VA PUGET SOUND HEALTH CARE SYSTEM  REFERRAL GUIDELINES

Lower Extremity Atherosclerotic Occlusive Disease

Intermittent Claudication

Intermittent claudication is a cramping, aching or burning in the muscles, associated with exercise, but not present at rest. The differential diagnosis includes musculoskeletal conditions, spinal stenosis or herniated disk, and peripheral neuropathy. Before referring the patient, a complete vascular examination of the peripheral pulses will be helpful in confirming the diagnosis. In general, intermittent claudication has a relatively benign prognosis, and the vast majority of patients do well with a conservative program of exercise, smoking cessation, weight loss, and control of atherosclerotic risk factors. An excellent conservative management and exercise program is outlined in a recent NEJM review (N Engl J Med. 2002 Dec 12;347(24):1941-51). Click here for the article. 

Appropriate Indications for referral for claudication:

Claudication is interfering with patient’s livelihood (e.g. postman), or limits the patient’s basic activities of daily living (e.g. can’t walk to the bathroom, or get the mail). Physical exam confirms absence of pulses.

Inappropriate Indications for referral for claudication:

• Claudication that does not interfere with livelihood or ADL, when a conservative management program has not been implemented.             
• Leg pain of unknown etiology.             
• Nocturnal muscle cramps.             
• Patients whose advanced age, arthritis or cardiopulmonary diseases are the dominant limitations to their mobility.

Ischemic Rest Pain, Ischemic Ulceration or Gangrene

Patients with ischemic rest pain typically have aching, gnawing deep pain in their toes, forefoot or foot. It is worse at night with elevation of the feet, and is relieved by dependency of the feet. On PE they do not have pedal pulses, and the foot is pale or ruborous. Ischemic ulcers are painful and slow to heal. Rest pain can be distinguished from peripheral neuropathy by the presence of pedal pulses.

Appropriate Referrals for Ischemic Rest Pain – these patients should be seen promptly (page or call Constance Bass R.N. to arrange appt).

• Absent pulses and typical symptoms             
• Ulcerations or tissue loss with absent pulses

Inappropriate Referrals for Ischemic Rest Pain

• Feet are cold             
• Painful feet with normal pulses