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Is It Peripheral Vascular Disease, Venous Insufficiency, or Sciatica?
Not all leg pain is caused by peripheral vascular disease — venous insufficiency and sciatica can mimic the symptoms, so an accurate diagnosis is key to treatment. Cardiovascular disease and peripheral vascular disease are closely tied together. The risk factors, including age, genetic predisposition, diabetes, smoking, high cholesterol, and high blood pressure, contribute to the development of narrowing of the arteries, which is the principal abnormality in both diseases.
The arteries of the heart are affected in cardiovascular disease, and the arteries feeding the legs in peripheral vascular disease. The global incidence of peripheral vascular disease is estimated to be 10-20% in adults over age 55 and increases to 20-30% in adults over the age of 70. The incidence is split between the sexes, with women and men equally at risk.
What is Venous Insufficiency?
Venous insufficiency is an independent disease from peripheral vascular disease.
The risk factors include:
- age
- sex
- gender
- pregnancy
- obesity
- occupational risk from prolonged standing or sitting
- genetic factors
- sedentary lifestyle
- hormonal changes
- obesity
- trauma
- injury
Venous disease occurs due to abnormal vein flow, which results from the loss of function of the one-way valves in the peripheral veins of the legs or obstruction of the veins in the pelvis. Blood normally travels up to the main circulation in a one-way direction as one uses the calf muscles. Gravity usually prevents the blood from traveling back down via these valves.
However, when they are incompetent, the blood flow becomes bidirectional, and blood pools in the lower extremities due to gravity. In the obstructive form of venous disease, the blood is partially prevented from returning. The incidence of venous insufficiency is estimated at 20-25% of the United States population. It is more prevalent in women and individuals over 50 but can affect people of every age and gender.
What is Sciatica?
The next disease state that commonly affects someone’s legs is sciatica or nerve compression of the lower back. The spinal column ends at the top of the pelvic bone for obvious reasons, as only the legs and no other body structure beneath that. Therefore, the nerves that control sensory and motor function travel from the end of the spinal column to the sides and legs.
This is a vulnerable area because the nerves are protected from compression by the bony structures and the discs between the bones. However, the nerves are not well protected, and prolonged pressure, such as sitting on a flight or car or even sleeping in certain positions in your bed, can cause compression of the nerves and temporary dysfunction and/or pain.
The discs start to dry out over time and no longer serve as an effective shock absorber. They can also herniate and put pressure on the nerves. The vertebrae can become compressed over time with aging and wear and tear, as most of the body’s weight is carried above the pelvis, which can also cause compression of the nerve roots.
With compression or nerve injury and inflammation, a person can experience pain, numbness, weakness, cramping, a sense of movement in the leg, and hot and cold sensations. Essentially, any sensory experience that the nerve can transmit can be experienced, and motor function can also be affected in more severe cases.
Diagnosing the Root Cause of Symptoms
There are multiple possibilities of giving similar symptoms to a person, so how do we diagnose the root cause of the symptom?
The main ways to distinguish these conditions are:
- history of the symptoms
- aggravating factors and location of symptoms
- the physical exam
- specific diagnostic testing.
Symptom Location and Aggravating Factors
The symptoms of venous insufficiency are most often in the calves and ankles, as they are the most dependent part of the legs. The symptoms are often described as heaviness or aching and worsened at the end of the day or by prolonged sitting or standing and improved by elevation of the legs. The symptoms associated with arterial disease are often also in the calf but can be in the thigh or buttocks. When the blockages are severe, the pain can be at rest, but more often, they are brought on by exercise and relieved by rest.
Sciatic or radiculopathy pain often radiates from where the nerve root originates to the distribution of the nerve and is aggravated with prolonged sitting, standing, or often at night when lying down, and the nerve is compressed because of the body’s position in bed. However, there is substantial overlap in these symptoms as they don’t always occur in reliable ways, so we rely on physical examinations.
Physical Exam Findings
In venous disease, one may find swelling of the ankles or calves, varicose veins, skin changes such as thinning, redness or scaliness of the skin, skin color changes or hyperpigmentation, and in more severe cases blisters or ulcers, which are more commonly located on the medial malleus, the bony prominence on the inner ankle, along the lower leg, or on the shin bone known as the pre-tibial area.
In arterial disease, you may find cool or blue lower extremities with decreased or absent pulses. Ulcerations and skin changes can occur more often on the toes, in between toes, the feet, but also on the bony prominences. The physical exam of sciatic or nerve pain will likely not have these abnormalities, but muscle weakness or decreased reflexes can be found in more severe cases. However, it is more the absence of skin, vein, and arterial findings that points to nerve problems.
Diagnostic Testing
Often, the physical exam is a mixture of findings, so next, we have to use outpatient diagnostic testing to help differentiate between the disorders. The first line in the office is the ultrasound and ankle brachial index. The ultrasound is the most useful initial diagnostic tool as it can delineate the anatomy of the venous system. Blood clots, venous occlusions, and venous reflux can be diagnosed readily. It can also be used to look at the arterial system, and the anatomy can be interrogated with color Doppler and velocity.
As an adjunct the blood pressure can be measured in the arms and the legs to generate an ankle brachial index which if diminished will tell if the arteries are not providing adequate blood flow.
If your initial testing is negative and you suspect sciatic or nerve disease then imaging studies of the lumbar spine, such as a CT scan or MRI, may be required and in some cases, the nerves can be interrogated with a test known as EMG, where a needle can be placed in the muscle and sensors on the skin to measure the nerve conduction after an impulse has been generated to determine if the nerve is functioning normally. Finally, if needed invasive arterial and venous studies can be performed if the initial testing warrants it.
Understanding Coexisting Conditions
This obviously seems all very confusing, and often, the diseases coexist. A patient with venous disease will have sciatica, and a patient with arterial disease will have venous disease and all the other possible combinations. That is why it is important to work with skilled clinics that can help sort through these issues.
We at the Metropolitan Vein and Aesthetic Center have over 15 years of experience in seeing tens of thousands of patients with venous, arterial, and nerve diseases. We will perform the initial history and physical exam and all of the initial diagnostic testing in-house to give you an honest assessment of what you’re experiencing in your lower extremities. Feel free to reach out for a question or consultation so that we may help you feel better every day.
