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Medically Reviewed by
Dr. Paul Hanna, DO, RPVI
Board Certified Vascular Surgeon
Every week in our vascular surgery practice at South Florida Multispecialty Medical Group, we see at least one patient who spent months, sometimes years, treating the wrong condition. They come in with a thick stack of spine X-rays, a physical therapy history, perhaps even a steroid injection in their lower back. And yet the leg pain never really went away. What we find, more often than you would expect, is peripheral artery disease.
Peripheral artery disease, or PAD, is a circulatory condition in which narrowed arteries reduce blood flow to the limbs, most commonly the legs. The hallmark symptom is leg pain that starts with activity and eases with rest, a phenomenon called intermittent claudication. But here is the problem: that same pattern of leg pain while walking is one of the most common presentations of lumbar spinal stenosis and sciatica. And because most patients see a primary care doctor or orthopedist first, the vascular cause gets missed, sometimes for a very long time.
The goal is to give patients, their families, and even fellow clinicians a clear picture of how PAD actually presents, why it gets misdiagnosed, and what we do about it here in our facility.
At the core of this diagnostic challenge is a frustrating overlap between two very different conditions. Peripheral artery disease causes muscle pain and cramping in the calves, thighs, hips, or buttocks, depending on which artery is narrowed. Lumbar spinal stenosis, a narrowing of the spinal canal that compresses nerves, causes nearly identical leg symptoms. Both conditions occur more commonly in people over 50. Both cause leg discomfort with walking. Both ease with rest.
What we tell patients before their first consultation is this: the location of your pain is not enough to diagnose you. We need to understand the character of the pain, what triggers it, what relieves it, how long it has been building, and what your vascular risk factors look like. Those details are what separate a nerve problem from a blood flow problem, and getting that distinction right changes everything.
One of the most consistent differences we observe in our clinical exams is this: PAD pain is a deep muscular cramp or ache that is directly tied to exertion and relieves quickly with rest, typically within 10 minutes. Sciatica and spinal stenosis pain, by contrast, often has a sharp, shooting, or burning electric quality that radiates along the nerve path, usually from the lower back through the buttock and down one leg, and may persist even at rest.
One detail that frequently surfaces in patient histories is body position and its effect on pain. With spinal stenosis, leaning forward (like pushing a shopping cart) often relieves symptoms because that posture opens up space in the spinal canal. With PAD, body position makes no meaningful difference. The pain is driven purely by blood supply, not nerve compression. Stopping walking is what stops the pain.
After treating hundreds of patients with vascular disease in South Florida, we have learned to ask a very specific question during intake: “When you stop and rest, does the pain go away, and if so, how long does it take?” If the answer is “yes, within a few minutes,” we move straight into vascular evaluation. That single question has redirected many diagnoses in our clinic.
Peripheral artery disease develops when atherosclerosis, the buildup of fatty plaques inside arterial walls, narrows or blocks the arteries that carry blood to the legs. As the blockage worsens, muscles downstream cannot receive enough oxygen-rich blood to meet the demands of movement. The result is ischemic muscle pain, which is the body’s signal that demand is outpacing supply.
The condition is far more common than most people realize. According to the Centers for Disease Control and Prevention (CDC), up to 4 in 10 people with PAD have no classic leg pain at all. This is what makes PAD genuinely dangerous. It can progress silently until blood flow becomes critically compromised. By the time some patients reach our clinic, we are no longer talking about lifestyle limitations. We are talking about limb salvage.
PAD also carries systemic implications. The same atherosclerosis narrowing the arteries in the legs is often narrowing arteries elsewhere in the body, including those supplying the heart and brain. Patients with diagnosed PAD carry a significantly elevated risk of heart attack and stroke. We always evaluate cardiovascular risk comprehensively when we confirm a PAD diagnosis.
The risk profile for PAD overlaps heavily with that of cardiovascular disease in general. The most common risk factors include:
In our Miami practice, we see a significant number of patients with diabetes-related PAD, which often progresses faster and presents with more severe limb complications than PAD in non-diabetic patients. Diabetic patients with PAD frequently develop foot ulcers that resist healing, and those wounds, if left untreated, can progress to infections requiring amputation.
Intermittent claudication is the clinical term for the recurring leg pain that defines early-to-moderate PAD. The word “intermittent” is key, the pain comes with activity and goes with rest. Patients describe it as a deep cramping, aching, or heaviness in the affected muscle. The location of the cramp depends on which artery is narrowed:
Patients often describe the experience as “my leg just giving out” or “it feels like my calf is in a vice.” Many assume they are simply out of shape or that the pain is coming from arthritis. That misinterpretation is one of the main reasons PAD goes undiagnosed. Patients adapt by walking less, which reduces symptoms but allows the disease to advance unchecked. If you recognize any of these patterns, our dedicated guide on claudication treatment in Miami explains what your next steps should look like.
As PAD progresses, the narrowing becomes severe enough that even minimal blood flow at rest is insufficient. At this stage, patients develop rest pain, a burning or aching sensation in the feet or toes, often worse at night when the legs are elevated. Many patients unconsciously hang their legs off the edge of the bed because gravity helps pull what little blood flow remains toward the feet. That behavioral pattern is a red flag we look for in our consultations.
Advanced peripheral artery disease also produces visible and palpable changes. We look for:
The critical limb-threatening ischemia (CLTI) stage is the most dangerous. At this point, we are working against a clock. The longer circulation remains compromised, the greater the risk of irreversible tissue loss.
A significant proportion of PAD patients, up to 40% by some estimates, have no classic claudication symptoms. This “atypical” or asymptomatic presentation is particularly common in patients with diabetes, where peripheral neuropathy (nerve damage from high blood sugar) blunts the normal pain response. These patients may have severe arterial disease with critical limb ischemia but feel very little discomfort until a wound develops or a toe turns black.
In our hospital, we actively screen for PAD in high-risk patients who present with any of the following: diabetes with foot changes, unexplained leg fatigue, non-healing wounds anywhere below the knee, or erectile dysfunction in men (a recognized vascular marker of PAD). Silent PAD is not benign PAD. It is dangerous precisely because the warning signals are absent.
The ankle-brachial index (ABI) is a simple, non-invasive, office-based test that compares blood pressure measured at the ankle to blood pressure measured at the arm. In a healthy individual, the pressures should be approximately equal or the ankle pressure should be slightly higher. In PAD, narrowed arteries reduce blood pressure in the legs, so the ratio comes out lower than expected.
We consider an ABI below 0.90 diagnostic for PAD. An ABI below 0.40 indicates critical limb ischemia. This test takes about 15 minutes, requires no needles or contrast dye, and gives us a real-time snapshot of how well blood is flowing from the heart to the lower extremities. When a patient comes in with leg pain that has been labeled “back-related” and they have known vascular risk factors, the ABI is the first test we order.
When the ABI confirms or strongly suggests PAD, we move to imaging to precisely locate and characterize the blockages. Our toolkit, detailed further in our overview of vascular imaging in Miami, includes:
The imaging findings guide our treatment decision. A short, focal blockage may be ideal for balloon angioplasty and stenting. Long, diffuse disease in multiple segments may require surgical bypass. Every case is individual, and we present our findings in a detailed discussion with the patient before recommending any intervention.
Not every PAD patient requires a procedure. For early-stage, stable claudication without critical ischemia, we start with aggressive risk factor management. This means smoking cessation (the single most impactful change a PAD patient can make), blood pressure control, cholesterol reduction with statins, antiplatelet therapy (aspirin or clopidogrel), and diabetic glucose management.
Supervised exercise therapy is one of the most evidence-supported treatments for claudication. Regular structured walking, performed consistently over weeks, stimulates the growth of collateral blood vessels that help bypass narrowed areas. What we tell patients before starting supervised exercise is that it may feel counterintuitive to walk through discomfort, but those controlled walks are therapeutic, not harmful.
When blockages are severe enough to limit daily life despite medical management, or when a patient presents with rest pain or non-healing wounds, we move to intervention. The first-line approach in most cases is endovascular treatment, procedures performed from within the artery through small access points, without open surgery.
Our vascular team performs:
Endovascular procedures carry much shorter recovery times than open surgery, typically requiring only one or two nights in the hospital or even same-day discharge.
For patients with long-segment blockages, anatomic configurations not amenable to endovascular treatment, or failed prior endovascular procedures, surgical bypass remains the definitive treatment. We create a detour around the blocked artery using either a vein graft (taken from the patient’s own body, most often the saphenous vein from the inner thigh) or a synthetic prosthetic graft.
In our hospital, bypass surgeries are performed under general or regional anesthesia and require a recovery period of several days inpatient followed by weeks of outpatient monitoring. The long-term patency (rate at which the bypass graft stays open) depends on the location of the bypass, the quality of the vessels involved, and the patient’s ongoing cardiovascular risk management. We follow every bypass patient closely after discharge because long-term surveillance is as important as the surgery itself.
The term “limb salvage” may sound dramatic, but for patients with advanced PAD and critical limb-threatening ischemia, it is exactly what is at stake. Patients who arrive at our clinic with non-healing foot ulcers, gangrene, or rest pain have a narrowing window for intervention before tissue loss becomes irreversible.
At South Florida Multispecialty Medical Group, our limb salvage approach is multi-disciplinary. Vascular surgery, podiatry, endocrinology, and wound care all work in coordination. We revascularize the limb to restore blood flow, debride or treat infected tissue, and manage the underlying conditions, particularly diabetes, that are perpetuating the wound healing problem. When patients are referred to us after months of wound care without vascular workup, we sometimes cannot save the limb. When patients are referred early, the outcomes are dramatically better.
The message we share with our referring physicians is straightforward: any non-healing wound below the knee in a patient with diabetes or smoking history should be assumed vascular until proven otherwise.
Most patients with PAD see a primary care physician first, and that is perfectly appropriate. But there are clear signals that a vascular surgery consultation is warranted, and those referrals should happen sooner rather than later. We encourage patients and physicians to pursue vascular evaluation in the following situations:
At SFL Medical Group, our vascular surgery consultations begin with a detailed history, physical examination, and same-visit ABI testing when indicated. We do not believe in sending patients home with a “watch and wait” plan when the clinical picture points toward a vascular etiology. To learn more about how our specialists compare and collaborate, read our guide on vascular surgeon vs. cardiologist vs. radiologist.
Peripheral artery disease is a marker of systemic atherosclerosis. Patients with PAD are at significantly elevated risk of heart attack and stroke, independent of whether their leg symptoms are mild or severe. That is why diagnosis and treatment extend far beyond the legs. When we confirm PAD in a patient, we assess their full cardiovascular risk profile, coordinate with cardiology when appropriate, and build a long-term management plan that addresses the underlying disease process, not just the arterial segment that brought the patient to our door.
The leg that hurts when you walk may be telling you something much more important than where you need physical therapy. If you or someone you know has leg pain with activity, has been told they have “back-related” leg symptoms that aren’t responding to treatment, or has any of the warning signs described above, we encourage you to request a vascular evaluation. Early diagnosis of PAD gives us the greatest number of treatment options and the best chance of protecting both the limb and the heart.
To schedule a consultation with our vascular surgery team at South Florida Multispecialty Medical Group, call us directly or send a message using our contact us page.
Dr. Paul Hanna is a board-certified vascular surgeon with specialized fellowship training in complex vascular interventions and minimally invasive endovascular techniques. He serves as Director of Vascular Surgery and General Surgery at South Florida Multispecialty Medical Group, with over a decade of experience treating vascular conditions affecting the limbs, aorta, and peripheral arterial system.
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