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Managing Diabetes Magazine - diabetes

Painful Walking
All about peripheral artery disease

If you have pain in your legs when you walk that goes away with rest, it could be peripheral artery disease (PAD). This condition is also called peripheral vascular disease (PVD). It can affect any arteries outside the heart and brain. Take PAD seriously, as it comes with a higher risk of heart attack and stroke. People with diabetes are two to four times more likely to develop PAD. The increased risk is mainly due to damage that high blood glucose can do to large and small blood vessels.

What causes PAD?

PAD is a progressive disease that hardens and narrows the arteries. Arteries are strong, flexible blood vessels. With each beat of the heart, they expand to accommodate blood pumped through them. They are the roads your blood and red blood cells use to deliver nutrients and necessary oxygen to the body. PAD can affect the arteries of the neck or those that take blood to the kidneys, arms and legs.

Hardening and narrowing of the arteries is called atherosclerosis. This term comes from the Greek words ‘athro’ (meaning gruel or paste) and ‘sclerosis’ (meaning hardness). Fatty substances, cholesterol, waste from cells, calcium, and fibrin (a clotting material in the blood) are deposited on the inner lining of a blood vessel. Scientists believe it starts when this inner layer of the artery becomes damaged.

Atherosclerosis is a complex process that can affect your whole body. Remember, arteries supply blood throughout the body. According to the Canadian Cardiovascular Society, PAD is a sign of widespread atherosclerosis. It brings a higher risk of heart attack, stroke and cardiovascular death – three to six times that of someone without PAD. If you do have PAD, take it seriously and work to reduce your risk factors.

Risk factors for PAD

  • increasing age
  • smoking
  • high blood pressure
  • abnormal cholesterol
  • low fruit and vegetable consumption
  • elevated blood glucose
  • being overweight
  • lack of physical activity

Symptoms and signs of PAD in the legs

  • Walking causes pain, aching, cramping, fatigue, numbness or heaviness. Once walking stops, the discomfort does too (usually within ten minutes). This is called claudication.
  • In severe disease, the leg will also be painful while elevated and resting.
  • The pulse in the leg or foot is weak or absent.
  • When sitting or standing, the leg or foot is reddish-blue in colour.
  • When the leg or foot is elevated, it turns pale.
  • The skin on the legs or feet is dry and scaly.
  • There is less hair on the leg.
  • Toenail growth is slow.
  • Wounds on the legs or feet are common and slow to heal.

If arteries in the leg become completely blocked, part or the entire limb can die from lack of blood flow.
Severe constant pain and a change in colour and temperature of the leg or foot suggests such a blockage. This is a medical emergency requiring an immediate trip to the emergency room. When the blockage is severe, surgery may be needed to save the leg or foot. If it cannot be saved, it may have to be amputated (removed).

How is PAD diagnosed?

You can walk anywhere – on a treadmill, track, outdoors or in a mall. The goal is to increase the time and distance you are able to walk without pain. Typically, you will begin to see results in a month or two, and continue to improve for upwards of six months.The Vascular Disease Cures has developed a pain scale to help you know when to stop walking and rest.

Vascular Disease Foundation Walking Pain Scale: 1. No pain
2. Mild to moderate pain3. Moderate pain4. Moderate to severe pain5. Severe pain

Certain tools are used to help confirm PAD:

  • A medical history and physical examination assess the legs and feet.
  • Ankle brachial indexes are done by taking blood pressure readings in the ankles and comparing the results to blood pressure readings in the arms. Blood pressure in the arms and ankles should be similar. A calculation is done to determine if the index is in the normal range.
  • An ultrasound measures the artery blood flow in the legs.
  • An angiogram enables blood vessels to be seen on x-ray film.
  • A CT scan checks for blockages and narrowing of blood vessels.

Ways to treat PAD

  • Stop smoking.
  • Use an antiplatelet medication like Aspirin (ASA) to stop blood clots from forming.
  • Keep blood pressure less than 140/90. In those with diabetes, it should be less than 130/80. The best blood pressure for everyone is less than 120/80.
  • Lower LDL cholesterol to less than 2.0 mmol/L.
  • If you have diabetes, keep your HbA1C at less than 7.0 per cent.
  • Exercise.
  • Maintain a normal weight.
  • Waist circumference, according to Canadian Obesity Network, should be less than 94 cm (37 inches) in men. For men of Hispanic, south Asian, Chinese and Japanese ancestry, it should be less than 90 cm (35 inches). In women, the waist should measure less than 80 cm (31.5 inches). For details on how to measure the waist properly, watch the video.

Exercising can help

A simple Walking Program for PAD1. Warm up2. Start3. Continue walking undtil the pain is 3-4 on the pain scale4. Stop until the pain is gone5. Restart - start again until your pain is 3-4 on the pain scale6. RepeatExercise is an important part of staying healthy, especially if you have PAD. The Peripheral Arterial Disease Coalition and Vascular Cures strongly encourage starting with a supervised exercise program.

Studies show that those who begin with a formal walking program before continuing on to a maintenance program will get the best results. If you have PAD of the legs, walking is your best exercise. It helps prevent further artery blockage, and the muscles in your legs become more efficient at using oxygen.

Foot care

You must take good care of your feet if you have PAD of the legs. PAD cuts down blood flow, meaning less oxygen and fewer nutrients are supplied to tissues. Oxygen and nutrients are essential to wound healing.

Even in normal everyday activities, feet take a lot of abuse. Injuries must be avoided. Simple problems, such as dry cracked skin, calluses, blisters or infected ingrown toenails, can become serious very quickly for someone with PAD. Infections are hard to heal and could lead to amputation. Caring for your feet is critical!

Basic foot care principles

  • Avoid placing too much pressure on your feet.
  • If you have diabetes, keep your blood glucose in target range. This is four to seven mmol/L before meals, and five to ten mmol/L (8 mmol/L is A1C is not under 7%) after meals.
  • Prevent infection with good foot hygiene and regular foot self-examinations.
  • Avoid injury to your feet.
  • Treat infection or injury quickly by getting help from your health care provider or podiatrist.

Proper foot care

  • Keep your feet clean and dry. Wash them daily and dry them well, especially between the toes. Next, apply a urea-based moisturizer to the areas that are dry. Avoid applying it between the toes. Your foot care specialist or pharmacist will have suggestions on types of moisturizers.
  • Promote circulation by exercising, and by avoiding smoking or blocking your circulation. Tight knee-high socks and nylons, tight shoes, cowboy boots, and crossing your legs can all constrict circulation. Put your feet up when sitting – this works against gravity and helps blood and fluid drain out of your legs. A simple exercise of rotating your ankles in a circle 10 times, three to five times throughout the day, can increase blood circulation, strengthen muscles of the foot and lower leg, reduce swelling and promote healthy nerve function. Try spelling your name or the whole alphabet with your foot without moving your knee or hip.
  • Select shoes carefully. Shoes that do not fit well create pressure or rub on your skin, putting you at high
    risk of injury and infection. (See tips on choosing shoes below.)
  • Prevent injury and minimize the risk of a foot cut or injury by avoiding going barefoot, even indoors. Avoid extreme temperatures and wear properly fitting, lined boots in the winter. Wear natural fibre socks (cotton or wool). Cut nails straight across and file to remove sharp edges. Stay away from any chemicals, including corn pads or wart remover, unless you are using them under medical supervision. Do not use any sharp objects, such as a razor, to remove calluses on your feet.
  • Find injuries by inspecting your feet daily for sores and redness that indicate pressure spots, early infection and injuries. Look for discoloured areas too. Remember to check between your toes.
  • Treat injuries. Keep sores and blisters clean and dry. Never break a blister open. If your doctor approves, use a pumice stone on calluses. See a foot specialist about large calluses or corns, ulcers, infections, ingrown nails, blackened areas, or embedded objects (such as a splinter) under the skin.

Although PAD is a serious condition, it can be managed with exercise, by controlling other conditions and caring carefully for your feet. For more information, talk to your local health care provider.

Tips for finding proper fitting shoes:


Your shoe should be wide enough at the end that you are able to comfortably wiggle all of your toes.


The heel should fit snugly with no gap in the instep. Avoid wearing high-heeled shoes for an extended time, as they can cause foot and back problems.


The shoe should have a cushioned sole with good tread and strong insole support.


Leather is the ideal material as it is breathable and molds to the foot. There should be no pressure areas or rubbing. A seamless interior is best. Lace-up shoes help prevent the foot from slipping in the shoe.

Time of day:

Go shoe shopping in the later afternoon. Your feet naturally swell during the day and will be at their largest by evening.

Use a shoe fitter:

Select a store with experienced shoe fitters who can help you find a shoe to best fit the shape of your foot. They can recommend shoes that will provide your feet with the best protection. It is best to choose a store with a certified pedorthist, who has special training in fitting shoes for those with foot problems.

FAMILY HEALTH is written with the assistance of:
College of Family Physicans of Canada
Alberta College of Family Physicians
FAMILY HEALTH is written with the assistance of:
College of Family Physicans of Canada
Alberta College of Family Physicians
While effort is made to reflect accepted medical knowledge and practice, articles in Family Health Online should not be relied upon for the treatment or management of any specified medical problem or concern and Family Health accepts no liability for reliance on the articles. For proper diagnosis and care, you should always consult your family physician promptly. © Copyright 2019, Family Health Magazine, a special publication of the Edmonton Journal, a division of Postmedia Network Inc., 10006 - 101 Street, Edmonton, AB T5J 0S1 [DI_MDab18]
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