Episodic Cramps in the Legs

CUCMS TEAM 1

OVERVIEW

35 year old male

Relieved by rest

Complaints of intermittent pain over both legs for one year

Onset upon exertion (went to a temple on a hilltop all along
walking)
Sedentary lifestyle
Smoker (2 packs/day for the last 5 years)
Hypertensive (149/90 mmHg)
Hyperglycemic (random blood glucose 7.5 mmol)
Weak pedal pulse compared to radial pulse

INTERMITTENT
CLAUDICATION

[1]

Claudication refers to reproducible discomfort of

muscles brought on by exertion and relieved with rest.

Causes :

Peripheral Artery Disease (PAD)

Atherosclerotic
Non-atherosclerotic (thromboangitis obliterans)

Non-arterial causes

Neurogenic (spinal stenosis) - normal pulse

Venous claudication - edema

Anatomical Review :

1.VASCULATURE OF LOWER LIMB

2. BLOOD VESSEL HISTOLOGY

1.VASCULATURE OF LOWER LIMB[2]

2. BLOOD VESSEL HISTOLOGY [3]

The wall of each vessel

except capillary contains

3 concentric layers or
tunics:

Tunica Intima
Tunica Media
Tunica Adventitia

[4]

Aorta

Vena cava

Normal blood flow

[5]

PERIPHERAL ARTERY
DISEASE
[6]

A disorder of the peripheral arterial system.

Primary cause is atherosclerosis formation. May also be

due to vasculitis (e.g. thromboangitis obliterans).

Most common symptom is intermittent claudication

(pain of the lower limb).

Involves occlusion of the artery supplying the upper

and lower extremities, reducing the blood supply, and
ultimately causing gangrene and ulceration.

PAD

ATHEROSCLEROSIS

THROMBOANGITIS
OBLITERANS

ATHEROSCLEROSIS
Atherosclerosis is the most common pathology
associated with PAD.

Atherosclerosis is a hardening of an artery

specifically caused by an atheromatous plaque

(atheroma = gruel) [7]

Risk factors [8]

Non-modifiable

Age (higher prevalence among the elderly)

Genetic predisposition

Gender (prevalence male>female, highest prevalence among post

menopausal women)

Modifiable

Hyperlipidemia
Hypertension
Cigarette smoking
Diabetes mellitus

MECHANISM
Hyperglycemia
Smoking

Hypertension

Endothelial
dysfunction
and injury
Smooth muscle
cell proliferation

Atheroma

[9]

Hyperlipidemia

Lipoprotein
accumulation
Inflammatory
reaction

Macrophage action
(foam cells)
Lipid
accumulation
(Fatty streak)

HISTOPATHOLOGY OF
ATHEROSCLEROSIS

Normal artery
(no occlusion)

[10]

Artery with atherosclerotic plaque

(fibrous cap, lipid core,
Inflammatory cells)

Location of lesion

For bilateral
intermittent
claudication to
occur, the lesion
should be located
at the abdominal
aorta or the
branching point of
the common
iliac arteries.

THROMBOANGITIS
OBLITERANS (TAO)

[11]

Chronic, inflammatory, thrombotic, non-atherosclerotic,

segmental, obliterative, tobacco-associated vasculopathy
primarily involving infrapopliteal and infrabrachial
medium-sized and small arteries of predominantly
young male smokers before the age of 45 years.

Characterized by a highly cellular arterial thrombus, extensive

intimal inflammation, and preserved internal elastic lamina.

The precise cause of TAO is not known

Shionoyas criteria for TAO diagnosis [12]

1. smoking history,
2. onset before the age of 50 years,
3. infrapopliteal arterial occlusive lesions,
4. either upper limb involvement or phlebitis migrans,
and
5. absence of atherosclerotic risk factors other than
smoking

Location of lesion
In TAO, the
lesion usually
located at
infrapopliteal
medium-sized
and small
arteries

[13]

CLINICAL FEATURES AND

FINDINGS of PAD

[14]

The severity of symptoms varies with degree of

PAD, collateral blood supply, and exertional
demands.

Classical symptom : exertional calf pain

(intermittent claudication), which causes the

patient to cease exertion and the pain generally
resolves within 10 minutes.

 Intermittent claudication occurs when the

oxygen demand of skeletal muscle during
effort exceeds the bloods oxygen supply
and results from activation of local
sensory receptors by accumulation of
lactate or other metabolites.

 Other symptoms of PAD (commonly referred to as

the 6Ps) [15]
1. pain
2. pallor
3. pulselessness
4. paresthesia
5. paralysis
6. poikilothermia (coldness)

Pain over both legs

The calf muscles triceps surae
(2 heads of gastronecmius and
soleus) use extra blood and oxygen
supply upon exertion. The
narrowed artery cannot deliver the
extra blood and so pain occurs
from the oxygen-starved muscles.

PAD

ATHEROSCLEROSIS

THROMBOANGITIS OBLITERANS

Definition

Hardening of an artery specifically

caused by an atheromatous plaque

Chronic, inflammatory, thrombotic, nonatherosclerotic, segmental, obliterative,

tobacco-associated vasculopathy

Location

Commonly affect large arteries

Infrapopliteal and infrabrachial mediumsized and small arteries

Risk Factors

Non-modifiable
Age
Gender
Genetic predisposition
Modifiable
Hyperlipidemia
Hypertension
Cigarette smoking
Diabetes mellitus

Predominantly affects young males

Heavy cigarettes smokers

Symptoms

Intermittent claudication and absent of pulse

Coronary heart
disease
involvement

Yes

No

DIAGNOSIS METHODS

[17]

CONCLUSION
Complaint: severe pain over both the legs midway
while walking uphill to a temple.
Diagnosis: Peripheral artery disease (PAD)
[atherosclerosis & thromboangiitis obliterans].
Further investigation has to be carried out to
confirm the diagnosis.

PRINCIPLE MANAGEMENT
[18]

Invasive Therapy
Limb
revascularization
Fogarty catheter
thrombectomy
Peripheral
Percutaneous
Transluminal
Angioplasty

Non-invasive Therapy
Non pharmacological
treatment
Lifestyle modification
Smoking cessation
Physical activity
Balanced diet
Management of risk factors
Anti hypertensive
Oral hypoglycemic agent

REFERENCES
[1], [14], [15], [17] Macleod, John. Clinical Examination. 13th ed. London: Elsevier Ltd,
2013
[2] Moore, Keith L., Dalley, Arthur F. II. Clinically Oriented Anatomy. 7th ed. Baltimore:
Lippincott Williams & Wilkins, 2014
[3], [4], Mescher, Anthony L. Junquieras Basic Histology Text and Atlas. 13th ed. New
York: McGraw Hill, 2013
[5], [6], [18] Creager, Mark A., Libby, Peter. Braunwalds Heart Disease: A Textbook of
Cardiovascular Medicine. 10th ed. New York: Elsevier Ltd, 2015.
[7], [8], [9], [10] Kumar, Vinay., Abbas, Abul K.., Aster, John C.. Robbins Basic Pathology.
9th ed. Philadelphia: Elsevier Saunders, 2013
[11], [12] Cronenwett, Jack L., Johnston, K. Wayne. Rutherfords Vascular Surgery. 8th ed.
Philadelphia: Elsevier Saunders, 2014