Peripheral arterial disease screening

Most People With PAD Don’t Know They Have It

Peripheral arterial disease screening saves legs. It saves lives. And most people who need it never get it. About 8.5 million Americans over 40 have peripheral arterial disease, according to the CDC. Half of them have no idea. That gap between who has it and who knows they have it — that’s the problem this article is about.

PAD happens when plaque builds up in the arteries that carry blood to your legs. Blood flow drops. Tissues starve. And the symptoms? They look like a dozen other things. Aging. A bad knee. Sciatica. That’s why peripheral arterial disease screening matters so much. Without a deliberate test, PAD hides behind other explanations until it becomes an emergency.

What Peripheral Arterial Disease Actually Does to Your Body

Your arteries narrow. Not overnight, but over years. Cholesterol, calcium, and fatty deposits stick to the inner walls of arteries in your legs. The opening gets smaller. Less blood reaches your feet and calves. At first, you might notice nothing at all. Then one day you walk to the mailbox and your calves cramp up. You stop. The pain fades. You keep walking. It comes back.

That pattern — pain with walking, relief with rest — is called intermittent claudication. It’s the most recognizable symptom of PAD. But plenty of people never experience it in that textbook way. Some feel numbness. Some feel coldness in one foot but not the other. Some notice a wound on their toe that just won’t close up, even after weeks.

PAD doesn’t stay in your legs, either. It’s a systemic vascular disease. If your leg arteries are narrowing, your coronary arteries and carotid arteries probably are too. People with PAD are four to five times more likely to have a heart attack or stroke. That statistic comes from the American Heart Association, and it hasn’t changed much in decades because we’re still under-screening.

Leg Pain and Peripheral Arterial Disease: The Symptom That Gets Brushed Off

Here’s where it gets frustrating. Leg pain and peripheral arterial disease go hand in hand, but leg pain also goes hand in hand with about fifty other conditions. Arthritis. Spinal stenosis. Muscle strain. Restless legs. Diabetic neuropathy. So when someone walks into a primary care office and says “my legs hurt when I walk,” the conversation doesn’t always go where it should.

A 2023 study published in the Journal of Vascular Surgery found that among patients eventually diagnosed with PAD, 64% had reported leg symptoms to a healthcare provider at least once before diagnosis. The average delay between first complaint and actual diagnosis was 2.1 years.

Two years. That’s two years of narrowing arteries, worsening blood flow, increasing risk of amputation and cardiovascular events.

One woman — we’ll call her Diane — shared her story at a vascular health conference in Chicago in early 2026. She was 58, a former marathon runner. Her calves started cramping during walks around her neighborhood. Her doctor told her it was probably overuse from decades of running. Suggested physical therapy. Diane did PT for six months. The cramping got worse. She went back. Got an X-ray of her knee. Nothing there. Eventually a second opinion led to an ankle-brachial index test. Her ABI was 0.6 in the left leg. Significant PAD. She needed a stent within the month.

Diane’s story isn’t unusual. It’s almost standard.

Symptoms Your Doctor Dismissed — And Why It Happens

Doctors aren’t careless. Most are genuinely trying. But the medical system has structural problems that make PAD easy to miss.

Time Pressure in Primary Care

The average primary care visit in the United States lasts about 18 minutes. In that window, a physician might be managing diabetes, adjusting blood pressure meds, reviewing lab work, and fielding three or four patient concerns. Leg pain lands on the list, but it doesn’t always climb to the top. Especially when the patient is already being treated for a musculoskeletal condition or has a known back problem.

Age Bias

Older adults hear “that’s just part of aging” more often than they should. Fatigue in the legs? Aging. Cold feet? Poor circulation — but the vague kind, not the kind anyone investigates. Slow-healing cuts on the feet? Diabetes complication, managed with wound care, no vascular workup ordered.

Gender Gaps in Diagnosis

Women with PAD are diagnosed later than men, on average. A 2022 analysis in Circulation found that women were 20% less likely to receive an ABI test when presenting with identical symptoms. Part of this is because the classic claudication pattern was historically studied in male populations. Women more often present with atypical symptoms — fatigue, aching, or reduced walking speed rather than sharp cramping.

Symptom Overlap With Neuropathy

In patients with diabetes, PAD symptoms often get lumped in with diabetic neuropathy. Both cause numbness, tingling, and pain in the lower extremities. But neuropathy is a nerve problem. PAD is a blood flow problem. They can coexist, and frequently do. The danger is treating only the neuropathy and never looking at the arteries.

How PAD Screening Works

PAD screening is not complicated. It’s not expensive. It doesn’t hurt. And it takes about ten minutes.

The Ankle-Brachial Index (ABI)

The gold standard for PAD screening is the ankle-brachial index. A technician or nurse places blood pressure cuffs on your arms and ankles. They use a handheld Doppler device to listen to blood flow. Then they compare the blood pressure in your ankle to the blood pressure in your arm.

A normal ABI is between 1.0 and 1.4. An ABI below 0.9 indicates PAD. Below 0.5 is severe. The test is noninvasive, reproducible, and has a sensitivity above 90% for detecting significant arterial blockages in the legs.

That’s it. No needles. No contrast dye. No fasting. Just cuffs and a Doppler.

Treadmill ABI

If your resting ABI is borderline — say 0.91 to 0.99 — your doctor might order a treadmill ABI. You walk on a treadmill at a set speed and incline for five minutes, then the ABI is measured again immediately after. Exercise can unmask PAD that doesn’t show up at rest. Blood demand goes up in the legs during walking, and a narrowed artery can’t keep up.

Toe-Brachial Index (TBI)

Some patients, particularly those with diabetes or chronic kidney disease, have calcified arteries that don’t compress normally under a blood pressure cuff. This can make the ABI falsely high. In those cases, a toe-brachial index is more accurate. The toe arteries are less prone to calcification. A TBI below 0.7 suggests PAD.

Duplex Ultrasound

If screening tests suggest PAD, the next step is usually a duplex ultrasound of the leg arteries. This combines standard ultrasound imaging with Doppler flow measurements. It shows where blockages are, how severe they are, and how blood is rerouting around them. Still noninvasive. Still painless.

Who Should Get PAD Screening

Guidelines from the American Heart Association and the Society for Vascular Surgery recommend peripheral arterial disease screening for the following groups:

Adults aged 65 and older, regardless of risk factors. Adults aged 50 to 64 with risk factors for atherosclerosis — that includes smoking history, diabetes, high blood pressure, high cholesterol, or a family history of vascular disease. Adults of any age with leg symptoms suggestive of PAD — claudication, rest pain, nonhealing wounds, or unexplained differences in leg temperature or color. Adults of any age with known atherosclerotic disease in another vascular bed, such as coronary artery disease or carotid artery disease.

Despite these guidelines, screening rates remain low. A 2024 report from the Vascular Disease Foundation estimated that fewer than 30% of eligible adults had ever received an ABI test.

What Happens When PAD Goes Undetected

Untreated PAD progresses. It doesn’t plateau. The natural history follows a grim path.

Stage one: asymptomatic. You have blockages, but you don’t feel them yet. Your body compensates with collateral blood vessels — smaller arteries that reroute blood around the blockage. This works for a while.

Stage two: claudication. Blood flow can’t keep up with the demands of walking. Muscles cramp. You slow down. You walk shorter distances. You stop doing things you used to do.

Stage three: rest pain. Blood flow is so reduced that your legs hurt even when you’re lying down. Especially at night. People with rest pain often sleep sitting up or hang their legs off the bed because gravity helps blood reach the feet.

Stage four: tissue loss. Ulcers. Gangrene. The tissues in your feet and toes die because they can’t get enough oxygen and nutrients. At this point, amputation may be the only option to prevent sepsis and death.

About 1% to 3% of PAD patients progress to critical limb ischemia each year. But among those who reach critical limb ischemia, amputation rates are high. A 2023 meta-analysis in The Lancet reported a major amputation rate of 22% at one year among patients presenting with chronic limb-threatening ischemia.

Early peripheral arterial disease screening catches the disease before stage three. Before rest pain. Before tissue loss. Before anyone loses a foot.

Common Mistakes People Make Around PAD

Assuming Leg Pain Is Muscular

Muscle soreness typically improves with stretching, massage, and rest over a few days. PAD-related claudication follows a specific pattern: it appears with exertion, at a predictable walking distance, and resolves within a few minutes of stopping. If your leg pain has that kind of mechanical, reproducible quality, get an ABI.

Ignoring Cold Feet

One foot colder than the other is a vascular sign. Both feet cold could be anything — poor heating, thin socks, Raynaud’s. But asymmetric temperature differences, especially combined with color changes (one foot paler or bluer than the other), should prompt a PAD screening conversation.

Skipping Foot Checks

People with diabetes are told to check their feet daily. But plenty don’t. And people without diabetes rarely think about it at all. A small cut, blister, or sore on the foot that doesn’t heal within two weeks is a warning. Reduced blood flow means reduced healing capacity. That nonhealing wound might be the first visible sign of PAD.

Not Mentioning Symptoms Because They Seem Minor

This is the big one. People self-edit before they even get to the doctor’s office. They think their symptoms aren’t serious enough to mention. Or they mentioned them once and got a reassuring answer, so they don’t bring it up again even though the symptoms have gotten worse. The reluctance to “bother” the doctor is real, and it delays diagnosis.

Risk Factors You Might Not Know About

Everyone knows smoking and diabetes increase PAD risk. Those are the heavy hitters. Current smokers are four times more likely to develop PAD than nonsmokers. Diabetes doubles the risk and also makes the disease progress faster and affect arteries below the knee, which are harder to treat.

But there are less obvious risk factors worth knowing.

Chronic kidney disease. Patients on dialysis have PAD rates above 35%. The combination of uremia, inflammation, and vascular calcification creates a hostile environment for arteries.

African American race. PAD prevalence is roughly twice as high in Black Americans compared to white Americans, even after adjusting for traditional risk factors. The reasons aren’t fully understood but likely involve a combination of genetic predisposition, disparities in healthcare access, and higher rates of coexisting conditions like hypertension and diabetes.

Elevated homocysteine levels. Homocysteine is an amino acid. High blood levels damage arterial linings and promote clot formation. It’s a modifiable risk factor — B vitamins can lower homocysteine — but it’s rarely checked unless someone specifically asks.

Sedentary lifestyle. Independent of other risk factors, physical inactivity increases PAD risk. Blood flow is a use-it-or-lose-it system. Regular walking actually stimulates collateral artery growth, which can partially compensate for blockages.

Treatment Isn’t As Scary As You Think

When PAD is caught early through screening, treatment is usually conservative. No surgery. No hospital stays.

Supervised exercise therapy is the first-line treatment for claudication. A structured walking program — typically three sessions per week for 12 weeks — has been shown to increase pain-free walking distance by 100% to 150% in clinical trials. That’s better than some medications.

Medications include antiplatelet drugs like aspirin or clopidogrel to reduce clot risk, statins to stabilize plaque and lower cholesterol, and cilostazol, which improves walking distance by dilating blood vessels and reducing platelet aggregation.

Risk factor modification is critical. Quitting smoking is the single most impactful thing a PAD patient can do. Tight blood sugar control in diabetes slows disease progression. Blood pressure management below 130/80 reduces cardiovascular event risk.

For more advanced disease, interventional procedures include angioplasty (inflating a balloon inside the narrowed artery), stenting (placing a mesh tube to hold the artery open), and atherectomy (shaving or drilling through plaque). These are minimally invasive, done through a small puncture in the groin or wrist, and most patients go home the same day.

Surgical bypass — rerouting blood flow around a blocked artery using a vein graft or synthetic tube — is reserved for the most severe cases or when less invasive options fail.

The point is: catching PAD early means more options, less invasive treatment, and better outcomes.

How to Talk to Your Doctor About PAD Screening

Be direct. You don’t need to diagnose yourself. Just describe what you’re experiencing and ask the question.

“I’ve been having cramping in my calves when I walk more than two blocks. It goes away when I stop. Could this be a circulation problem? Can I get an ABI test?”

That’s all it takes. If your doctor dismisses it, ask again. Say you’d like the test anyway for peace of mind. An ABI is cheap, fast, and noninvasive — there’s no medical reason to refuse it.

If you have diabetes, kidney disease, or a history of smoking, you can frame it around guidelines: “I read that the AHA recommends PAD screening for people with my risk factors. I’d like to get tested.”

Bring a list of your symptoms, even the ones you think are minor. Write down when they started, what makes them worse, and what makes them better. Cold feet at night. A toe that changed color. A wound that’s taking too long. These details matter more than you think.

The Bigger Picture: PAD Screening as Cardiovascular Prevention

Peripheral arterial disease screening isn’t just about your legs. An abnormal ABI is one of the strongest predictors of future heart attack and stroke. It’s a window into the health of your entire cardiovascular system.

A 2019 meta-analysis in the European Heart Journal — still the largest of its kind — found that an ABI below 0.9 was associated with a 2.5-fold increase in cardiovascular mortality and a 3-fold increase in all-cause mortality over a ten-year follow-up period. Those numbers held even after controlling for traditional risk factors like cholesterol, blood pressure, and smoking.

Getting a PAD screening isn’t just about finding leg blockages. It’s about understanding your vascular age. Some 55-year-olds have the arteries of a 70-year-old. Some 70-year-olds have clean vessels. The ABI tells you where you actually stand.

And once you know, you can act. Adjust medications. Start walking programs. Quit smoking with a real sense of urgency rather than a vague intention. PAD screening turns abstract risk into a concrete number — and concrete numbers change behavior.

Think About What You’ve Been Telling Yourself

If you’ve been chalking up leg pain to getting older, or to that old sports injury, or to standing all day at work — maybe it is those things. But maybe it isn’t. And the only way to know is a ten-minute test that doesn’t require a needle, a hospital, or even a copay in many screening programs.

Think about the symptoms you’ve already rationalized away. The calf tightness you blamed on dehydration. The cold foot you covered with an extra sock. The wound that took six weeks to heal instead of two. Consider whether you mentioned those to your doctor — and whether your doctor took them seriously.

If something felt off and you were told it was nothing, bring it up again. Ask for the ABI. Ask for the referral. The worst outcome of peripheral arterial disease screening is finding out your arteries are fine and walking out with one less thing to worry about. The best outcome is catching a disease early enough to treat it with a walking program instead of a scalpel.

Your legs have been talking to you. Write down what they’ve been saying — the cramps, the numbness, the cold, the ache — and hand that list to your doctor at your next visit.