Poor circulation in the feet: the warning signs of peripheral artery disease

“Poor circulation” gets blamed for all kinds of things: cold feet, numb toes, leg cramps at night. Sometimes the blame is misplaced. But one kind of poor circulation matters a great deal, both for your feet and for the rest of your body. It’s called peripheral artery disease, and it’s often found late, because many people don’t have the symptoms they expect.

What PAD is

PAD is caused by atherosclerosis: plaque made of fat, cholesterol and other material builds up in the arteries and reduces the flow of blood. When it affects the legs, less oxygen-rich blood reaches the muscles and the skin of the feet.^[1] Because the same process affects arteries elsewhere, people with PAD also have a higher risk of heart attack and stroke.^[1]

The symptoms, including the quiet ones

The most familiar symptom is pain, aching, heaviness or cramping in the legs that comes on with walking or climbing stairs and eases after a few minutes of rest. It’s called intermittent claudication and is usually felt in the calf, though it can be in the thigh, buttock or foot.^[1]

But only about 1 in 4 people with PAD have these classic symptoms. More than half have other, less typical symptoms, and about 1 in 5 have none they report.^[1] That’s why the signs in the feet matter:^[1]

• One foot that feels colder than the other.
• Skin on the foot or leg that looks pale, discolored or bluish.
• Toenails and leg hair that stop growing.
• Weakness or numbness in the legs.
• Sores on the toes, feet or legs that heal slowly or not at all.
• In severe disease, pain in the leg and foot even at rest.

Who is at risk

The risk rises with age; most Americans with PAD are 65 or older. Smoking is the main risk factor. Diabetes, high blood pressure, high cholesterol, chronic kidney disease, and a family history of PAD, heart disease or stroke all raise it too.^[1]

Diabetes deserves special mention. About half of people with diabetes and a foot ulcer also have PAD, and it makes serious leg and heart complications more likely.^[3] Our article on foot wounds that won’t heal explains why blood flow matters so much for healing.

Is it circulation, or nerves?

Nerve problems can cause leg and foot pain that’s easy to mistake for PAD. One clue: PAD pain is usually brought on by walking and quickly relieved by resting, without needing to change position.^[1] If numbness, tingling or burning in your feet is the main problem, our sister practice, the Lower Extremity Nerve Institute (external site), specializes in peripheral neuropathy.

How PAD is checked

At a foot exam, we feel the pulses in your feet and look at skin color, temperature, hair growth, nails and any wounds.^[1] If blood flow may be reduced, the usual first test is the ankle-brachial index (ABI), which compares blood pressure at the ankle with blood pressure in the arm using a cuff and an ultrasound device. A resting ABI below 0.90 suggests PAD. When the ankle arteries can’t give a reliable reading, a similar test at the big toe is used instead.^[1] Doppler ultrasound can show where blood flow is reduced.^[1]

If testing points to PAD, we work with your primary care doctor and a vascular specialist, who treats the arteries themselves.

Treatment and what you can do

The goals are to ease symptoms, help you walk farther, protect your feet, and lower the risk of heart attack and stroke.^[1]

• Stop smoking. It’s the most important step, and it reduces symptoms and complications.^[1]
• Walk, in a structured way. Exercise programs improve how far people with claudication can walk before pain starts, and how far they can walk in total, with high-quality evidence behind them.^[2] Supervised programs usually meet at least three times a week for 3 to 9 months.^[1]
• Medicines to prevent clots and lower cholesterol and blood pressure, prescribed by your doctors.^[1]
• Procedures to open or bypass blocked arteries, when other treatment isn’t enough.^[1]

Protecting your feet

When blood flow is reduced, sores can heal slowly and become infected.^[1] Check your feet every day, never walk barefoot, wear well-fitting shoes, and don’t cut corns or calluses yourself. Our daily foot check guide applies to anyone with PAD, and our wound care page explains how we treat sores that won’t heal.

When to see a podiatrist