Physical Exam and Chronic Lower-Extremity Ischemia
In the early decades of this century, Buerger published a book detailing clinical signs physicians have adopted as indicative of clinically significant arteriosclerosis of the lower extremities. Among these findings were absent pulses, toe and foot ulcers, nail growth impairment, soft tissue atrophy, poor capillary refill, pallor with elevation, and hyperemia when dependent.
Lower limb arteriosclerotic disease is generally divided into aortoiliac, femoropopliteal, and peroneotibial segments. The ratio of ankle (posterior tibial or dorsalis pedis) systolic arterial to arm (brachial) systolic arterial pressure is known as the ankle-to-arm index (AAI). In health, the AAI is greater than 0.97. An AAI between 0.5 and 0.8 is found in most individuals with claudication; patients with rest pain or gangrene have AAIs less than 0.5. The specificity and sensitivity of a less than normal AAI exceeds 94%. This study examined the value of physical findings, when compared with AAI, in determining location of arterial stenoses.
Up to one-third of patients with limb-threatening occlusive disease have at least one palpable pedal pulse. One helpful observation is that this "false positive" palpable pulse may disappear during exercise, but the exact percentage frequency of this finding remains to be established.
Though the presence of a femoral bruit is a reasonably strong indicator of disease, its low sensitivity (0.2-0.29) results in the absence of a bruit not altering disease likelihood. Pallor and rubor were both weak disease predictors, and were not helpful in multivariate analysis. Other findings not shown to be clinically helpful were capillary refill time, absent hair growth, and atrophic skin. The authors' data indicate that abnormal pedal pulses, a unilaterally cool extremity, femoral bruit, and prolonged venous filling time are helpful physical examination tools to diagnose the presence of peripheral arterial disease; other physical examination findings evaluated in this study were not.
McGee SR, Boyko EJ. Arch Intern Med 1998;158:1357-1364.
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