Foot pain at night that eases when you hang your leg down

What ischemic rest pain feels like

Rest pain from poor circulation usually settles in the forefoot and toes, is often worse at night, and often needs strong pain medicine.⁠^[2] It gets worse when you lie flat or raise the leg and eases when the foot hangs down,⁠^[1,2] which is why dangling the foot over the edge of the bed can bring relief.

The foot often gives clues. A foot short of blood may turn pale when raised and dusky red when it hangs down, and it can feel cool, with dry skin, hair loss and misshapen toenails.⁠^[2,1] Color changes in the toes themselves are covered in dark, black or blue toes.

Why rest pain is a warning sign

Peripheral artery disease (PAD) narrows the leg arteries. About 40% of people with it have no leg symptoms at all, and only about 10% have the classic pattern of leg pain with walking that eases with rest.⁠^[5] Rest pain means PAD has reached chronic limb-threatening ischemia, defined as PAD with rest pain, gangrene, or a leg or foot wound open for more than 2 weeks.⁠^[2] See peripheral artery disease and foot wounds.

CLTI is responsible for most amputations related to PAD.⁠^[1] Yet this stage is treatable, so speed matters. Anyone with suspected CLTI should be referred urgently to a vascular specialist, and a sudden loss of blood flow calls for a vascular surgeon right away.⁠^[2,5]

Night pain from circulation, nerves or cramps

Three causes can feel alike in the dark, but the details differ.

Nerve pain (neuropathy). Diabetic nerve pain is characteristically burning, stabbing, tingling or shooting like an electric shock, and typically worse at night; the touch of socks or bedclothes can hurt. Some people mainly notice numbness. The changes show up evenly in both feet, starting at the toes and spreading upward.⁠^[3] See our sister practice’s guide to burning feet at night (external site).

Night cramps. A night cramp usually strikes the calf, though foot cramps are common too, and an episode lasts about nine minutes on average. Stretching the foot upward, toward the shin, may help release it.⁠^[6] Night cramps are linked with vascular disease and with nerve damage, so frequent cramps are worth mentioning at your visit.⁠^[6]

Burning or tingling does not rule out poor circulation. Leg pain from PAD can feel that way,⁠^[1] and many people with CLTI, especially those with diabetes, also have nerve damage that may cause tingling, numbness or burning.⁠^[2] The more telling clue is position: pain that is worse lying flat and eases with the foot hanging down points to circulation.⁠^[2] Nerve damage can also hide the warning: in diabetes, PAD often lacks its classic symptoms, rest pain included, probably in part because nerve damage dulls pain.⁠^[4] So with diabetes, have your feet checked for poor circulation at least once a year and whenever something changes.⁠^[4] Still unsure? See cold feet or numb feet (external site) at the Lower Extremity Nerve Institute.

What to do if your foot hurts at night

• Call us the same day. New pain at night or at rest needs a prompt check, above all if you have diabetes, kidney disease, high blood pressure or high cholesterol, or you smoke: the strongest risk factors for PAD.⁠^[5] When rest pain is likely, we arrange an urgent vascular referral. If you already see a vascular specialist, call them too.
• Protect the foot. Keep heating pads, hot water bottles and heaters away from your feet; wear socks in bed if they get cold.⁠^[7,1]
• Ask about pain relief. The global vascular guidelines advise pain medicine strong enough to control rest pain until it settles after blood flow is restored.⁠^[2] Ask your physician what is safe for you.
• Stop smoking and keep up your medicines. Smoking can lower blood flow to your feet.⁠^[7] The global vascular guidelines also advise medicines for everyone with CLTI to lower the risk of clots and to control cholesterol, blood pressure and, with diabetes, blood sugar.⁠^[2]

How the circulation is checked

We examine the skin, nails, color and pulses of both feet and look for any small sore. Noninvasive circulation testing is done at our practice.

The usual ankle test can mislead. In diabetes and kidney disease, stiff leg arteries may not squeeze shut under a blood pressure cuff, giving a falsely high ankle-brachial index. Toe arteries rarely behave this way, so a toe pressure or toe-brachial index can be used instead.⁠^[1] For rest pain to count as CLTI, it should last more than 2 weeks and come with at least one very low reading, such as a toe pressure under 30 mmHg or an ankle-brachial index under 0.4.⁠^[2]

To plan how to restore blood flow, the arteries are mapped with ultrasound, CT or MR angiography, or a catheter angiogram;⁠^[1] we arrange this with vascular specialists. See circulation tests for foot wounds.

How restoring blood flow helps, and where surgery fits

Vascular specialists restore blood flow in two main ways: from inside the artery with a balloon (angioplasty) or stent, or with bypass surgery that routes blood around a blockage. For CLTI, these procedures are recommended whenever feasible to limit tissue loss, heal wounds, ease pain and preserve a working limb.⁠^[1] We refer you and coordinate your foot care with their team. See restoring blood flow.

When rest pain comes with a sore, an infection or gangrene, foot care, often including surgery, is the other half of the plan. A foot infection can spread quickly, especially with diabetes, and needs prompt antibiotics and often surgery.⁠^[1] After successful revascularization, most feet with gangrene are evaluated for a minor amputation, meaning a toe or part of the foot, with staged closure or reconstruction when feasible.⁠^[1] Dr. Efe Ozturk, a Foot and Ankle Surgeon, is board certified in wound care (FAPWH). He performs this surgery when a foot needs it, from draining infection to toe and partial foot amputations, removing only what must go so you can keep walking. See gangrene of the toes and foot and limb salvage surgery.

Limits and risks. Revascularization is not an option for everyone, and treated arteries can narrow again, so they are checked afterward.⁠^[2,1] Spinal cord stimulation, compression pumps, prostanoid medicines and hyperbaric oxygen have not been established as effective in place of restoring blood flow.⁠^[2] The US guideline adds that an arterial compression pump may be considered to ease rest pain when blood flow can’t be restored.⁠^[1] Our page on hyperbaric oxygen therapy explains who it may help. Foot surgery has limits too. After a toe or partial foot amputation, the wound can become infected. Once healed, sores often return in feet with both poor circulation and nerve damage, so follow-up care, offloading and the right footwear stay part of the plan.⁠^[1] Before a major amputation is decided, the US guideline recommends that a team of specialists review the options for restoring blood flow, unless sepsis, a life-threatening reaction to infection, makes it an emergency.⁠^[1] See a second opinion before amputation.

When to seek care

New rest pain, particularly with diabetes or known PAD, is a same-day call. See us within a day or two for any foot wound that isn’t healing, especially if you have diabetes. A sudden blockage is different from rest pain: pain that comes on suddenly, with a pale, cool, numb or weak foot, needs emergency evaluation.⁠^[1] A red, hot, swollen foot has its own causes and urgency; see a red, hot, swollen foot with diabetes.