Diagnostic Approach for Bilateral Leg Pain

Clinical Assessment and Diagnostic Recommendations

The American College of Cardiology recommends that patients with leg pain undergo a comprehensive medical history and review of symptoms to assess for exertional leg symptoms, including claudication or other walking impairment 3, 4
The American Heart Association and American College of Cardiology suggest a physical examination including palpation of lower extremity pulses, auscultation for femoral bruits, and inspection of the legs and feet 4, 5
The resting ankle-brachial index (ABI) is the initial diagnostic test recommended for suspected peripheral artery disease (PAD) and may be the only test required to establish the diagnosis 6, 4
For patients with normal ABI but persistent symptoms, exercise treadmill ABI testing is recommended to evaluate for PAD 4, 5
The American College of Cardiology notes that a patient with bilateral leg pain and normal neurological examination should undergo a complete vascular examination including ABI measurement to rule out PAD 3, 4
Consider exercise treadmill testing if symptoms are exertional, as recommended by the American College of Cardiology 4, 5

The differential diagnosis for bilateral leg pain includes peripheral arterial disease (PAD), which presents with intermittent claudication, fatigue during effort, according to the American College of Cardiology 1, 2
Spinal stenosis often presents with bilateral buttock/posterior leg pain and weakness that worsens with standing/extending spine, as noted by the American College of Cardiology 1, 2
Venous claudication presents with tight, bursting pain that subsides slowly and improves with elevation, according to the American College of Cardiology 1, 2
Chronic compartment syndrome presents with tight, bursting pain after strenuous exercise, as reported by the American College of Cardiology 1, 2
Arthritis presents with aching pain after variable exercise, not quickly relieved by rest, according to the American College of Cardiology 1, 2