Rapid Review·Cardiovascular
Select any text to highlight it or add a note.
HY Approach
T1Must knowApproach to Leg Pain & Ulcers
Focus on
Leg pain and leg ulcers sorted by vessel: arterial (claudication, cold hairless limb, punched-out painful ulcer on the toe or lateral malleolus, absent pulses), venous (heaviness, edema, medial gaiter ulcer, stasis dermatitis), neuropathic (painless plantar ulcer, palpable pulses). Then the mimics — spinal stenosis and DVT — and the emergencies: acute limb ischemia and phlegmasia.
Key takeaways
Read the leg to name the vessel
The four clues
the pain pattern, the skin, the pulses and the ulcer separate arterial disease (Peripheral Artery Disease), venous disease (Chronic Venous Insufficiency) and diabetic neuropathy.| Feature | Arterial ulcer | Venous ulcer | Neuropathic ulcer |
|---|---|---|---|
| Location | Pressure points of the foot and shin (lateral malleolus, tips of the toes) | Gaiter region above the ankle, usually medial | Plantar pressure points (heel, metatarsal heads) |
| Mechanism | Vessel occlusion and tissue ischemia | Chronic venous hypertension | Diabetic microvasculopathy and neuropathy |
| Wound | Punched-out, no exudate | Irregular borders, exudative, superficial | Hyperkeratotic borders, deep |
| Pain | Severe | Mild | Absent |
| Surrounding findings | Pale, shiny, cold, hairless skin; nail dystrophy; absent pulses | Varicose veins, edema, stasis dermatitis | Charcot joints, absent ankle reflex, impaired vibration sense, claw toes |
| Test | Ankle-brachial index of 0.9 or less | Duplex with reflux | Monofilament and vibration; normal ankle-brachial index |
| Treatment | Exercise, antiplatelet, statin, revascularization | Compression, elevation, wound care, vein ablation | Offloading, glucose control, wound care |
Claudication and its mimics
Vascular claudication
reproducible muscle pain at a fixed walking distance, relieved within minutes by standing still.- The level sets the muscle group: buttock and thigh, aortoiliac (Leriche Syndrome); calf, femoropopliteal; foot, tibial.
| Patient | Disorder | Features |
|---|---|---|
| Over 60; immobilization, obesity, thrombophilia or malignancy | Deep vein thrombosis | Swelling, warmth (cool in arterial disease), erythema (pale in arterial disease), progressive tenderness |
| Middle-aged to older | Spinal stenosis (neurogenic claudication) | Weakness or numbness with the pain; back and leg pain, bilateral or unilateral; improved by lumbar flexion (walking uphill, cycling); normal pulses |
| Middle-aged to older, high body mass index | Diabetic neuropathy | Progressive symmetric stocking sensory loss; normal ankle-brachial index; a warm dry foot with palpable pulses |
Lower extremity edema, typically unilateral
deep vein thrombosis, muscle strain, lymphedema, a paralyzed limb, cellulitis.Lower extremity edema, typically bilateral
heart failure, venous insufficiency, a drug effect (amlodipine).The limb emergencies
Acute limb ischemia
the six P's; heparin and revascularization within 6 hours (Acute Limb Ischemia).Phlegmasia cerulea dolens
massive iliofemoral thrombosis with a swollen blue painful leg.Compartment syndrome
after reperfusion or trauma; pain out of proportion; fasciotomy.Vascular trauma
Vascular Trauma.Non-atherosclerotic arterial disease and the examination
Fibromuscular dysplasia
young women with renal artery hypertension or carotid dissection (Fibromuscular Dysplasia).Thromboangiitis obliterans (Buerger disease)
young heavy smokers with distal ischemia, digital gangrene and superficial thrombophlebitis.Raynaud phenomenon
episodic white-blue-red digits with cold or stress; primary in young women, or secondary to scleroderma or lupus; calcium-channel blockers.Others
vasculitis (Takayasu, giant-cell), Cholesterol Embolism Syndrome.The arterial examination
in order.- Pulses at every level: femoral, popliteal, posterior tibial, dorsalis pedis.
- Skin: capillary refill, temperature, hair and nails.
- Buerger sign: elevation pallor, dependent rubor.
- Bruits and arm pressures: listen for bruits, and check both arm pressures.
- The ankle-brachial index: the first objective test.
A 64-year-old with back pain gets bilateral leg pain and numbness on walking downhill, relieved by sitting and bending forward, with normal foot pulses and a normal ankle-brachial index. Is this vascular claudication?
No: this is neurogenic claudication (spinal stenosis); improvement with lumbar flexion and normal pulses and ankle-brachial index separate it from vascular claudication, which is relieved by standing still.
How it's tested
A punched-out painful ulcer on the lateral malleolus with a cold hairless leg and absent pedal pulses: arterial ulcer — ABI, then angiography and revascularization.
A shallow weeping ulcer above the medial ankle with brown skin and varicosities: venous stasis ulcer — compression and elevation.
A painless deep ulcer under the first metatarsal head in a diabetic with good pulses: neuropathic ulcer — offload, debride, glucose control.
Bilateral leg pain on walking relieved by sitting down or leaning on a shopping cart, with normal pulses: lumbar spinal stenosis, not PAD.
A 35-year-old heavy smoker with gangrenous fingertips and migratory superficial thrombophlebitis: Buerger disease — stop smoking completely.
Go deeper
Guidelines: 2024 ACC/AHA Peripheral Artery Disease Guideline
Related Step 2 pages: Peripheral Artery Disease, Acute Limb Ischemia, Leriche Syndrome, Chronic Venous Insufficiency, Superficial Thrombophlebitis, Fibromuscular Dysplasia, Femoral Artery Disease, Vascular Trauma
Flashcards for this page
Card 1 of 5 · try-out only, nothing is saved
You just read one page of 236
The rest of Step 2 CK, written exactly like this.
Rapid Review is the reading layer of a full Step 1 platform: a schedule fitted to your exam date, flashcards for every page, and a mentor a message away.
Every Step 1 system
Written the same way: what to know, how it’s tested, where to go deeper.
A plan built to your exam date
Tell us when you sit, and the schedule fits the whole library and your question bank to it.
Flashcards for every page
Ready-made spaced-repetition decks linked to each topic, so nothing you read gets forgotten.
