Claudication

Claudication
Classification and external resources
ICD-10	I73.9
ICD-9	443.9
DiseasesDB	2777
MeSH	D007383

Claudication, literally 'limping' (Latin), is a medical term usually referring to impairment in walking, or pain, discomfort or tiredness in the legs that occurs during walking and is relieved by rest.^[1][2] The perceived level of pain from claudication can be mild to extremely severe. Claudication is most common in the calves but it can also affect the feet, thighs, hips, buttocks, or arms.^[1] The word "claudication" comes from the Latin "claudicare" meaning to limp.

Claudication that appears after a short amount of walking may sometimes be described by US medical professionals by the number of typical city street blocks the patient can walk before the onset of claudication. Thus, "one-block claudication" refers to claudication that appears after walking one block, "two-block claudication" appears after walking two blocks, etc.

Types

Intermittent vascular

Main article: Intermittent claudication

Intermittent vascular (or arterial) claudication (Latin: claudicatio intermittens) most often refers to cramping pains in the buttock or leg muscles. It is caused by poor circulation of the blood to the affected area. The poor blood flow is often a result of atherosclerotic blockages more proximal to the affected area;^[3] individuals with intermittent claudication may have diabetes—often undiagnosed.^[4]

Spinal or neurogenic

Main article: Neurogenic claudication

Spinal or neurogenic claudication is not due to lack of blood supply, but rather it is caused by nerve root compression or stenosis of the spinal canal,^[5] usually from a degenerative spine, most often at the "L4-L5" or "L5-S1" level. This may result from many factors, including bulging disc, herniated disc or fragments from previously herniated discs (post-operative), scar tissue from previous surgeries, osteophytes (bone spurs that jut out from the edge of a vertebra into the foramen, the opening through which the nerve root passes). In most cases neurogenic claudication is bilateral, i.e. on both sides, but it can also be present unilaterally.

Jaw

Jaw claudication is pain in the jaw or ear while chewing. This is caused by insufficiency of the arteries supplying the jaw muscles, associated with giant cell arteritis.^[6][7]

Differential diagnosis

Vascular (or arterial) claudication typically occurs after activity or ambulation for a distance with resultant vascular insufficiency (lack of blood flow) where the muscular demands of oxygen outweighs the supply. Symptoms are lower extremity cramping. Resting from activity even in a standing position may help relieve the symptoms.

Spinal or neurogenic claudication may be differentiated from arterial claudication based on activity and position. In neurogenic claudication, positional changes lead to increased stenosis (narrowing) of the spinal canal and compression of nerve roots and resultant lower extremity symptoms. Standing and extension of the spine narrows the spinal canal diameter. Sitting and flexion of the spine increases spinal canal diameter. A person with neurogenic claudication will have worsening of leg cramping with standing erect or standing and walking. Symptoms may be relieved by sitting down (flexing the spine) or even by walking while leaning over (flexion of the spine) a shopping cart.^[4]

The ability to ride a stationary bike for a prolonged period of time differentiates neurogenic claudication from vascular claudication. Weakness is also a prominent feature of spinal claudication that is not usually present in intermittent claudication.^[4]

Prognosis

The prognosis for patients with peripheral vascular disease due to atherosclerosis is poor; patients with intermittent claudication due to atherosclerosis are at increased risk of death from cardiovascular disease (e.g. heart attack), because the same disease that affects the legs is often present in the arteries of the heart.^[8]

Treatment

Pletal is FDA approved for intermittent claudication. Some things to know before use are the following: contraindicated in patient with heart failure, should be taken 30 minutes before or 2 hours after a meal, and improvement of symptoms may not be evident for two to three weeks.

References

1. ^ ^{a b} Peripheral Arterial Disease at Merck Manual of Diagnosis and Therapy Professional Edition
2. ^ "claudication" at Dorland's Medical Dictionary
3. ^ Simon RW, Simon-Schulthess A, Simon-Schulthess A, Amann-Vesti BR (April 2007). "Intermittent claudication". BMJ 334 (7596): 746. doi:10.1136/bmj.39036.624306.68. PMC 1847882. PMID 17413176. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1847882. 
4. ^ ^{a b c} Burns P, Gough S, Bradbury AW (March 2003). "Management of peripheral arterial disease in primary care". BMJ 326 (7389): 584–8. doi:10.1136/bmj.326.7389.584. PMC 1125476. PMID 12637405. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1125476. 
5. ^ Comer CM, Redmond AC, Bird HA, Conaghan PG (2009). "Assessment and management of neurogenic claudication associated with lumbar spinal stenosis in a UK primary care musculoskeletal service: a survey of current practice among physiotherapists". BMC Musculoskelet Disord 10: 121. doi:10.1186/1471-2474-10-121. PMC 2762954. PMID 19796387. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=2762954. 
6. ^ Reiter S, Winocur E, Goldsmith C, Emodi-Perlman A, Gorsky M (2009). "Giant cell arteritis misdiagnosed as temporomandibular disorder: a case report and review of the literature". J Orofac Pain 23 (4): 360–5. PMID 19888487. 
7. ^ Rieck KL, Kermani TA, Thomsen KM, Harmsen WS, Karban MJ, Warrington KJ (July 2010). "Evaluation for Clinical Predictors of Positive Temporal Artery Biopsy in Giant Cell Arteritis". J Oral Maxillofac Surg 69 (1): 36–40. doi:10.1016/j.joms.2010.02.027. PMID 20674120. 
8. ^ Shammas NW (2007). "Epidemiology, classification, and modifiable risk factors of peripheral arterial disease". Vasc Health Risk Manag 3 (2): 229–34. doi:10.2147/vhrm.2007.3.2.229. PMC 1994028. PMID 17580733. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1994028.