Diagnostic Approach to Leg Pain

Initial Clinical Assessment

The American College of Cardiology recommends beginning with a focused history targeting pain characteristics and performing a comprehensive lower extremity vascular examination, including bilateral pulse palpation and ankle-brachial index (ABI) testing if peripheral artery disease (PAD) is suspected 1
Pain characterization, including location specificity, claudication features, atypical exertional symptoms, rest pain, and positional factors, is crucial in narrowing the differential diagnosis 1, 2
The American College of Cardiology suggests assessing for diabetes, smoking history, dyslipidemia, hypertension, chronic kidney disease, or family history of PAD to risk-stratify patients for PAD evaluation 1, 2

The American College of Cardiology recommends resting ABI as the initial diagnostic test for PAD, with an ABI <0.90 confirming the diagnosis (Class I recommendation, Level B-NR evidence) 2
If PAD is suspected based on history and physical findings, the American College of Cardiology suggests proceeding with ABI testing 2

If ABI is abnormal or PAD is confirmed and further anatomic detail is needed for revascularization planning, the American College of Radiology recommends duplex ultrasound, CT angiography, or MR angiography of the lower extremities 4
If initial vascular workup is normal but symptoms persist, the American College of Radiology suggests considering plain radiographs or MRI without contrast to evaluate for arthritis, fracture, or bone lesions, or soft tissue, nerve, or musculoskeletal pathology 5

The American College of Cardiology advises against assuming all exertional leg pain is claudication, as only one-third of PAD patients present with typical claudication 1, 2
The American College of Cardiology recommends against skipping bilateral pulse examination, as the presence of all four pedal pulses bilaterally makes PAD unlikely and redirects the workup 3