in PAD.
7. Management
Asymptomatic patients and those with intermittent claudication are
generally referred to primary care. Therefore, addressing modifiable risk
factors early (smoking cessation, blood pressure and glycated haemo­
globin control, antiplatelet prescription, and weight loss for overweight
patients) is a mainstay for PAD management (Morley et al., 2018). The
initial management also comprises exercise therapy for symptom
reduction (Morley et al., 2018). Physiotherapists play a central role in
the prescription and implementation of the exercise management.
Although both supervised and unsupervised exercises improve
3
Musculoskeletal Science and Practice 61 (2022) 102611
symptoms in patients with PAD, clinical practice guidelines recommend
supervised exercise therapy as first-line treatment (Gerhard-Herman
et al., 2017). However, also a home-based program is an effective and
safe alternative to be considered (Waddell et al., 2021), as frequently
patients are not referred for supervised exercise due to unavailability of
programs or lack of access (Abaraogu et al., 2020). Inconsistencies be­
tween guidelines exist regarding the dosage of the exercises. The
ACC/AHA recommends that each session must be performed for a
minimum of 30–45 min, at least 3 times/week for a minimum of 12
weeks. However, little guidance is offered for exercises’ intensity. A
recent systematic review demonstrated that a low-to-moderate exer­
cises’ intensity provides more benefits on pain-free walking distance
(Fassora et al., 2021). However, more vigorous exercise provides better
results on the maximal walking distance and the cardiorespiratory
fitness. Concerning the types of exercise, walking is more suitable for
improving walking capacity, while other forms of exercise (e.g., cycling
and upper extremities exercises) achieve better results for cardiorespi­
ratory fitness. Therefore, a personalized approach tailored on the pa­
tient’s characteristics and goals is advisable (Fassora et al., 2021). When
the exercise management is ineffective in symptom control, vasoactive
drugs (e.g., Naftidrofuryl oxalate and Cilostazol) are recommended
(Morley et al., 2018). In case of worsening of symptoms, claudication
that affects the quality of life, or presence of critical limb ischemia, a
vascular consultation is recommended for further investigation (e.g.,
duplex ultrasound) and to consider a revascularization procedure. To
date, no trials are available to determine the impact of prehabilitation
for revascularization procedure (Palmer et al., 2020).
8. Conclusion and reccomendations
The increasing population age, the high prevalence of cardiovascular
diseases and PAD, and the typical clinical presentation—which poten­
tially mimic symptoms of other common neuromusculoskeletal condi­
tions–support the concept that physiotherapists need to be trained and
capable to triage PAD. This professional issue highlights the role of
physiotherapy vigilance in the consideration and assessment for PAD
and in initiating the appropriate management pathway. Also, this pro­
fessional issue raises the notion that the vascular system must be
considered as a whole: a complete vascular examination must be per­
formed to collect better anatomical clues and understanding of the pa­
tient’s presentation, avoiding any lack of recognition which can
potentially have severe consequences.
Appendix 1. Supplementary data
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.msksp.2022.102611.
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