Of course, the most important thing is always the patient's background and the risk factors actually are really important.

And this is something I reflect on in the case study, as I didn't really dig enough into those.

But in terms of the tools we have in clinic, once we suspect peripheral arterial disease, people talk about capillary refill, they talk about checking skin quality, and all those things are useful and do no damage.

But really for us, the king is pulses.

Pulses are king for the physiotherapist.

Welcome back to Case Studies from Physio Network.

In this episode, we're tackling peripheral artery disease.

How to suspect it, how to differentiate it, and how to handle the workup and referrals, all centred around a real-life case study that brings these concepts to life.

I'm delighted to be joined by Tom Jesson.

If you haven't come across Tom before, he's a physiotherapist and writer who specialise in making the complex world of lumbar ridicular pain and cordial Aquinas Syndrome understandable.

He's the author of essential guides like Understanding Sciatica and Cordero Aquinas Syndrome, the MSK Clinician's Guide, and is currently finishing another major work on sciatica.

Tom's known not just for his deep expertise, but for his talent in turning confusing clinical concepts into clear and vivid insights.

Today, he's here to help us navigate peripheral artery disease through a real case study, covering everything from how we spot it to the work up to making the right referrals.

Stay tuned because by the end of this episode, you'll never look at peripheral artery disease in the same way again.

I'm James Armstrong and this is Case Studies.

Tom, it's great to have you back on the podcast, and this time on a case studies podcast, which is fantastic.

How have you been?

Very well.

It's getting finally cool weather here in Houston, so I'm happy the hot summer's over.

How are you doing?

Very well indeed.

Yeah, we're wet and windy in the UK.

Listeners are listening at the same time as this getting released.

So we're talking today about peripheral artery disease, and we're going to be covering all sorts in terms of its differentiation, how you might suspect it, how it's easily missed, work up referrals, and everything in between, all wrapped around a case study, which is going to be fantastic.

But I thought we'd start off with a good old-fashioned definition.

So everyone, we're all on the same page of what are we talking about when we talk about peripheral artery disease, Tom?

So peripheral arterial disease is very common.

It's very common asymptomatically.

Lots of people have atherosclerotic buildup in their arteries for various reasons, which we can come on to.

When it comes to physios and chiropractors and the like, what we tend to think of as peripheral arterial disease is symptomatic peripheral arterial disease, which tends to present as pain in the legs with exertion.

So when you go for a walk, James, you're a physio.

So as you know, your muscles move, your calf muscles, your thigh muscles, and in order to work more, your muscles need more blood.

They need blood to bring them oxygen and to take away all the metabolites of exercise.

Usually that works very well.

If you have peripheral arterial disease, then your heart is trying to pump that blood to your moving muscles, but it can't get through because of all the atherosclerosis in your arteries.

So you do your exercise, the muscles say, We want oxygen and we want to get rid of all these metabolites.

Let's get some more blood flow.

The heart is trying to get it there, but it can't get past the narrowing of the arteries.

So the muscles begin to hurt.

You get essentially ischemic pain in the muscles.

So what this typically shows as is patients typically in their 50s and 60s will come to us and they'll say, Whenever I go for a walk, it starts to hurt in my calf, for example, might be thigh, buttock.

It starts to hurt in my calf after a certain amount of time.

And when I rest, the pain subsides.

And all that's happening there is the patient is walking, the muscles are working.

The heart is trying to get the blood there to support the muscles, but because of the peripheral arterial disease, the blood can't get there.

So you get this pain in the muscles as they're kind of gasping for oxygen and gasping for blood, basically.

That's typically what we think of as peripheral arterial disease.

As I say, it can be asymptomatic and it can also be much more symptomatic, kind of critical limb ischemia and so on.

But what we're looking for, like I say, is that symptom pattern.

And it's particularly important, not only because those symptoms are bothersome, but because it's often a gateway or an early sign, a warning sign, let's say, of more serious cardiovascular problems in the future for the patient.

Brilliant.

And I'm sure listeners, we're gonna talk about this in a minute, but I'm just gonna say it anyway.

But listeners are probably thinking potentially that those symptoms could sound just like someone's muscles fatiguing.

They could sound lots of other things that as a physio, we might think, oh, brilliant.

We can treat that.

We're gonna see you, we're gonna set you these things, and we're gonna see you again in two, three, four weeks, and so on and so forth.

So we're gonna hopefully pick apart today how we might differentiate that.

So should we dive into the case, Tom?

Shall we get it started?

Yeah, as you say, it can be confusing.

Classic peripheral arterial disease textbook is actually quite clear and it's often relatively unambiguous.

But in the case study that I presented, Physio Network, there's actually a mistake that I made, thankfully a long time ago, where I diagnosed a man in his late 50s with sciatica.

Who'd have thought it?

Me, uh seeing sciatica everywhere.

But I diagnosed him with sciatica when in fact he did have peripheral arterial disease.

In the case study, I go through all the details, but the bottom line is that this chap turned up and he had what I just described, which is whenever he walked 150 yards in this case, he got this sort of vague cramping pain in his calf.

It forced him to stop, and every time he stopped, the pain went away.

So you get exertional and predictable pain of peripheral arterial disease.

Those are the two key words for me: exertional.

So it's not positional, it's not based on stress, it's just based on using the muscles, typically walking, of course, and predictable.

So it's not like, oh, I have, you know, some days I can do great, or you know, some days it's fine while I'm exercising, but it flares up afterwards.

No, it's predictable.

Most people will be able to say I can go three times around the block, or I can get this far on a walk to work, predictably comes on and predictably goes away when they stop.

So this chap described all the symptoms, but what I was confused by was on top of those, he also had some pretty normal symptoms of lower back pain and sciatica.

So he had the straight leg raise, he had some loss of function signs, and he and himself said he thought he had sciatica because he'd had it in the past as well.

So I had my classic sort of bias that we talk about.

I had my MSK hat on, and I also was led by him mentioned, not to bless him blaming him, but he mentioned sciatica, and I was like, great, I know what that is.

So we ran with that.

The upshot was that his musculoskeletal symptoms, it took them fading away with time, or maybe with my incredible treatment, for it to be revealed that actually what was really bothering him was the calf pain, that predictable exertional pattern, and then we could go on with a bit more of an assessment to confirm that he had peripheral arterial disease.

Brilliant.

You lead us really nicely onto that.

And it is interesting, Tom Nase.

It took for the musculoskeletal symptoms to improve for them to be left with something else that became a little bit more clear.

So what when you went on to your objective or your assessment now, so this is the point where these musculoskeletal sciatic-like symptoms have improved.

Where did you go next with your assessment?

Of course, the most important thing is always the patient's background and the risk factors actually are really important.

And this is something I reflect on in the case study, as I didn't really dig enough into those.

But in terms of the tools we have in clinic, once we suspect peripheral arterial disease, people talk about capillary refill, they talk about checking skin quality, and all those things are useful and do no damage.

But really for us, the king is pulses.

Pulses are king for the physiotherapist.

There's a million and one YouTube videos on how to do those, but I also always just kind of remember there's four of them, and the kind of vascular structure of the leg is there's one river, and at the knee it splits into two rivers to the toes, and you're you're testing at the top of the river, the femoral pulse, at the point where it splits for the popliteal pulse, and then as you go to the toes, you've got the dorsalis pedus and the tip post pulse there as well.

So we give a few kind of tips in the presentation about kind of how to find those and how to do them, because for me it took a long time for that apparently quite simple information to kind of click so it felt natural.

But check the pulses and confirm that the symptoms are exertional by bringing them on in clinic.

So go for a walk if you can.

But in this case, we just did a heel raise test.

If your patient's symptoms are sciatica, just simply heel raising, shouldn't really bring them on.

And especially if it does it, they shouldn't the symptoms shouldn't subside immediately afterwards.

But in this case, a heel raise test, he said, yep, that's exactly what it is, and the symptoms subsided afterwards.

At that point, you haven't really diagnosed peripheral arterial disease, nor is it your job.

Most listeners won't do ankle brachial pressure index testing, but that's really the next step.

Whether via GP in this case, sometimes there'll be a pathway to like a vascular specialist or clinic that will do it.

But that's what's going to call the shots.

It's still not perfectly sensitive or specific, but that's going to call the shots if their blood pressure is lower in the legs relative to in the arms, because that blood isn't getting through.

The only important exception there is diabetics who often they'll have calcified arteries, so their blood pressure will actually be higher, which is always a neat thing to remember.

But the ABPI test is to check whether the blood pressure is indeed lower in the legs than it is in the arms, 0.9 or below.

And then if the symptoms fit, then the patient can be confirmed with that diagnosis and you can pat yourself on the back for doing a good job.

Because actually, this is one of those things that is quite consequential, especially if in the case study this was this chap's first inkling that he had any problems with his cardiovascular system.

And in fact, knowing that making lifestyle changes, getting treatment, can be pretty consequential for the patient and prevent or delay pretty more serious events down the line.

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And you you mentioned earlier, Tom, that you didn't dig deep enough into those risk factors.

Talk us through that.

What in hindsight now might have led you to today, as the clinician you are today, or hers or recently, what might have led you to suspect more?

To define what I mean, there's obviously a long list of risk factors for peripheral arterial disease.

I always think try and limit it to what I call like the plaque five.

So it's like diabetes, smoking, high blood pressure, high cholesterol, and then like a previous cardiovascular event.

So like something going on with the brain or ischemic arc disease.

And those are there may be different lists, but those are if you can only remember five, though the five to remember.

But in in the case study, I kind of reflect on what was actually the problem was I just didn't really understand what I was asking about.

So I kind of in the case study try to break down into more detail.

Okay, well, I know that there was something called peripheral arterial disease, but I didn't fully have the understanding of what it was.

And so what happened talking to this chap was I tried to do a checklist in my mind, but I forgot to ask him if he was a smoker.

Because I was doing a kind of bit of a naive checklist approach.

Forgot to ask him if he was a smoker.

And in fact, that should should have been the thing that at the first appointment made me think, okay, there's definitely something potentially wrong with his vascular system because he'd been a heavy smoker since his teens.

Right.

So in the case study, I kind of argue that checklists are great, but actually, if we develop our understanding of these conditions, then it's less likely that I would forg have forgotten such an obvious thing as to ask about smoking if I'd had a more holistic understanding of the vascular system.

Brilliant, brilliant.

So then going there's those things there, going back to that first presentation, that first appointment, what would you do differently now, Tom?

Apart from maybe switch on to that side of things a little bit, maybe?

Is there anything else that you think, actually, yeah, this is this is how I'd play this one differently?

It was a case of the risk of repeating myself, maybe putting on different kinds of hats, a bit more of what they sometimes call systems thinking.

So at the time, I was a relatively new graduate, and I was just thinking everything's MSK if it doesn't tick these red flag check checklists, which of course is an absolutely fine way to do things.

And everyone starts that way, and I'm still in some ways at that level in some with some aspects of practice.

But there's limits, for example, if you forget one of the boxes on the checklist, because that's you're just trying to read a mnemonic in your head, for example.

But also, for example, I I would reflect that he had simp he did have symptoms of sciatica with his symptoms of pad, but I didn't pause to discriminate between them.

Okay, so do these symptoms come on at different times?

Do they have different aggs and eases?

Which is something I always kind of often think of this chat when I do that now, I say, okay, so you're telling me about these two symptoms, let's split them up and say what aggravates this one, what eases this one, and then the same questions for the other one.

And then if I'd done that, I didn't even need to have any knowledge really of vascular conditions to know that he was describing two quite different sets of ags and eases, quite two quite different symptom presentations.

And also, I suppose in essence, when you did the objective assessment for your for the sciatica element side of it, it says, yeah, the positive straight leg rays, would that symptom have been quite different to the one that he would have felt at so many minutes of walking?

Good point.

Yeah, it would have been completely different if I'd asked him something like, is that your pain?

Is that why you came to see me today?

Instead of again that kind of, well, it's technically positive, which it was.

There's other things like, so he had a loss of his Achilles reflex and some numbness on his knee, which made me think, okay, nerve root.

But actually, when you think about it, Achilles typically S1, knee sensation, typically L4.

That doesn't actually fit a picture of sciaticat.

It fits a picture of maybe he had sciatica in the past, and maybe he's had a knee injury.

Maybe he should have picked up on those things.

So there's maybe uh also his pain wasn't dermatomal.

So we talk a lot of rubbish about the dermatomes and how they're not perfect, which they're not.

But actually, it would have been useful to have thought at the time, which I did not, hang on, this guy's just got like this kind of throbbing, localized calf pain.

Sat I could usually you'd think of it being a bit more dermatomal than that, even if it doesn't look like it does in the textbook.

It's one of those case studies which I I like it because there's quite a few things where you can look back and think, hey, I actually I've got better at this job.

You do learn things that actually are just knowing these things about ridiculopathy presentations, dermatomes, vascular system does make you a bit sharper.

Thankfully, in this case, I delayed this chap's care by two or three weeks.

Hopefully, it didn't do any harm in doing that.

But the other nice thing, as I say, about this particular area is it really helped him out.

I must admit I didn't follow it up with him, but it at least put him in the right position to get care for potentially for hopefully preventing something more serious.

Brilliant.

Yeah, I think it's great.

And I think a lot of the things you described there are things that we probably all as clinicians thought, well, actually, yeah, that's exactly how I've done it in the past.

And actually, you might have done it more recently.

And I think everyone has been guilty of the straight leg raise being positive when the patient goes, ow, and not asking those further questions.

I think something that's very, very normal.

So, new clinicians and new grads listening to this, this is part of the development of a clinician.

This is what we all go through.

So I think that's really important to highlight.

What do I need to gather?

What information is really important for me to get, and who do I get it to, and in what formats the best way of doing it?

I might sort of be repeating myself, but it's just about explaining why there's a reasonable suspicion with this chap, particularly the smoking, explaining the symptoms.

In this case, it would I was working in a GP practice, so it was a fairly easy kind of referral to the GP for that test to confirm his his problem.

And from there, he probably would have been referred to a vascular specialist.

So I think it's just a case of summarizing uh summarizing everything I've said and the pulses as well, being something that kind of proves you've done your work there and something for them to hang a hat on and and bring him in.

Yeah, so something tangible that's that's that's useful for that that that diagnosis.

So anything else I think in terms of leaving the listeners with things that you think this is real takeaway stuff, what you'd say to some new grads or any clinician out there to that you've taken away from this, how would you summarize your your key key things, Tom?

If I would go back and say myself rather than I don't know what advice to give everyone, but if I was to say to myself, it would be to learn your checklists for your red flags and use them because that's how to do your job.

But actually sit down and read some papers and textbooks about peripheral arterial disease and get to know it as a condition, just like you kind of know what an ankle sprain is, who knows what low back pain is, but you kind of know what sciatica is, get to know these red flag conditions because actually when you're gonna make these decisions, it's a case of saying, Hey, this sounds like this thing that I know.

Right.

Because if you would go and buy a checklist, it's never going to be quite right.

You need to kind of learn about this condition and and how it works and how it presents.

And that's what I would say.

I think it's same with a lot of things.

I was having having a conversation at work today about quarter aquina, for instance, and not using just a checklist, but actually understand what's going on, therefore what you might see, why you might see it, rather than just thinking this, this, this must be that.

So I think understanding conditions, understanding pathologies is quite important and useful.

And it gets you out of binds, like with cordial syndrome, if you're wondering, well, this person said that they they've got this problem when they're peeing.

Latin means they've got urinary dysfunction.

So what do I do?

But if you actually kind of have read a lot of case studies and maybe read a certain book about corduroquina syndrome, then you can say, oh, it actually doesn't sound anything like Corderoquina syndrome, it just it sounds like they've got a UTI, basically.

I don't try and be too preachy in the but the last because the only thing I would say is all this stuff is actually very interesting too.

It's very interesting and fun to learn about it and kind of enrich your day-to-day life too.

Definitely, definitely.

I think it genuinely makes our lives easier.

The the better understanding we have of things it allows us to be more investigative and potentially have a little bit more, dare I say it, fun with with our patients and and and really think and get get kind of our teeth into our patients.

Tom, this has been brilliant, really interesting, and obviously, listeners, you can all get far more detail on this case study with with Tom's case study with Physio Network.

Also mentioned the great masterclass that that Tom's also done some time ago now, but is still an absolute corker.

And I can't have Tom Jesson on the podcast without mentioning the great books that Tom's done on Corderoquina Syndrome and Sciatica.

They really are fantastic and have helped me an awful lot in my practice and and helped my team on a weekly basis for sure.

So I can't not say that.

Tom, thank you so much for your time.

We'll sure have you on the Podcast and all the best, and we'll speak to you soon.

Thanks, James.

Appreciate it.