The Biggest Walking Mistake I See: PAD Q&A

Peripheral artery disease Q&A — including one of the biggest mistakes people make when trying to “walk off” PAD symptoms.

In this video, we break down:
• Why erectile dysfunction is actually a sign of vascular disease
• What an ankle-brachial index (ABI) actually measures
• Normal ABI ranges and what abnormal results can mean
• Whether you should have vascular testing done at home or in a certified vascular lab
• The difference between artery disease and vein disease (including spider veins and varicose veins)
• PAD treatment options — from walking programs to procedures and surgery
• Recovery times after PAD interventions
• How to use progressive overload with walking so you actually improve over time instead of staying stuck

As a vascular surgeon, one of the hardest parts of PAD is that people are often given oversimplified advice: “just walk more.” But how you walk, how you progress, and how you interpret symptoms actually matters.

Hopefully this helps make the whole thing a little less confusing — and gives you a framework that’s practical, realistic, and evidence-based.

Question: Have you or someone you know ever had an ABI test or been diagnosed with PAD?

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🧬 About Dr. Lily Johnston
  
Dr. Johnston is a double board-certified vascular and general surgeon in San Diego, specializing in metabolic and cardiovascular prevention. She’s the founder of CorSight Health and a passionate advocate for reimagining how medicine approaches chronic disease.

Transcript

SPEAKER_00 0:00

You guys came up with amazing questions about blood vessels, peripheral arterial disease. We are gonna get right into it today. Hey guys, if you don't know me, I am Dr. Lily Johnson. I'm a board certified vascular surgeon, and today we're talking about vascular surgery stuff. Here is our first question from Jacksonville. Is it true that ED or erectile dysfunction can be caused by plaque in your arteries? If yes, which arteries would be most implicated? This is probably one of the biggest hidden signs for plaque in our arteries, whether that's in our legs, in our hearts, or in the neck, in the vessels leading up to the brain. If you have erectile dysfunction, I absolutely want to want you to talk to your doctor about getting more testing, more screening for peripheral arterial disease and coronary artery disease, meaning plaque building up in the arteries of our legs or our heart. Erectile dysfunction has many causes, but poor blood flow, typically from the internal iliac arteries, is absolutely a very common culprit for this problem. And the other place you could have plaque would be upstream of that in the common iliac arteries, which can be treated. Most commonly, the internal iliac arteries are not actually things that we treat surgically, but of course, there are a number of medications and procedures, interventions that can help men with erectile dysfunction, but you should absolutely get checked out, look for signs of plaque in your arteries if this is something that you are struggling with. Our next question comes from Live Physiology, who asks what is the surgery like? What happens? How long of a recovery is there from the surgery? This is all about where the disease is, how severe is it, and what are we going to do to fix it? So the first question is Do you need surgery? And obviously, many patients get to a point where we are talking about procedures to improve circulation, to either improve their ability to get around and function in their day-to-day lives, or because we have to improve circulation if we're going to save the leg. The circulation is so bad that if we do nothing, they are at very high risk for amputation or losing the leg. So the first question is where is the narrowing or the blockage that's causing the problem? And then what are our options to fix it? Because the solutions are different based on the location of our plaque. For example, the common femoral artery is pretty much in the hip crease for most people. And that is a place where we often will begin an angiogram type procedure. But even though we poke it a lot with needles, so we can use our wires, catheters, and stents, all of the equipment that we use to do these minimally invasive types of repairs, the common femoral artery is actually, if the plaque is right there, that's best treated most of the time with open surgery, where we make an incision, we uh stop the water flow in the blood vessel temporarily, we scrape all the plaque out, and then we put a little patch over top of it, just like you would patch a hole in your blue jeans and sew it all back up and then restore the flow. And that's because that area is so subject to motion with all of the bending at the hip crease that we do, that it's possible to put stents there. And certainly it's commonly done, more commonly done in Europe, for example. And I have a couple of patients that I have considered doing this for. I'm actually not certain that I've done a common femoral stent myself. I've seen it in other patients, but here in the United States, it's very rare for us to do that in most practices, but it's a possibility for people who, for whatever reason, couldn't have an open surgical repair. The other places are the iliac arteries, which are up in the pelvis, so closer, but like between the belly button and your hip bones. The iliac arteries uh are frequently managed with stents. So that's a minimally invasive approach, and that's a much shorter recovery, typically. And then if we're talking about areas behind the knee or below the knee, some of those areas can be treated with balloons like angioplasty or the stents, both. But some of them also will require an open surgical bypass, where we take either a piece of your vein or an artificial tube and we go around the area that's narrowed or blocked. So often that will start up in the groin in that common femoral artery, and we go around the area that's blocked and plug in down below where the artery is open downstream. Bypass is probably the longest recovery of these operations, and it will depend a lot on how strong you are going into surgery and you know how many other medical conditions we might be battling as we are taking care of you. If you have sick heart or sick lungs, problems with blood sugar control, um, difficulty with pain control, all of these things will impact your ability to recover swiftly and get out of the hospital. Uh, we can see patients in the hospital anywhere from two days uh up to you know over a week for a bypass, depending on what happens in the recovery process. So, life physiology, that's a bit of a complicated answer because surgery is actually a whole host of different tools and techniques. If you have disease in multiple locations, we combine, we can mix and match. So it's really everything from an outpatient procedure with hours of recovery all the way to a week or more in the hospital and big open surgery. Uh, we didn't even talk about, you know, aortic-based reconstructions. Those are even more intensive, uh, but also are a key component in helping restore blood flow to the legs. The new cinema asks, what about pain in the shins with walking, the front of the lower legs? So this was from the short we did on cloudication or cramping pain in the legs with walking. Most commonly, this is in the calves, and you can get claudication in the shins. There is a muscle in that anterior or front compartment of the lower leg, and there is a blood vessel, one of the three we have below the knee that feeds the leg and the foot that could cause some pain there. It is not the most common presentation of clodication, and more commonly, that's shin splints or irritation related to either the type of activity or your conditioning or your footwear, or something like that. Um, but if you have a lot of risk factors for peripheral arterial disease, so age over 65, history of smoking, high blood pressure, elevated cholesterol or triglycerides, uh, any of the other factors that we always talk about on this channel, please, by all means, go ask your doctor and get checked out for that. Because there was another question here about how is it diagnosed that comes from at MermacD. And uh it sounds like what you've been experiencing. So there are a number of videos on YouTube that will tell you you can do this test at home, and that's kind of true. So the test that we recommend is something called an ABI or an ankle brachial index. This is the ratio of the blood pressure in your ankle to the blood pressure in your arm. And so we would generally take the blood pressure in both of your arms. We pick the highest one, and it's the top number that we're looking at here, the systolic blood pressure. And then for a true ABI, we actually take the blood pressure and measure the flow in two different arteries in the leg, both the dorsalis pedus, which is on the top of your foot, and the posterior tibial artery, which runs along the backside of your middle ankle bone. And we need a Doppler device to do that, or sometimes uh you can listen to it with a stethoscope, but you'll need a blood pressure cuff down at the ankle, and then we measure that pressure as well. And it is the highest blood pressure at the ankle divided by the highest blood pressure in your arms, and then you get a ratio. So that's ABI in a nutshell. If you have a home blood pressure cuff, uh, you can get a measurement of your blood pressure in the ankle. I don't know if it's going to be your dorsalis petus or your posterior tibial, it's probably your DP, but we don't know for sure. And I think maybe it's the highest one, but I don't exactly know how precise those home blood pressure cuffs are. So I can't and we're back after a brief technical hiccup. One more point I want to talk about with ankle brachial index or ABI is what the normal range is. So the blood pressure in your feet should be about the same as the blood pressure in your arms. So a ratio of anywhere around one to 1.3 is considered normal. Anything less than 0.9 is abnormal and reflects reduced circulation. And how low it is, you know, I start to talk about it with patients like a percent of normal, right? So anything less than 90% is 0.9, and that's abnormal. But you can imagine if your circulation is about 80% of normal, you're probably okay most of the time. But if you're gonna drop down to 60%, 50%, 40% or less, now we're in the territory of limb-threatening ischemia. That's not defined by a particular ABI number, but I begin to see patients in that range begin to have those symptoms of pain at rest in the feet and wounds that don't heal. And that is what what defines limb-threatening ischemia or poor circulation. So that's ABI. The only other thing to be aware of with an ABI is that if you have diabetes or kidney failure, your arteries can become stiff. And stiff arteries don't compress very well, and it means that the blood pressure that we take in your ankles is unreliable. So if you have an ABI of 1.3, 1.4, then we might actually think that that's abnormally elevated and it might reflect what we call um non-compressible arteries or that stiffening in the wall of the artery. It doesn't always have to be high, like over 1.4. Sometimes it's just normal at one, but the waveform doesn't look right. So, all that to say, if you have diabetes or kidney failure, severe kidney disease, and have had that for some time, you may have stiffened arteries, and an ABI is not as reliable for you, but we can always look at the waveforms, do a formal ultrasound test, and get more information that way. Next, I am moving on to user Candace, who says, I'm 60 and I've had spider veins in my legs since my teens. I've had them treated with sclerotherapy many times over the years, but they return. Are they a sign of a serious vein condition that I should look into? So let's just back up one second, right? Arteries bring blood away from the heart, they carry the oxygenated blood into our tissues, they deliver the nutrients and the oxygen that we need, and then veins bring blood back into the heart. They carry the blue or the deoxygenated blood back to get new oxygen from the lungs and repeat that cycle all over again. Mostly when we're talking about PAD, it's the artery side of things, right? Poor circulation getting into the legs, unable to deliver the oxygen that the muscles and the tissues need to work and survive. Veins bringing blood back tend to be a little less severe in terms of the diseases that we see. Most commonly, spider veins are on a spectrum of things that we would call chronic venous insufficiency, or things like varicose veins, leg swelling, heaviness, aching, or itching. All of those symptoms have to do with the fact that veins are a gravity problem. So veins don't pump themselves. Unlike the arteries, which have a muscular layer in the wall, the veins rely on our actual muscles to squeeze, and then blood moves upwards, like toothpaste out of a tube. But when we stop moving, our muscles relax, gravity starts to pull that blood back down towards the floor. And you can imagine in the legs, particularly, uh, there's a long way to go. And we are gifted with these little one-way valves on the inside of our veins that are supposed to shut as the blood starts to drop back down towards the floor. But if those valves are leaky or they get stretched out for any reason, then blood does begin to pool. Long story, this ends up causing vein disease or varicose veins, leg swelling. It's one of several causes of leg swelling. And in some cases, this can be treated, like with procedures. Other cases, we just manage it with things like compression socks, leg elevation, and staying active and moving if we're going to be sitting or standing for long periods. Spider veins uh are very, very common. Not everybody has worse symptoms, they just have that cosmetic problem. So, in general, no candles, I'm not super worried about the spider veins. And as long as your legs feel good and you're not having issues, I don't think you need to be too worried about it. Even if your legs are heavy and achy, it's probably not serious, but you're welcome to get that checked out and talk to a vascular specialist about how you might improve the quality of your life. So hope that helps. All right. Last but not least, we have a really good question that I think we all need to pay a lot of attention to. So Chichortez says, I have mild cloudication and I walk one mile in the morning, one mile at night, no pain, and I walk briskly. At the end of my day, my ankles would swell. And then we go on to say some things now, the swelling is better with some compression socks, and has some nighttime leg cramps. Also, by the way, very common, not necessarily associated with PAD. And um the there's actually not a real question in here. What I wanted to focus on, though, is the biggest mistake that I see people with who have claudication that they make with walking. And the mistake is getting comfortable in the routine. So think about it this way: if you have a pile of cash sitting around, you could tuck it under your mattress and you say, Well, great, I have it safe. It's for safekeeping, and it's gonna retain the same value forever, right? It's just money, it's the same $100 today as it will be, you know, next year. But you know that's not true, right? Because now we have inflation and cost of living changes. And so $100 is actually not the same today as it will be in a year from now, right? It will be worth less. And exercise, lifestyle interventions, they're kind of the same way. If we keep doing the same thing as we age, our muscles are less responsive, they become uh resistant to hypertrophy, they become resistant to more training. We have to work harder to maintain the same amount of fitness on muscle. So unfortunately for all of us, if we are not pushing harder year over year, week over week, then we're actually losing. We're slowing down, right? It's like money that's actually not accumulating any interest and is devaluing because inflation carries on. So for claudication in particular, walking is such a great exercise and it's fundamental to improving the course of your disease. But to show big improvements in walking with claudication, I'm gonna push you. I'm gonna tell you whatever you're doing now, that's awesome. And I'm so excited, you're gonna have to do more. I'm gonna ask you to be increasing it a little bit every week or every month. And if you're constrained by time, which is normal, then you're gonna have to pick up the intensity of it. When I prescribe a walking program for my patients with cloudication, I tell them you have to walk until it's medium uncomfortable or medium painful, right? So that's like a five on a one to 10 scale. And at that point, stop and rest, however long that takes, and then you have to go again. And we tally up your total amount of walking time and whatever that is this week, next week we go up by 10%. But you have to get to the point where it's pretty moderately uncomfortable to signal your body that it is worth the extreme amount of energy that it takes to build new pathways around the areas that are narrowed or blocked and to increase the synthesis of nitric oxide to help relax those vessels and allow them to get just a little bit bigger and overcome that narrowing. So I'm again like walking is awesome. If you're walking two miles a day, that is more than many of my patients, and you are absolutely to be congratulated for this. And we're gonna need to keep pushing a little harder every week, every month, every year, so that our body will build those collaterals, those beautiful side county roads that go around the blocked freeway. And so we continue to maintain our strength, our fitness, our muscle mass as we age. So, not continuing to have progressive overload, that is the biggest mistake I see with people who are in fitness of any kind as part of their health and wellness journey. Thank you guys so much for the amazing questions. I am really excited to see you this coming Saturday at 2 p.m. Pacific, 5 p.m. Eastern for our next live Ask Me Anything. Bring more questions. I can't wait. Until then, take really good care.