On Tuesday evening, May 11, the Navigating the Medical System Lecture Series presented an informative virtual lecture hosted by Congregation Etz Chaim on the topic of leg pain. Dr. Mel Breite, Founder and Director of the Lecture Series, introduced the program and the guest speaker, Varuna Sundaram, MD, FACS, RPVI. She is an assistant professor of the Department of Vascular Surgery at the Weil Cornell Medical Center and a surgeon at NewYork-Presbyterian Queens. Dr. Breite shared that he has seen people misdiagnosed when they have leg pain, so he realized that we need education on this topic. This lecture was planned for a year ago, but due to COVID it was postponed until now.
Dr. Sundaram explained that she specializes in all the blood vessels in the body except the heart and the brain. Leg pain is not always a vein or artery issue. She then listed common leg complaints that include peripheral arterial disease and peripheral venous insufficiency. She noted that a common complaint is that a person says her leg hurts every time she walks more than two blocks and the pain is a cramping pain in the calf that improves with rest. This, she said, can be vascular pain. On the other hand, pain in the knee, hip, or foot – or a grinding or grating sensation or stiffness or swelling that improves with rest and is worse when using the joint – is not a vascular problem.
Peripheral arterial disease affects ten million people. The incidence increases with age, high cholesterol, hypertension, diabetes, obesity, smoking, or genetic causes. It can lead to limb loss, stroke, or kidney failure. It creates significant disability, the need for long-term care, or even death. It needs to be diagnosed quickly so that it doesn’t worsen.
She explained the source of arterial disease. As we age, arteries can build plaque, or this can occur with diabetes or high cholesterol. The artery grows narrow or stiff like when a lane on a highway is blocked. The first stage is that there is reproducible pain when you start moving. If it goes untreated, it can progress to pain even at rest, and it can lead to gangrene, leg loss, etc.
When there is pain in joints that worsens after using the joint, this could be arthritis. In arthritis, pain is specific to the joint.
There are different types of arthritis, so you need to see your primary care physician first. Then you may need to see an orthopedic specialist or rheumatologist. She then explained diagnostic tests. The doctor looks at pulse volume recordings, viewing blood flow volume at each section of the leg and comparing it to blood pressure. This way, the doctor can predict disease by a change in the pressures. Noninvasive tests can be conducted in the doctor’s office without needles or radiation. Ultrasound can also be used. With ultrasound, the technician can see where the blockage is and how much it is blocked.
CT and CTA scans can provide a lot of information and they employ radiation and an IV. This information helps because the doctor can see other structures and they can see what else is happening in that area. An MRI uses dye and it can determine any issues with the kidneys.
There are also invasive diagnostic tools such as catheterization. One of the main treatments is angiogram. In PAD (peripheral artery disease), angiogram treatment is used, where the artery is opened with a balloon, or a stent is put inside if the balloon is not enough. The goal of this treatment is to increase blood flow as much as possible through normal channels.
The next common complaint is when someone says her leg hurts all the time. The doctor will ask the patient to describe the pain and the position that alleviates it. Sharp constant pain, and if the foot is pale or has coolness, or numbness working its way up the leg, could be vascular. With a vascular problem, dangling feet makes it better.
The problem may be neuropathic if the pain is a dull sharp pain and there is no change in color, or if the pain is better lying flat on your back or worse sitting in a chair.
Acute ischemia happens suddenly. It can be due to acute occlusion of blood vessels if the foot turns pale and it’s not cellulitis or an infection. PAD doesn’t affect the hands as much as the legs because there are more blood vessels feeding the arms and hands.
She explained that the doctor can do bypass surgery on the legs just as it is done on the heart. She explained leg problems involving the veins, as well. The lecture ended with a question-and-answer session.
Everyone left very well informed about leg problems.
By Susie Garber