Your Foot and Ankle and Peripheral Vascular Disease
Oftentimes, when we experience lower extremity pain with activity or even at rest we are quick to blame it on musculoskeletal issues. We are unaware that there are more acute underlying issues such as lack of blood flow to our lower extremity.
Peripheral vascular disease (PVD) is the pathology of blood vessels causing decreased blood flow most commonly to your foot and ankle. Peripheral vascular disease can involve the arterial or venous system of your lower extremity. The arterial system is involved in bringing blood down to your lower extremity, while the venous system is involved in bringing blood back to your heart. Pathology of arteries usually involves occlusion of blood vessels due to cholesterol, known as atherosclerosis, or due calcification of blood vessels, both leading to decreased blood supply to the lower extremity. Blood flow is important as it provides oxygen and nutrition needed for maintenance of tissue health.
The effects of PVD are manifested in the lower extremity with functional and visual changes. Loss of blood flow can cause ischemic (decreased blood flow) pain with activity (known as claudication) that may improve at rest. If disease has progressed then lower extremity pain may be present even at rest.
Some visual changes seen with PVD are nails becoming thick and brittle, decreased hair growth, changes in skin temperature, skin being shiny, thin or thick, and changes in skin color. Patients with PVD are at high risk of ulceration, amputation and life threatening infections.
Gangrene indicates that blood flow is less than adequate to allow for the tissues basic metabolic need to survive. Disease location is associated with survival in patients with peripheral arterial disease.
Factors contributing to increasing susceptibility to PVD are history of Diabetes, history of smoking, hyperlipidemia, increased body mass index and individuals over the age of 60. The leading cause of PVD is associated with cigarette smoking . Studies show that nicotine from smoking injures the blood vessel lining, and also makes patients at higher risk for blood clots and can lead to death (1). In addition, the development of wounds that can lead to amputation increases your risk of future complications and more proximal amputations.
The American College of Cardiology and the American Heart Association identifies high risk groups for patient with PVD:
- Patient with Age ≥70 years
- Patients between ages 50 to 69 year old with a history of smoking or diabetes
- Patients between ages 40 to 49 with diabetes and at least one other risk factor for atherosclerosis
- Known atherosclerosis at other sites (for example: coronary, carotid artery disease)
In addition, studies have indicated that patients who develop vascular disease at an earlier age have much more aggressive progression of the disease and a significantly higher mortality rate. 20% of patients with a major amputation die within 5 years of the amputation (2). This is why early diagnosis is essential for prevention of complications.
A podiatrist is able to identify these vascular changes during a routine clinical exam, order detailed diagnostic studies. These studies may include Ankle Brachial Index (ABI) which evaluates the blood flow in your arm and compares it to the blood flow in your feet, segmental pressures and imaging such as ultrasound to evaluate blood flow in your lower extremity. Once this is performed, slowing down progression and appropriate treatment can be implemented.
Picture A: ABI is evaluated by comparing the blood pressure in the upper extremity to the pressure in the lower extremity.
Your podiatrist is often the first member of your health care team to identify and diagnose PVD. Podiatrists at Foot and ankle Specialist of the Mid-Atlantic work in a multidisciplinary limb salvage approach and will be by your side to guide and help you with treatment that is most appropriate for your level of disease. Sometimes this will consist of a smoking cessation regimen, improving diabetic health, taking oral medication to improve walking distance, wound management, and of course actively work on decreasing risk factors. Depending on the level of disease, vascular intervention and surgery may be needed. This involves improving blood flow through the use of angioplasty and sometimes even a bypass.
Because PVD is insidious and can hide behind vague symptoms, it is important to be seen by your foot and ankle specialist regularly. Benign changes such as small cuts, blisters and sores can lead to severe complications. It is crucial to be proactive in your lower extremity health: check your feet daily for any skin changes, skin break down and pain that occurs. Also be protective of your feet by wearing supportive shoes that provide balance and stability to avoid injury. Early diagnosis and prevention is most important in preventing life threatening complications.
Dr. Sana Shamim lives and practices in Frederick, Maryland. She has a special interest in limb salvage, skin issues and sports injuries. In her free time she enjoys hiking with her family.
References:
- I;, Rahman MM;Laher. “Structural and Functional Alteration of Blood Vessels Caused by Cigarette Smoking: an Overview of Molecular Mechanisms.” Current Vascular Pharmacology, U.S. National Library of Medicine, pubmed.ncbi.nlm.nih.gov/17979794/.
- Chen, Qian, et al. “Disease Location Is Associated with Survival in Patients with Peripheral Arterial Disease.” Journal of the American Heart Association, Blackwell Publishing Ltd, 21 Oct. 2013, www.ncbi.nlm.nih.gov/pmc/articles/PMC3835235/.
Picture A:
https://www.mayoclinic.org/tests-procedures/ankle-brachial-index/multimedia/ankle-brachial-index/img-20008490
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