Physical examination and chronic lower-extremity ischemia: a critical review.

OBJECTIVE To determine the clinical utility of physical examination in patients with suspected chronic ischemia of the lower extremities. DATA SOURCES MEDLINE search (January 1966 to January 1997), personal files, and bibliographies of textbooks on physical diagnosis, surgery, and vascular surgery. STUDY SELECTION Both authors independently graded the studies as level 1, 2, or 3, according to predetermined criteria. Criteria deemed essential for analysis of sensitivity, specificity, and likelihood ratios were (1) clear definition of study population, (2) clear definition of physical examination maneuver, and (3) use of an acceptable criterion standard test for comparison. RESULTS The following positive findings help clinicians diagnose the presence of peripheral arterial disease: abnormal pedal pulses, a unilaterally cool extremity, a prolonged venous filling time, and a femoral bruit. Other physical signs help determine the extent and distribution of vascular disease, including an abnormal femoral pulse, lower-extremity bruits, warm knees, and the Buerger test. The capillary refill test and the findings of foot discoloration, atrophic skin, and hairless extremities are unhelpful in diagnostic decisions. Mathematical formulas, derived from 2 studies using multivariate analysis, allow clinicians to estimate the probability of peripheral arterial disease in their patients. CONCLUSION Certain aspects of the physical examination help clinicians make accurate judgments about the presence of peripheral arterial disease and its distribution.

[1]  D G Smith,et al.  Diagnostic utility of the history and physical examination for peripheral vascular disease among patients with diabetes mellitus. , 1997, Journal of clinical epidemiology.

[2]  J. Knottnerus,et al.  Diagnostic Value of Signs and Symptoms Associated with Peripheral Arterial Occlusive Disease Seen in General Practice , 1997, Medical decision making : an international journal of the Society for Medical Decision Making.

[3]  A. Kazmers,et al.  Assessment of noninvasive lower extremity arterial testing versus pulse exam. , 1996, The American surgeon.

[4]  R. Hamman,et al.  Effect of diagnostic criteria on the prevalence of peripheral arterial disease. The San Luis Valley Diabetes Study. , 1995, Circulation.

[5]  E. Boyko,et al.  Ruling Out or Ruling In Disease with the Most sensitiue or Specific Diagnostic Test , 1994, Medical decision making : an international journal of the Society for Medical Decision Making.

[6]  M. Criqui,et al.  Guidelines for peripheral percutaneous transluminal angioplasty of the abdominal aorta and lower extremity vessels. A statement for health professionals from a special writing group of the Councils on Cardiovascular Radiology, Arteriosclerosis, Cardio-Thoracic and Vascular Surgery, Clinical Cardiolo , 1994, Circulation.

[7]  K. Callum,et al.  Predictive value of bruits and Doppler pressure measurements in detecting lower limb arterial stenosis. , 1993, European journal of vascular surgery.

[8]  D L Sackett,et al.  The rational clinical examination. A primer on the precision and accuracy of the clinical examination. , 1992, JAMA.

[9]  T. Magee,et al.  Should we palpate foot pulses? , 1992, Annals of the Royal College of Surgeons of England.

[10]  C. Shearman,et al.  Peripheral pulse palpation: an unreliable physical sign. , 1992, Annals of the Royal College of Surgeons of England.

[11]  T. Walsh,et al.  The warm knee sign--an evaluation. , 1990, European journal of vascular surgery.

[12]  B. Bullen,et al.  The incidence of congenitally absent foot pulses. , 1990, Annals of the Royal College of Surgeons of England.

[13]  R. Hamman,et al.  Diagnostic methods for peripheral arterial disease in the San Luis Valley Diabetes Study. , 1990, Journal of clinical epidemiology.

[14]  R. Davies,et al.  Significance of Buerger's Test in the Assessment of Lower Limb Ischaemia , 1989, Journal of the Royal Society of Medicine.

[15]  R. Porter,et al.  Walking and Cycling Tests in Neurogenic and Intermittent Claudication , 1989, Spine.

[16]  B. Jacobsen,et al.  Clinical relevance of pedal pulse palpation in patients suspected of peripheral arterial insufficiency , 1989, Journal of internal medicine.

[17]  K. Myers,et al.  Palpation of the femoral and popliteal pulses: a study of the accuracy as assessed by agreement between multiple observers. , 1987, European journal of vascular surgery.

[18]  E. Barrett-Connor,et al.  The sensitivity, specificity, and predictive value of traditional clinical evaluation of peripheral arterial disease: results from noninvasive testing in a defined population. , 1985, Circulation.

[19]  D. Sackett,et al.  The Ends of Human Life: Medical Ethics in a Liberal Polity , 1992, Annals of Internal Medicine.

[20]  D. Righi,et al.  A Study of the Semeiological Reliability of Dorsalis Pedis Artery and Posterior Tibial Artery in the Diagnosis of Lower Limb Arterial Occlusive Disease , 1984, Angiology.

[21]  D. Flanigan,et al.  Is femoral pulse palpation accurate in assessing the hemodynamic significance of aortoiliac occlusive disease? , 1984, American journal of surgery.

[22]  J. Mannick.  Current concepts in diagnostic methods. Evaluation of chronic lower-extremity ischemia. , 1983, The New England journal of medicine.

[23]  C E Metz,et al.  Critical evaluation of stress testing in the diagnosis of peripheral vascular disease. , 1982, Surgery.

[24]  S. Carter.  Arterial auscultation in peripheral vascular disease. , 1981, JAMA.

[25]  K. Johnston,et al.  Difficulty in Assessing the Severity of Aorto-Iliac Disease by Clinical and Arteriographic Methods , 1981, Angiology.

[26]  S. Ingman,et al.  Reliability of Palpation of Pedal Pulses As Ascertained by the Kappa Statistic , 1980, Journal of the American Geriatrics Society.

[27]  R. Greenhalgh,et al.  Standard exercise test to assess peripheral arterial disease. , 1980, British medical journal.

[28]  K. Beach,et al.  Noninvasive testing vs clinical evaluation of arterial disease. A prospective study. , 1979, JAMA.

[29]  N. Parfrey,et al.  HAIRLESS LOWER LIMBS AND OCCLUSIVE ARTERIAL DISEASE , 1979, The Lancet.

[30]  J. S. Yao,et al.  Rational approach to the differentiation of vascular and neurogenic claudication. , 1978, Surgery.

[31]  S. String,et al.  Diagnosis of peripheral occlusive disease: comparison of clinical evaluation and noninvasive laboratory. , 1978, Archives of surgery.

[32]  A. L. Evans,et al.  Thermography in lower limb arterial disease. , 1976, Clinical radiology.

[33]  R. Kester,et al.  Current status of thermography in peripheral vascular disease. , 1975, The Journal of cardiovascular surgery.

[34]  M. Lapayowker,et al.  Angiography, ultrasound, and thermography in the study of peripheral vascular disease. , 1972, Radiology.

[35]  S. Carter.  Response of ankle systolic pressure to leg exercise in mild or questionable arterial disease. , 1972, The New England journal of medicine.

[36]  H. Okino.  [Pulsatile blood flow]. , 1972, Kokyu to junkan. Respiration & circulation.

[37]  S. Carter.  Clinical measurement of systolic pressures in limbs with arterial occlusive disease. , 1969, JAMA.

[38]  P. C. Richardson,et al.  Observer variability in recording the peripheral pulses. , 1968, British heart journal.

[39]  V. Willman,et al.  Intermittent claudication with pedal pulses. , 1968, JAMA.

[40]  S A Carter,et al.  Indirect Systolic Pressures and Pulse Waves in Arterial Occlusive Disease of the Lower Extremities , 1968, Circulation.

[41]  H. Barner,et al.  Prevalence of congenitally absent pedal pulses. , 1968, The New England journal of medicine.

[42]  P. Yu,et al.  Clinical examination of the arterial pulse. , 1967, Progress in cardiovascular diseases.

[43]  H. Gaylis.  Warm knees and cold feet. A new sign in arterial occlusion. , 1966, Lancet.

[44]  A. Zweifler.  SIGNIFICANCE OF KNEE SKIN TEMPERATURE IN ISCHEMIC LEGS. , 1965, Archives of internal medicine.

[45]  J. Ludbrook,et al.  Significance of Absent Ankle Pulse , 1962, British medical journal.

[46]  G. L. Stephens.  Palpable dorsalis pedis and posterior tibial pulses. Incidence in young men. , 1962, Archives of surgery.

[47]  J. Deweese.  Pedal pulses disappearing with exercise. A test for intermittent claudication. , 1960, The New England journal of medicine.

[48]  J. Silverman.  The incidence of palpable dorsalis and pedis and posterior tibial pulsations in soldiers; an analysis of over 1,000 infantry soldiers. , 1946, American heart journal.

[49]  E. K.,et al.  Vascular Disorders of the Limbs Described for Practitioners and Students , 1936, The Indian Medical Gazette.

[50]  R. Reich.  The Pulses of the Foot: Their Value in the Diagnosis of Peripheral Circulatory Disease. , 1934, Annals of surgery.

[51]  G. Pickering.  ON THE CLINICAL RECOGNITION OF STRUCTURAL DISEASE OF THE PERIPHERAL VESSELS * , 1933, British medical journal.

[52]  H. Morrison.  A Study of the Dorsalis Pedis and Posterior Tibial Pulses in One Thousand Individuals without Symptoms of Circulatory Affections of the Extremities , 1933 .

[53]  W. B. Saunders.  The Circulatory Disturbances of the Extremities Including Gangrene, Vasomotor and Trophic Disorders , 1925, The Indian Medical Gazette.