Leg pain when walking may result from a variety of causes, such as natural age-related changes in your knees, ankles or other structures in your lower extremities. Whatever the cause, you might wonder when to worry about leg pain.
If you ask “why does my leg hurt when I walk?” you might have peripheral arterial disease (PAD).
That’s because one of the classic symptoms of PAD is leg pain when walking. Every few steps, leg cramps force you to stop. After a brief rest, the pain resolves, and you resume walking, only to find the pain returns a few steps later.
Although you may be tempted to walk less in order to avoid leg cramps, walking more can actually help prevent them.
“Exercise, particularly supervised exercise therapy, improves pain-free walking,” says Cleveland Clinic cardiologist and vascular disease specialist Pulkit Chaudhury, MD. “We don’t fully understand the reasons, but the results can be as good as revascularization for some patients.”
What Causes Leg Cramps?
Doctors don’t always know what causes leg cramps, but a number of factors—for example, dehydration, electrolyte disorders, and a number of medical conditions—can contribute to them.
One of those contributors is PAD, in which atherosclerotic plaque builds up in leg arteries, thereby restricting blood flow. Using your legs increases the need for oxygenated blood, which narrowed arteries can’t deliver. Your muscles respond by cramping, aching, burning or exhibiting other signs of discomfort. When you stop and rest, the need for oxygen drops, and within a few minutes the discomfort disappears. This condition is known as claudication.
“The predictable cycle of claudication distinguishes PAD from other causes of leg cramps,” says Dr. Chaudhury.
About half of patients—primarily women and older adults—may experience atypical symptoms, such as pain in the hips or buttocks, that may or may not be predictable. Consequently, diagnosing PAD can be difficult.
“They often see multiple specialists before ending up in my office,” says Dr. Chaudhury.
PAD: When to Worry About Leg Pain
Diagnosing PAD is important. Due to the systemic nature of atherosclerotic cardiovascular disease (ASCVD), people with PAD are likely to have plaque in their coronary and carotid arteries, as well as in their legs. The increased risk is due to cardiovascular risk factors commonly seen in individuals with PAD: high blood pressure, high cholesterol levels, diabetes, tobacco use and family history of CVD.
“PAD patients have a significantly increased risk of heart attack and stroke. In fact, a person with PAD has a higher risk of future heart attack and stroke than a person with prior heart attack,” Dr. Chaudhury says. “It is important to identify any risk factors the individual has and start medical therapy to prevent a cardiovascular event, as well as a major limb event.”
Physicians generally prescribe antiplatelet and anticoagulant medications to people with PAD. Depending on individual risk factors, high-intensity statins and medications to lower blood pressure or blood sugar will be prescribed, along with advice to stop smoking.
Recent clinical trials have revealed that adding the anticoagulant rivaroxaban (Xarelto) to aspirin further reduces the risk of future cardiovascular events and acute limb ischemia (a medical emergency in which blood flow to the limbs is suddenly blocked), as does adding the PCSK9 inhibitor evolocumab (Repatha) to statin therapy.
In PAD patients with type 2 diabetes, the GLP-1 receptor agonist semaglutide (Ozempic) significantly increases maximum pain-free walking distance and reduces the progression of ASCVD.
Tackling PAD Progression
Despite exercise and medication, PAD may progress in some individuals, causing them to experience painful leg cramps at rest. This condition, called chronic limb-threatening ischemia, signifies their leg muscles are receiving insufficient oxygenated blood under normal conditions.
In other individuals a blood clot may block blood flow through the artery, causing acute limb ischemia. In both cases, revascularization—i.e., reopening blood vessels with angioplasty and stenting—may be needed to save the leg.
Managing Symptoms
While they make efforts to prevent a future heart attack or stroke, PAD patients also want to improve their ability to walk without leg cramps. The antiplatelet agent and vasodilator cilostazol (Pletal) can help. However, because it has side effects, more patients find success with supervised exercise therapy. In one-hour sessions, patients walk on a treadmill until they feel moderate leg pain, rest until the pain subsides and then resume walking.
Medicare reimburses for up to three supervised exercise sessions a week for 12 weeks. At this point, individuals are able to walk much farther before leg pain kick in.
Supervised, structured exercise programs are available in hospitals and outpatient facilities. Selected fitness facilities in the community offer similar programs.
“If you are highly disciplined, you can exercise at home,” Dr. Chaudhury says. “However, supervised, structured exercise programs are the most effective way to relieve leg cramps and improve pain-free walking.”
