Calf pain on walking that stops with rest. The leg is the messenger — the real issue is arteries everywhere.
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Peripheral arterial disease is narrowing of the arteries supplying the legs, caused by the same fatty plaque that narrows the arteries of the heart and brain.
The characteristic symptom is intermittent claudication: a cramping ache in the calf, thigh or buttock that comes on after a predictable distance of walking, and settles within a few minutes of standing still. The same hill, the same distance, every time.
The single most important thing to understand is that PAD is not really a leg problem. It is a marker that arterial disease is established throughout the body. Someone with claudication carries a substantially raised risk of heart attack and stroke, and the treatment that matters most is aimed at those, not at the leg.
That reframing is the whole point of the diagnosis. The leg is what brings people in. It is not what is most likely to harm them.
Pain in the foot at rest, particularly at night and relieved by hanging the leg out of bed, is critical limb ischaemia. So is an ulcer that will not heal, or a black or blue toe.
These are urgent — same-day — and the limb is at risk.
The risk factor list is the same as for heart attack and stroke, because it is the same disease in a different artery.
The ABPI is the test. Blood pressure is measured at the ankle and at the arm, and the ratio calculated. A ratio below 0.9 indicates peripheral arterial disease; below 0.5 suggests severe disease.
It takes about ten minutes, needs no needles and no radiation, and it is usually done in a GP practice or a vascular clinic.
In people with long-standing diabetes or kidney disease, the arteries can become stiff and calcified, which produces a falsely normal or even high ABPI. A reassuring number in that group does not exclude PAD, and a toe pressure or duplex ultrasound is used instead.
This is a well-recognised trap and it is worth knowing if you have diabetes and have been told your circulation is fine.
Spinal stenosis is the great mimic. It also causes leg pain on walking — but it typically eases on sitting or leaning forward rather than simply standing still, and the distance is less predictable. Distinguishing them changes the entire management.
Also considered: sciatica, arthritis of the hip or knee, and venous claudication after a previous DVT.
PAD is not diagnosed remotely. It needs the pulses in your feet felt and an ankle-brachial pressure index measured — a comparison of blood pressure at the ankle and the arm, which takes minutes and cannot be done over video.
Foot pulses, the ABPI, and any assessment of an ulcer or a discoloured toe. Anyone with diabetes and a foot problem needs urgent in-person review — that threshold is deliberately very low.
Seek emergency assessment — A&E or 999 — if:
Seek same-day assessment if:
Book a routine consultation for: cramping calf pain on walking that reliably settles with rest, cold feet, or a walking distance that has been shrinking over months.
Supervised exercise is first-line treatment for intermittent claudication, and it works better than most people expect — often better than a procedure for walking distance.
The instruction that surprises people: walk until the pain comes on, rest until it eases, then walk again. Aim for around two hours a week over three months. Walking into the discomfort is what drives the small collateral vessels to develop.
Ask specifically about a supervised exercise programme. NICE recommends it should be offered before considering angioplasty or surgery, and it is frequently skipped.
In PAD this is not general advice, it is the single most effective thing available. Continuing to smoke substantially increases the risk of the disease progressing, of grafts failing, and of amputation.
NHS stop smoking services are free and roughly triple the chance of success.
Take the statin and the antiplatelet. They do little for the leg pain and a great deal for your heart and brain, which is precisely the point.
For anything urgent — rest pain, an ulcer, a discoloured toe — go to the NHS today. Limb-threatening problems are managed by vascular surgery and time matters.
Men are invited for NHS AAA screening in the year they turn 65 — a single painless ultrasound for an abdominal aortic aneurysm. It is offered once, and arterial disease in the legs shares its risk factors, so it is worth attending if you are invited.
This page follows NICE CG147, Peripheral arterial disease: diagnosis and management.
NICE NG19 covers diabetic foot problems, and sets a deliberately low threshold: anyone with diabetes and a new foot problem should be assessed within one working day by a foot protection or multidisciplinary foot service.
Reviewed against NICE CG147 and NG19 current at the date shown above.
Age slows people down; it does not usually produce cramping calf pain at a reproducible distance that stops within minutes of standing still.
That specific pattern is worth an ABPI, and it is regularly dismissed for years.
Because walking into the discomfort is what encourages small collateral vessels to develop. Supervised exercise is first-line treatment and improves walking distance substantially.
Walk to the pain, rest, repeat — about two hours a week over three months.
Not usually as a first step. Guidance is clear that supervised exercise should be tried before angioplasty is considered for claudication.
Procedures are reserved for people whose symptoms remain limiting, or where the limb is threatened.
Because the leg is the symptom and the arteries are the disease. Having PAD substantially raises your risk of heart attack and stroke.
The statin and antiplatelet are aimed at those — they are the treatments most likely to extend your life, even though they do little for the cramp.
In this condition, more than almost any other. Continuing to smoke increases the risk of progression, of grafts failing, and of amputation.
Free NHS support roughly triples your chance of stopping.
Not necessarily. Long-standing diabetes can stiffen the arteries and produce a falsely normal or high ABPI.
A toe pressure or ultrasound is used instead — worth asking for if symptoms persist despite a reassuring number.
Quite possibly — spinal stenosis is the main mimic.
The useful distinction: stenosis usually eases on sitting or leaning forward, and the distance varies. PAD eases on simply standing still, at a predictable distance.
Advanced disease where blood supply is inadequate even at rest — foot pain at night, non-healing ulcers, or blackened toes.
It is limb-threatening and needs urgent vascular assessment, not a routine appointment.
Because reduced blood supply means wounds heal slowly and infections spread quickly.
Small problems found early stay small. With diabetes on top, any new foot problem should be seen within a day.
August 30, 2026
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