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Managing Diabetes Magazine - diabetes

The Pain of Walking
All about peripheral arterial disease

If you have pain in your legs when you walk that goes away with rest, it could be peripheral arterial disease (PAD). This condition, also called peripheral vascular disease (PVD), can affect any arteries outside the heart and brain. Since having it multiplies the risk of heart attack and stroke, take this condition seriously. People with diabetes are two to four times more likely to develop PAD, largely due to the damage high blood glucose can do to large and small blood vessels.

Risk factors for PAD

  • increasing age
  • smoking
  • high blood pressure
  • abnormal cholesterol
  • elevated blood glucose
  • being overweight
  • lack of physical activity

What causes PAD?

PAD is a progressive disease that involves the hardening and narrowing of the arteries. Arteries are strong, flexible blood vessels that expand to accept blood pumped into them with each beat of the heart. They deliver necessary oxygen and nutrients to the body. PAD can affect 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). It involves deposits of fatty substances, cholesterol, cellular waste, calcium, and fibrin (a clotting arteries diagrammaterial in the blood) 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 are all over the body. According to the Canadian Cardiovascular Society, PAD is a sign of widespread atherosclerosis. It brings with it a higher risk of heart attack, stroke and cardiovascular death – three to six times that of someone without PAD. Approximately 30 per cent of people with PAD are thought to have triple vessel (serious) heart disease. If you do have PAD, take it seriously and work to reduce your risk factors.

Symptoms and signs of PAD in the legs

  • Pain, aching, cramping, fatigue, numbness or heaviness caused by walking. The discomfort stops when walking is stopped – this is called claudication.
  • Pain at rest when the leg is elevated (with severe disease)
  • Pulse in leg or foot is weak or absent
  • When sitting or standing, the leg or foot is reddish-blue
  • When elevated, the leg or foot turns pale in colour
  • Dry scaly skin on legs or feet
  • Less hair on the leg
  • Slow toenail growth
  • Wounds on the legs or feet that are slow to heal

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

How is PAD diagnosed?

These tools can be used to help confirm PAD:

  • Medical history and physical examination of the legs and feet.
  • Ankle brachial indexes, done by taking blood pressure readings in the ankles and comparing the results to the blood pressure readings in the arms. The 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 that measures the artery blood flow in the legs.
  • An angiogram that enables blood vessels to be seen on x-ray film.

Ways to treat PAD

  • Stop smoking.
  • Use an antiplatelet medication like Aspirin™ (ASA) to block the formation of blood clots.
  • Keep blood pressure less than 140/90. For 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.
  • Keep your HbA1C at less than 7.0 per cent.
  • Exercise.
  • Maintain a normal weight.
  • Achieve a healthy waist circumference. According to Obesity Canada, waist circumference should be less than 94 cm (37 inches) in men and less than 80 cm (31.5 inches) in women. A video of how to properly measure the waist can be found at

Exercising can help

Vascular Disease Foundation
Walking Pain Scale:

  1. = no pain
  2. = onset of pain
  3. = mild pain
  4. = moderate pain
  5. = severe pain

Exercise is an important part of health, especially if you have PAD. The Peripheral Arterial Disease Coalition and the Vascular Disease Foundation strongly encourage starting with a supervised exercise program.

Studies show that those who first attend a formal walking program before continuing on 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 in using oxygen.

Walking programs for PAD of the legs involves walking until a moderate amount of pain is felt, resting until the pain is gone, and then walking again. This can be done 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.

The Vascular Disease Foundation has developed a pain scale to help in knowing when to stop walking and rest.

Walking program

Warm-up: 5 minutes of slow gentle walking.
Start: Start walking at a pace that will cause pain in 3 to 5 minutes. If you can walk longer than 5 minutes without pain, you need to walk faster, or if on a treadmill, you need to increase the incline.
Continue: Keep walking until the pain is a 3 to 4 on the pain scale.
Stop: Stop until the pain is gone. Pain scale score = 1.
Restart: Start walking again until your pain is 3 to 4 on the scale.
Repeat: Continue walking and resting for 50 minutes. Start slowly, perhaps only 15 minuutes then increase the time each week, until at 50 minutes.

Foot care

You must take good care of your feet if you have PAD of the legs. PAD cuts down blood flow, which means less oxygen and nutrients are supplied to tissues. Oxygen and nutrients are very important for wound healing.

With 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 essential!

Basic foot care principles

  • Avoid placing too much pressure on feet.
  • If you have diabetes, keep your blood glucose in target range – four to seven mmol/L before meals and, two hours after meals, five to ten mmol/L, best is five to eight mmol/L.
  • Prevent infection.
  • Avoid injury.
  • Treat infection or injury quickly by getting help from your health care provider or podiatrist.

Proper foot care

  • Keep feet clean and dry, washing them daily and drying well, especially between 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 avoid smoking or blocking your circulation. Knee high socks and nylons, tight shoes, support hose, cowboy boots, and crossing your legs can all constrict circulation. Put your feet up when sitting. 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, as shoes that do not fit well create pressure or rub on your skin, putting you at high risk of injury and infection. (See sidebar on p. 9 for tips on choosing shoes.)
  • Prevent injury - never go barefoot, not 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. Do not use any sharp objects, such as a razor to remove callouses, on your feet.
  • Find injuries by inspecting your feet daily for sores and redness that indicate pressure spots, early infection, injuries, and discoloured areas. Remember to look between your toes.
  • Treat injuries by keeping 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.

walking shoesTips for finding proper fitting shoes:

Toes: when standing, the width of your thumb should fit between the tip of your longest toe and the end of your shoes.
Heels: the height of the heel should be less than two inches. Wearing heels greater than two inches puts 90 per cent of your body weight onto your forefoot. Your body weight should be half on your heel and half on your forefoot. Shoes with a low heel are best.

Material: the material should be soft and breathable, and adapt to the shape of your 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. Velcro™ is also acceptable in many cases. Do not use slip-on shoes.

Support: the shoe should have a cushioned sole with good tread. The sole of the shoe should not bend more than two centimetres in any direction.

Time of day: buy your shoes at the end of the day. Your feet naturally swell during the day and will be at their largest by evening.

Use a shoe fitter: select a store that has 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. A store with a certified pedorthist, who has special training in fitting shoes for those with foot problems is best.

FAMILY HEALTH is written with the assistance of
Alberta College of Family Physicians
FAMILY HEALTH is written with the assistance of
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 2018, Family Health Magazine, a special publication of the Edmonton Journal, a division of Postmedia Network Inc., 10006 - 101 Street, Edmonton, AB T5J 0S1    [DI_MDb08]
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