peripheral circulation

Of the four systems, peripheral circulation problems are potentially the most damaging to the foot. Lets face it, without proper blood flow to the foot or impaired circulation away from the foot the tissues of the foot will suffer and in some cases die (gangrene).

Unfortunately, as we age our circulation to our feet does become impaired. The degree of impairment will vary from person to person with factors such as genetics, life style (smoking, poor diet, lack of exercise), and other disease states (diabetes, hypertension,) all contributing to a decreased blood flow to and from the foot.

When the foot is examined in regards to peripheral circulation we note the following: color and texture of the skin, hair distribution as loss of hair can but not always signal a loss of circulation to the foot, rashes, ulcers, venous patterns and venous enlargement, edema (swelling), temperature decreases and temperature differences between the two feet. In general, one cold foot is suggestive of poor circulation, two cold feet may be indicative of anxiety, neurological or a cold environment. Pulses are palpated and evaluated for consistency between the two feet.

A change in a patient’s recent history can give us a clue to circulatory impairment. If a patient complains of rest pain meaning their feet and legs will hurt at night, but find that if they put their feet in a dependant position (sitting), or even standing, the pain subsides that is highly suggestive of circulatory problems. People who complain of walking a few blocks and experiencing calf pain, finding that if they stop and rest the pain goes away, only to return when they walk about the same distance is highly suggestive of vascular problems.

Feet and ankles that appear normal in the morning but progressively swell during the course of the day may be exhibiting poor venous flow. Keep in mind that there is varying degrees of swelling and not all swelling is indicative of serious disease, however, on the other hand if one foot is constantly swollen then circulatory compromise has to be ruled out.

The most common cause of poor blood flow into the foot is atherosclerosis or hardening of the arteries. This is a progressive degenerative process characterized by the deposition of fatty substances inside the wall of the artery along with a fibrous thickening of the artery wall resulting in a diminished ability of blood to flow down to the foot.

Below is a diagram of the arterial flow into the foot.

This condition in most people will go undiagnosed until the condition becomes symptomatic. When the initial symptoms of intermittent claudication (pain in the calf after walking a short distance) presents, there is already significant disease present.

This condition occurs predominately among men between the ages of 50 and 70 years and usually starts after age 60 in women. An estimated 8-12 million Americans have this condition. Fifty percent of people with PAD (peripheral arterial disease) are asymptomatic and usually go undiagnosed.

Major causes of atherosclerosis include diabetes, which affects both the major blood vessels bringing blood into the foot and the smaller vessels, which actually supply each area of the foot.

Hypertension or high blood pressure can also cause damage to the arteries of the foot and leg and over time diminish blood flow to the feet. It is also worth mentioning that some anti-hypertensive medicine will also adversely affect the feet in that they can cause swelling and discoloration of the extremities.

Smoking, however, may be the worst cause of damage to the arteries that bring blood to the feet (as well as the heart, brain and kidneys). Smoke from tobacco directly damages the inside of the arteries.

There are a few different treatments for arteriosclerosis in the lower extremity and treatment is based on a number of factors including the degree of blockage either by occlusion (calcified plaque) or by stenosis (narrowing of the artery), the age of the patient, their general overall health, etc.

As of this writing (April,2008) walking is considered the primary treatment in treating arteriosclerosis in mild to moderate cases. In fact walking works better than oral medication. However, we are talking about a daily walking program on a graded treadmill for 30 minutes. Initially, that may be impossible for many, so you need to work up to that number. This should be a supervised program and you should have clearance from you doctor. Exercise on a regimented, physician supervised program can reduce the symptoms of intermittent claudication in as little as 6 months in many individuals. The problem here is that many people would rather pop a pill daily than to go out and get some exercise, but statistically it has been shown that walking is far superior to medication in this situation. (Vascular Medicine and Intervention2, Holy Name Hospital Interventional Institute, April 2008)

Below is a picture of very poor circulation into the foot. Notice how pale, thin and shiny the skin is along with sores that have developed on the foot.

The most common cause of poor blood flow out of the foot is varicose veins. This is a very common disorder seen twice as often in women than men and the prevalence increases with age.

Below is a diagram of the venous system in the foot.

Generally, the patient’s foot and ankle will be normal in appearance in the morning only to swell as the day progresses and return to normal the next morning. The common complaint is a feeling of a dull heavy ache that develops after long periods of standing, which is relieved by elevating the leg or by the use of elastic stockings. Occasionally symptoms of itching, burning and cramps may also be present.

Increased humidity, obesity and the cyclic premenstrual period may exacerbate the symptoms.

In simple to moderate cases compression stockings may relieve the symptoms. They should be applied first thing in the morning before the extremity has started to swell, however in those that require a heavier compression, the stockings can be very difficult to put on and take off and can be very uncomfortable in hot weather.

Under the category of "folk remedies" there are two ways to minimize simple varicose veins.

The first is apple cider vinegar. Soak a cheesecloth bandage in apple cider vinegar and use it to wrap the affected area for thirty minutes. Make sure you legs are reclined above the level of your heart. Do this twice a day. Vinegar is believed to encourage varicose veins to contract. Some people also suggest drinking two teaspoons of apple cider vinegar in a cup of warm water after each session.

The second is bromelain. This collection of enzymes found in pineapples has anti-inflammatory properties believed to inhibit the unattractive swelling around varicose veins. Take 500-1000mg with each meal. Bromelain is available in health food stores.

Sclerotherapy has become very popular. The enlarged vein is sclerosed through injection thus preventing it from enlarging.

Venous ligation or excision is reserved for more severe cases.

In more severe cases of venous insufficiency the leg can become chronically swollen and inflamed. The leg is now much more susceptible to ulceration and infection.

Below is a picture of severe venous stasis. Notice the swelling and discoloration of the leg. A complication of this condition is a venous stasis ulcer.

The diagnosis is usually made with the use of a venous doppler. In patients who exhibit shortness of breath, fever, rapid heart beat or dizziness, a pulmonary embolism also has to be ruled out.

Factors that increase the chance of a deep venous thromobus (DVT) consist of injury to the inner wall of the vein, a hypercoagulable state which means means the blood has a greater tendency to clot. Factors such as smoking, malignancy, use of birth control pills, hormone replacement therapy, congestive heart disease and obesity all can contribute to this problem. Lastly, people who exhibit venous stasis or excessive pooling of blood in the veins around the lower leg are also more prone to forming a DVT. The most common risk factor, however, is a previous history of embolism in the lower extremity.

People with any of the above mentioned conditions which may lead to a DVT should be very careful when contemplating foot or ankle surgery and should make their doctor aware of any of the above problems. Hopefully your surgeon will take a proper history and these problems will become known during the interview.

Most cases of DVT following lower extremity surgery is associated with major orthopedic procedures involving the hip and knee but a blood clot can form after foot and ankle surgery so it is imperative both patient and doctor are aware of the possibility.

Below is a picture of DVT, deep venous thrombosis of the right leg.

A more common condition with less potential complications is a superficial phlebitis. This is an inflammation of one of the superficial veins such as on top of your foot that forms a clot and inflammation ensues.

This is usually a benign and self-limiting condition. Typically, a patient will present complaining of a painful, red area on the foot or lower leg with a lump underneath the skin. The lump is cord-like in its appearance. They can occur spontaneously or after trauma directly to the area.

Treatment consists of warm compresses and anti-inflammatory medication.

NOTE: there are many more conditions of peripheral circulation that have not been discussed. For example, see my discussion on blue toe syndrome. The more serious conditions described above are generally diagnosed with sophisticated testing such as arteriograms and venograms. Inspecting the area can give us an idea of the problem but testing confirms them. These conditions are best treated by vascular surgeons.