Peripheral Artery Disease: A Silent Condition Affecting Millions—Here Are the Symptoms

Peripheral artery disease (PAD) is a common cardiovascular condition in which narrowed arteries restrict blood flow, most often to the legs, and sometimes to the arms.

It affects 10 to 14 million Americans. In severe cases, reduced blood flow can lead to nonhealing wounds, tissue death, and even amputation. PAD also increases the risk of heart attack and stroke.

There is a hallmark symptom to watch for, and several lifestyle approaches can alleviate the condition or even prevent it from happening.

[shortcut_anchor id=”anchor_1794551450655″ label=”Symptoms”]What Are the Symptoms of Peripheral Artery Disease?[/shortcut_anchor]Arteries carry oxygen- and nutrient-rich blood from the heart to organs and tissues throughout the body. The arteries that supply the arms, hands, legs, and feet are known as peripheral arteries. PAD occurs when these arteries narrow.

Up to 40 percent of people with PAD have no symptoms, despite impaired blood flow. This may be partly because the body develops collateral blood vessels, which are small alternative routes that carry blood around a narrowed or blocked artery. Some people also avoid symptoms by limiting their activity, while others develop mild symptoms that may worsen over time.

The Hallmark Symptom

In its early stages, lower-extremity PAD—the most common form—may cause intermittent claudication, characterized by cramping pain, numbness in the leg muscles, buttocks, or feet during walking or exertion. This occurs when narrowed or blocked arteries restrict blood flow to the muscles. The pain typically fades when you rest, as the muscles need less blood.

The distance you can walk before pain begins is worth tracking, because a shrinking pain-free distance may mean the disease is progressing. Claudication is the classic sign, but only about 10 percent to 35 percent of people with PAD experience it. It is more common among people over 50, men, and people who smoke.

As the condition progresses, many other symptoms may develop, including:

• Coldness or Numbness: The arms, legs, fingers, or toes may feel unusually cold or numb.

• Reduced Sensation: The arms or legs may have decreased sensation, including pins-and-needles tingling in the legs or feet.

• Skin and Color Changes: The feet or legs may become pale, bluish, or otherwise discolored.

• Unequal Temperature: One foot may feel colder than the other.

• Reduced Hair and Nail Growth: Leg hair may thin, and toenails may grow more slowly.

• Leg Weakness and Muscle Wasting: Weakness can affect balance and make walking harder, and leg muscles may shrink.

• Slow-Healing or Nonhealing Wounds: Sores or ulcers on the toes, feet, or legs may heal slowly or not at all and can become infected.

• Erectile Dysfunction: This may occur, particularly in men with diabetes.

In severe PAD, inadequate blood flow may cause persistent pain in the feet or legs even at rest. This can indicate chronic limb-threatening ischemia and an increased risk of amputation. Skin ulcers or tissue death (gangrene) may also develop at this stage. People may experience intense burning pain in the soles of their feet that worsens at night and disrupts sleep.

When PAD affects the arms, it can cause pain or cramping during activity (arm claudication), as well as pain in the hands or fingers at rest. In severe cases, poor blood flow may lead to finger ulcers and gangrene.

[shortcut_anchor id=”anchor_1794552836366″ label=”Causes”]What Causes Peripheral Artery Disease?[/shortcut_anchor]The primary cause of PAD is when plaques form on the inner walls of the arteries, or atherosclerosis. The accumulation of plaque, over time, restricts the flow of oxygen-rich blood.

In the early stages, arteries may compensate by expanding outward, which keeps blood flowing. However, as plaque grows, this compensation fails and blood flow drops. Although smaller collateral blood vessels may develop to help maintain circulation, they cannot supply enough blood when muscles demand more oxygen during physical activity.

In advanced stages, severe arterial narrowing may reduce blood flow below what tissues need even at rest.

Because atherosclerosis is a body-wide condition, PAD often signals plaque buildup elsewhere. Plaque in the arteries supplying the brain raises the risk of stroke, while plaque buildup in the coronary arteries that supply the heart increases the risk of a heart attack.

Less common causes of PAD include the following:

• Vasculitis: The immune system can attack blood vessel walls, causing inflammation, thickening, and narrowing that may block the artery.

• Trauma: An injury or fracture can damage an artery, leading to narrowing, tearing of the artery wall, blood clot formation, or poor circulation.

[shortcut_anchor id=”anchor_1794552850878″ label=”Risks”]What Are the Risk Factors for PAD?[/shortcut_anchor]The risk factors for PAD are largely similar to those for coronary heart disease and carotid artery disease, as all three conditions stem from atherosclerosis.

• Smoking: Smoking increases the risk of developing PAD fourfold and is linked to faster progression to critical limb ischemia, higher amputation rates, and shorter life expectancy. It promotes atherosclerosis, increases blood clot formation, and reduces oxygen delivery to tissues. Nicotine in tobacco also causes blood vessels to constrict.

• Overweight and Obesity: Excess body weight may increase the risk of PAD and is associated with other risk factors, such as high blood pressure and high cholesterol.

• Physical Inactivity: Lack of physical activity increases the risk of PAD by contributing to high blood pressure, elevated cholesterol, and excess weight.

• Saturated Fats: A diet overly high in saturated fats can raise LDL cholesterol levels, promoting plaque buildup in the arteries and increasing the risk of PAD.

• Stress: Stress can cause arteries to constrict, potentially reducing blood flow.

• Irregular Sleep: Both short sleep (less than five hours per night) and oversleeping (eight hours or more) have been linked to a higher risk of PAD, although more research is needed to confirm this.

• Pollutants and Certain Metals: Exposure to environmental pollutants, particularly air pollution and toxic metals such as lead, cadmium, and arsenic, may increase the risk of PAD by contributing to inflammation, blood vessel damage, high blood pressure, and plaque buildup in the arteries.

• Diabetes: Diabetes, particularly Type 2 diabetes, is a major risk factor for PAD. High blood sugar can damage blood vessels, causing them to narrow and restrict blood flow.

• High Blood Pressure and High Low-Density Lipoprotein (LDL) Cholesterol: Both contribute to atherosclerosis and arterial narrowing.

• Other Medical Conditions: Up to 25 percent of people with chronic kidney disease (CKD) also have PAD. Blood clotting disorders and vascular conditions such as fibromuscular dysplasia, which causes abnormal artery narrowing, can also increase risk.

• Hyperhomocysteinemia: High levels of the amino acid homocysteine in the blood are a significant, independent risk factor for PAD. Excess homocysteine may contribute to endothelial dysfunction, or impaired function of the inner lining of blood vessels, through increased oxidative stress and reduced nitric oxide bioavailability (a molecule that helps blood vessels relax).

PAD risk also increases with age, particularly after 65, and is influenced by family history of blood vessel disease and certain genetic variations. In the United States, PAD is more common among African Americans and American Indian women than among some other populations.

[shortcut_anchor id=”anchor_1794552894921″ label=”Diagnosis”]How Is Peripheral Artery Disease Diagnosed?[/shortcut_anchor]Diagnosing PAD generally involves reviewing your medical history, performing a physical exam, and ordering appropriate diagnostic tests.

During the medical history assessment, your doctor will ask about existing medical conditions, such as diabetes, heart disease, and chronic kidney disease, as well as PAD symptoms and discuss current or previous smoking habits and your family history of PAD.

During the physical exam, your doctor will check pulses in the legs to identify any that are weak or absent, use a stethoscope to listen for abnormal blood flow sounds called bruits, and examine the legs and feet for signs of poor circulation, including swelling, sores, and pale skin.

Your doctor may also conduct or request additional tests, such as:

• Ankle-Brachial Index (ABI): This noninvasive test is usually the first diagnostic test of PAD. It compares blood pressure in the ankles with that in the arms using a Doppler ultrasound probe, a handheld device that uses sound waves to measure blood flow.

• Exercise ABI: This test is used when you have leg pain while walking but a normal resting ABI. Blood pressure is measured again after treadmill exercise to detect PAD that is hidden at rest.

• Segmental Doppler Pressure Testing: This test uses several cuffs to measure blood pressure at different levels of the arm or leg. Pressure differences help identify where an artery is narrowed or blocked.

• Arterial Duplex Ultrasound: This noninvasive imaging test uses ultrasound to assess blood flow speed and visualize arterial narrowing, atherosclerotic plaques, and calcification. It helps identify the location and severity of arterial blockages.

• Computed Tomographic Angiography: This imaging technique uses X-rays and contrast dye to produce detailed images of the arteries and identify areas of narrowing or blockage.

• Magnetic Resonance Angiography: This test uses magnetic fields and radio waves, rather than X-rays, to produce detailed images of the arteries. It may not be suitable for people with certain implanted devices, and the contrast dye requires caution in people with severe chronic kidney disease.

• Catheter-Based Angiography: This invasive procedure can visualize the arteries of the lower extremities. A catheter is inserted into an artery, usually in the groin, and guided to the affected area. Contrast dye is injected, and X-rays reveal narrowing or blockages. It is generally used for severe leg or foot symptoms, when other diagnostic tests are inconclusive, or when further evaluation is needed before an intervention.

[shortcut_anchor id=”anchor_1794552906886″ label=”Lifestyle Approaches”]What Are the Natural and Lifestyle Approaches to Peripheral Artery Disease?[/shortcut_anchor]The first-line treatment for PAD focuses on conservative, noninvasive measures to improve walking distance, relieve leg pain caused by intermittent claudication, and lower cardiovascular risks.

Lifestyle modifications include quitting smoking and avoiding secondhand smoke. People with PAD should also maintain good control of blood glucose and blood pressure, limit salt intake, and lower LDL cholesterol and triglyceride levels through healthy dietary choices. Stress management, adequate sleep, and relaxation are also important for overall health.

Even minor wounds or injuries can increase the risk of infection and lead to serious complications, so proper foot care is essential to prevent ulcers and infections. People with PAD should inspect their feet daily for dryness, cracks, blisters, sores, cuts, bruises, redness, swelling, or tenderness. Keep the skin moisturized, and promptly report any abnormalities to their healthcare provider.

1. . Heart-Healthy Diet

Nutritional guidance and adherence to a heart-healthy diet are vital components of effective PAD management.

A heart-healthy diet may help slow plaque buildup in the arteries, improve blood vessel function and circulation, reduce inflammation, and control major cardiovascular risk factors such as high cholesterol, high blood pressure, and diabetes.

Some specific foods have been studied in people with PAD:

• Beets and Beetroot Juice: A 2025 systematic review of five studies involving 64 people examined the effects of beetroot juice, a natural source of dietary nitrate. Two studies reported improvements in walking distance and the onset of claudication, while three found reductions in blood pressure. Researchers suggested that dietary nitrate increases nitric oxide availability, which may improve blood vessel relaxation, circulation, and oxygen delivery to working leg muscles.

• Cocoa Beverages: A 2020 study involving 44 people with PAD, 40 of whom completed the study, found that drinking a cocoa beverage daily for six months improved six-minute walking distance by 42.6 meters compared with placebo when measured 2.5 hours after the final drink. Cocoa also improved calf muscle function and increased capillary density. However, the improvement in walking distance was not statistically significant 24 hours after the final drink.

• Dark Chocolate: In a 2014 study, 20 people with PAD ate either dark chocolate containing more than 85 percent cocoa or milk chocolate containing 35 percent cocoa or less, with each portion weighing 40 grams. Two hours after consumption, dark chocolate significantly improved maximum walking distance by 11 percent and walking time by 15 percent. It also increased nitric oxide availability by 57 percent and reduced oxidative stress markers.

2. Exercise Therapy and Weight Management

Supervised exercise therapy is one of the most effective treatments for claudication, improving pain-free walking distance and functional capacity in people with intermittent claudication. Programs typically involve repeated walking and resting intervals for 30 to 45 minutes, at least three times per week, for at least 12 weeks. Treadmill walking is the most common form of exercise, although some programs also incorporate upper-body exercise equipment.

Home-based exercise programs can provide benefits similar to clinic-based supervised programs, typically involving outdoor walking for 30 to 50 minutes per session.

Staying active is also important to help prevent disease progression and control weight. For people who are overweight, losing 3 percent to 5 percent of their current body weight can improve PAD-related risk factors, including elevated cholesterol and diabetes.

Two studies show how the type and intensity of exercise matter:

Nordic Walking and Strength Training: A 2020 study involving 80 people with PAD compared three supervised exercise programs: treadmill walking, Nordic walking (walking with poles), and a combination of Nordic walking and strength training. All participants exercised three times per week for three months. Nordic walking produced the greatest improvements in walking ability, walking distance, and overall walking patterns. Adding strength training helped improve lower-body muscle function.

High-Intensity: A 2021 study involving 305 people with PAD found that high-intensity walking that induced moderate to severe leg symptoms significantly improved six-minute walking distance by 34.5 meters over one year. In contrast, low-intensity walking that did not cause leg symptoms showed no significant benefit compared with no exercise. Both walking groups exercised up to 50 minutes per session, five times per week, in an unsupervised setting.

People with PAD can work with their health care team to choose an appropriate exercise program, particularly if they have severe pain at rest or nonhealing wounds.

3. Supplements

These supplements are generally available over the counter; however, you should consult your doctor before starting to take them.

• Annurca Apple Polyphenol Extract: Annurca is an apple variety native to southern Italy. A 2019 study involving 180 people with PAD found that after 24 weeks, participants taking the supplement experienced a 69 percent increase in walking ability, a 25 percent improvement in ankle-brachial index, and a 3.6 percent improvement in arterial blood flow measurements (acceleration time).

• Propionyl-L-Carnitine: This is a naturally occurring derivative of the amino-acid-like compound L-carnitine, which helps carry fatty acids into the mitochondria, the cells’ energy-producing structures, where they are converted into usable energy. A 2021 systematic review of 12 studies involving 1,423 participants found that propionyl-L-carnitine improved maximum walking distance by approximately 26 percent and pain-free walking distance by 31 percent compared with a placebo.

• L-Citrulline: L-citrulline is an amino acid found in high concentrations in watermelon and produced naturally in the body. A 2025 study involving 51 people with PAD found that supplementation with L-citrulline (3 grams twice daily for 12 weeks) improved maximum walking distance by approximately 20 percent, compared with 5.7 percent in the placebo group. Researchers suggested that L-citrulline raises L-arginine levels, helping the body produce nitric oxide, a molecule that relaxes artery walls and improves blood flow.

• Nicotinamide Riboside: This is a form of vitamin B3 and a precursor of nicotinamide adenine dinucleotide, an essential coenzyme involved in mitochondrial energy production and the reduction of oxidative stress. A 2024 study involving 90 people with PAD found that after six months, those taking nicotinamide riboside improved their six-minute walking distance by 17.6 meters compared with the placebo group.

• Mitoquinone Mesylate (MitoQ): This is a synthetic mitochondria-targeted derivative of coenzyme Q10 with antioxidant properties. A 2020 study involving 11 people with PAD found that a single oral dose of 80 milligrams of MitoQ significantly improved blood vessel function in both arm and leg arteries, increased antioxidant enzyme activity, improved maximum walking time and distance, and delayed the onset of exercise-related leg pain. Researchers suggested that MitoQ reduces reactive oxygen species made in the mitochondria, improving antioxidant defenses and enhancing nitric oxide bioavailability, which may improve endothelial function and blood flow.

[shortcut_anchor id=”anchor_1794552920983″ label=”Treatments”]What Are the Treatments for Peripheral Artery Disease?[/shortcut_anchor]The management of PAD aims to relieve symptoms, slow disease progression, prevent major adverse limb events such as amputation, and reduce the risk of heart attack, stroke, and death.

1. Medications

Your doctor may prescribe medications, including:

• Antiplatelet Drugs: Aspirin and clopidogrel help prevent blood clots by reducing the clumping of platelets, blood cells involved in clotting. They also lower the risk of heart attack and stroke.

• Anticoagulants (blood thinners) : Help prevent blood clots.

• Statins: These medications lower LDL cholesterol and help slow the buildup of plaque in the arteries, potentially reducing the risk of heart attack, stroke, and serious limb complications.

• Blood Pressure Medicines: Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers help lower blood pressure by relaxing blood vessels.

• Cilostazol: This medication can relieve leg pain during walking and improve walking distance by helping blood vessels relax and widen. However, it must not be used in people with heart failure.

2. Endovascular Procedures

 These minimally invasive treatments involve inserting small instruments through a tiny puncture, usually in the groin, to reach and treat the affected blood vessels.

Angioplasty: This procedure is used to open narrowed or blocked arteries and restore blood flow. Your doctor guides a thin tube (catheter) with a small balloon at its tip into the affected artery. The balloon is inflated to push the plaque against the artery walls and widen the opening. A small mesh tube called a stent may also be inserted to help keep the artery open.

Atherectomy: This procedure removes plaque buildup from narrowed or blocked arteries to improve blood flow. Your doctor inserts a catheter with a special cutting device, rotating blade, or laser into the affected artery. The instrument is then used to remove or break up the plaque, helping widen the artery and restore blood flow.

3. Surgery

Surgery may be recommended when less invasive treatments are unsuitable or insufficient, or when severe PAD threatens the limb.

• Arterial Bypass: This procedure may restore blood flow around a severely narrowed or blocked artery. Your surgeon uses a healthy blood vessel, usually a vein taken from another part of the body, or an artificial vessel to create a new pathway around the blockage. Bypass may be recommended to relieve severe pain, help wounds heal, or save a damaged foot.

• Endarterectomy: In this procedure, your surgeon opens the affected artery, removes the plaque, and may use a patch made of natural or synthetic material to widen the artery and reduce the risk of it narrowing again.

• Thrombectomy: This procedure removes a blood clot (thrombus) from a narrowed or blocked artery to restore blood flow. During the procedure, your surgeon guides a specialized device into the vessel to capture, break up, or remove a blood clot and restore flow.

• Amputation: This is generally the last resort for severe PAD when there is an uncontrolled infection, persistent pain at rest, or gangrene. When appropriate, a below-the-knee amputation is preferred over an above-the-knee amputation because it may allow the person to use a prosthetic limb and maintain better mobility.

4. Padma 28 Herbal Formula

Consult your healthcare professional before using this herbal medicine to ensure it is safe and appropriate for your individual needs.

Padma 28 is a Tibetan herbal formula. An older study involving 36 people with intermittent claudication found that taking Padma 28 twice daily for four months improved walking ability. Among those receiving the treatment, pain-free walking distance increased from 52 meters to 86 meters, while maximum walking distance increased from 115 meters to 227 meters. The placebo group showed no significant improvements.

5. Laser Acupuncture

A 2022 study involving 30 older men with mild-to-moderate PAD found that laser acupuncture, combined with standard medication, improved claudication symptoms and walking ability. Half the participants received laser treatment twice weekly for five weeks. Their six-minute walking distance increased from an average of 214 meters to 318 meters.

Researchers suggested that laser acupuncture may improve circulation by promoting blood vessel relaxation and widening, increasing nitric oxide production, improving oxygen delivery and energy production in muscles, reducing inflammation and oxidative stress, and helping relieve pain.

6. Experimental Therapies

The U.S. Food and Drug Administration has not approved these therapies for PAD, and larger trials are needed to confirm their safety and effectiveness.

Gene Therapy: This approach involves injecting genetic material into affected muscles or arteries to encourage the production of growth factors that stimulate new blood vessels, which could improve blood flow and tissue repair in people with PAD.

Cell Therapy: This approach aims to repair damaged tissues and improve circulation by introducing specialized cells, such as mesenchymal stem cells or bone marrow-derived cells, to stimulate new blood vessel formation and tissue regeneration.

[shortcut_anchor id=”anchor_1794552936627″ label=”Mindset”]How Does Mindset Affect Peripheral Artery Disease?[/shortcut_anchor]A 2020 study involving 1,243 people with PAD found that depressive symptoms were associated with poorer health status and less improvement in symptoms over 12 months. Maintaining a positive mindset and addressing mental health concerns may improve self-confidence, motivation, treatment adherence, and coping abilities, helping people remain physically active and better manage the challenges of living with PAD.

[shortcut_anchor id=”anchor_1794552949254″ label=”Prevention”]How Can I Prevent Peripheral Artery Disease?[/shortcut_anchor]The healthy lifestyle changes discussed earlier may help prevent PAD. Certain foods and dietary patterns have also been linked to a lower risk:

• Nuts: Nuts, including tree nuts and peanuts, are rich in heart-healthy nutrients such as monounsaturated and polyunsaturated fats, fiber, protein, vitamins, minerals, and antioxidants. Regular nut consumption may help lower cholesterol and modestly improve blood pressure, blood glucose regulation, endothelial function, and inflammation. Additionally, the PREDIMED study involving 7,447 participants at high cardiovascular risk found that eating approximately 30 grams of nuts daily as part of a Mediterranean diet reduced major cardiovascular events by about 30 percent over five years, as well as a 49 percent reduction in PAD risk.

• Foods High in Dietary Fibers: A 2019 study involving 26,010 middle-aged adults, followed for a median of 21.7 years, found that higher fiber intake was associated with a 16 percent lower risk of developing PAD.

• Anti-Inflammatory Diet: A 2022 study involving 82,295 adults, followed for a median of 22 years, found that greater adherence to an anti-inflammatory diet was associated with a 16 percent lower risk of developing PAD, with stronger protective associations among current and former smokers.

[shortcut_anchor id=”anchor_1794552969554″ label=”Complications”]What Are the Possible Complications of Peripheral Artery Disease?[/shortcut_anchor]People who smoke or have diabetes are at greater risk of serious complications. These include:

• Acute Limb Ischemia: A sudden, severe reduction or blockage of blood flow to a limb is a medical emergency. 

• Heart Attack and Stroke: People with PAD have a two- to sixfold higher risk of dying from a heart attack or stroke.

• Chronic Limb-Threatening Ischemia: Severe, long-term reduction in blood flow can cause persistent pain at rest, nonhealing sores, infections, and gangrene, potentially leading to amputation.

• Compartment Syndrome: In severe cases of acute limb ischemia, particularly after blood flow is restored, swelling can increase pressure within the leg muscles, causing severe pain, muscle weakness, tingling, or numbness. This is a medical emergency.

• Serious Infections: Foot sores caused by poor circulation can become infected and spread to surrounding tissues, muscles, bones, or the bloodstream. Severe infections may require hospitalization and antibiotics. The risk is especially high in people with both PAD and diabetes.

• Blood Clots: Blood clots can form in an artery or travel from elsewhere through the bloodstream and block blood flow, potentially causing acute limb ischemia.

• Erectile Dysfunction: PAD can contribute to erectile dysfunction by reducing blood flow to the penis.

• Reduced Mobility and Loss of Independence: Poor circulation and leg pain can limit walking and make everyday activities harder.

• Anxiety and Depression: Chronic leg pain, reduced mobility, fear of disease progression, and loss of independence can contribute to anxiety and depression, affecting a person’s mental well-being.