PAD & Arteries

Peripheral artery disease is narrowing of the arteries that carry blood to the legs and feet. It is common, it is often silent, and it is treatable — but the treatment is medical, not something you buy.

What is actually happening

Arteries are the delivery system. Oxygen-rich blood leaves the heart, travels down through the aorta into the pelvis, then into each leg through progressively smaller vessels until it reaches the foot. In PAD, fatty plaque builds up inside those arteries and narrows them. Less blood gets through.

At rest, a narrowed artery often delivers enough. The shortfall shows up when demand rises — which is why the classic first symptom appears during walking rather than sitting. As narrowing progresses, the shortfall starts to show at rest too, and that is a more serious stage.

What it feels like

The textbook symptom is claudication: cramping, aching or fatigue in the calf, thigh or buttock that comes on after a fairly predictable walking distance, eases within a few minutes of standing still, and returns at roughly the same distance next time. The reproducibility is the giveaway.

But many people with PAD never get that. Instead there may be:

• Legs that simply tire quickly, which is easy to attribute to age or being out of shape
• Feet that are persistently cold, or one foot colder than the other
• Hair loss on the lower legs, shiny or thin skin, slow-growing or thickened toenails
• A sore, blister or crack on the foot that takes far longer to heal than it should
• Pain in the forefoot or toes at rest, worse lying flat, relieved by dangling the foot
• Nothing at all

That last one matters. PAD is frequently asymptomatic, and its presence signals raised risk of heart attack and stroke regardless of whether the legs hurt. Finding it is useful even when it is not bothering you.

Who is more likely to have it

How it gets diagnosed

The first-line test is the ankle-brachial index (ABI) — blood pressure at the ankle compared with blood pressure at the arm. It takes a few minutes, needs no needles, and gives a number. In people with diabetes or kidney disease the ankle vessels can be stiff enough to give falsely reassuring readings, which is why a toe-brachial index (TBI) is often added. Ultrasound, and sometimes CT or MR angiography, map where the narrowing is when that matters for planning treatment.

What the ABI and TBI actually involve →

How it gets treated

PAD treatment runs on several tracks at once, and the tracks are not alternatives to each other.

1. Risk-factor treatment. Stopping smoking, and medicines for cholesterol, blood pressure and blood sugar. This is aimed at the heart and brain as much as the legs, and it is the part with the largest effect on how long you live.
2. Antiplatelet therapy. Usually aspirin or clopidogrel, sometimes in combination with a low-dose anticoagulant, depending on the individual picture.
3. Structured exercise. Supervised walking programs have a well-established place in improving walking distance in stable claudication. This is a prescribed program with a specific structure, not simply “walk more”. How structured walking works →
4. Symptom-specific medicine. Cilostazol is used in some people with claudication; whether it suits you depends on other conditions, particularly heart failure.
5. Revascularization. Angioplasty, stenting or bypass surgery to restore flow. These are considered when symptoms are limiting despite the above, or when the limb is threatened by rest pain or tissue loss.

The treatment map in more detail →

Living with it day to day

Two things do most of the work: protecting the feet, and keeping moving within the plan your clinician set. Reduced blood flow means small injuries heal slowly and get infected more easily, so daily inspection, well-fitting shoes, and prompt attention to anything new are not fussiness — they are the main way limbs are saved. Daily foot and leg checks →

Common questions

Is PAD the same as poor circulation?

“Poor circulation” is a loose phrase people use for cold feet, swelling, discoloration and numbness, and most of those have nothing to do with arteries. PAD is one specific cause — narrowed leg arteries — and it is diagnosed with a measurement, not a feeling.

Can PAD be reversed?

The plaque itself is not usually reversed. What can change substantially is how far you can walk, how you feel, and your risk of heart attack, stroke and limb loss. Stopping smoking, taking the prescribed medicines and doing a structured walking program all have real effects on those outcomes.

Should I walk through the pain?

Only if a clinician has diagnosed stable claudication and given you that plan. Walking into discomfort is part of how supervised programs work for claudication — but the same instruction is wrong, and potentially harmful, if you have a wound, rest pain, an undiagnosed limb, or a sudden change. Get the diagnosis first.

My ABI was normal. Does that rule PAD out?

Not entirely. Stiff, calcified ankle arteries — common in diabetes and kidney disease — can push the ABI into the normal or even falsely high range. That is why a toe-brachial index, an exercise ABI, or imaging is sometimes added when symptoms suggest PAD but the resting number looks fine.

Can a podiatrist manage PAD?

A podiatrist is one part of the team, not the whole of it. Foot and skin assessment, wound care, footwear, offloading and recognizing a limb at risk sit squarely in podiatry. Diagnosis of the arterial disease itself, medical therapy and any procedure involve primary care and vascular specialists. Good PAD care is usually several clinicians coordinating.

Written by Tom Biernacki, DPM, FACFAS. Published 20 September 2026. General education, not medical advice.