Is walking hurting your legs?

Plain old walking usually tops the list of recommended exercises to improve health because it’s easy, convenient, and free, and it requires minimal equipment — just a comfortable pair of shoes. The trouble is that walking isn’t so easy for everyone. Indeed, it’s agony for many. And forget the “brisk” pace advised for health and fitness.

With age — and occasionally without it — a number of conditions can result in leg pain that makes walking difficult. Some are very familiar, such as arthritis that makes knees and hips creaky; others such as peripheral artery disease aren’t. Today’s article looks at four non-arthritic conditions that cause leg pain and may affect walking, and some ways to treat and manage them — no need to limp and bear it. These conditions are being discussed separately, but people may have two or more of them at the same time, which complicates diagnosis and treatment.

1. Peripheral artery disease. Peripheral artery disease is a form of atherosclerosis, the same condition that leads to most strokes and heart attacks. Fat- and cholesterol-filled plaque narrows arteries, and blood clots can collect on the plaque, narrowing them further. In peripheral artery disease, the arteries affected by atherosclerosis tend to be the ones that supply the leg muscles. The risk factors are similar to those for heart disease and stroke: smoking, high cholesterol levels, high blood pressure, and especially diabetes.

The classic symptom is cramping, tight pain that’s felt in muscles “downstream” from the narrowed artery. It can occur in the buttocks, thigh, calf, or foot but occurs most often in the calf. The pain tends to come on with walking, gets worse until the person stops walking, and goes away with rest. Similar to angina, the pain caused by peripheral artery disease comes from working muscle cells “starved” for oxygen because of obstructed blood flow. The medical jargon for this kind of pain is intermittent claudication, from the Latin word claudicatio for limping.

Peripheral artery disease by itself can be serious and debilitating, but it may also serve as an important warning of even more serious trouble. Atherosclerosis in the legs often means there’s atherosclerosis elsewhere, and people with peripheral artery disease are six to seven times more likely to have a heart attack, stroke, or transient ischemic attack than people without it.

Researchers have found that tightly structured, supervised exercise programs can help people increase the amount they can walk before the pain kicks in. These programs usually involve walking till it hurts (which may be only for a few minutes), resting till the pain goes away, then walking again. These walk-rest-walk sessions are most effective if people do them for about 30 minutes at least several days a week.

If the disease is more advanced, medications or surgery (angioplasty or bypass) may be tried. More serious cases can cause tissue death and gangrene.

2. Chronic venous insufficiency. Like peripheral artery disease, chronic venous insufficiency is a condition of poor circulation, but it involves the veins and the blood’s return trip to the heart and lungs. Our arteries are springy and help push blood along, but our veins are relatively passive participants in circulation. Particularly in the legs, it’s the muscles surrounding the veins that provide the pumping power that drains the vessels near the surface of the skin and then pushes the blood up through the “deeper” vessels that travel toward the heart. Tiny valves inside the veins even out the pressure and keep the blood from flowing backward.

In people with chronic venous insufficiency, the valves are damaged, so blood tends to pool in the legs and feet instead of traveling “north” to the heart. It’s often a vicious cycle: If the valves aren’t working, pressure from the blood collecting in the veins increases, so the veins stretch out. As a result, the valves don’t close properly, so even more blood flows backwards, adding pressure.

Symptoms include swelling, inflammation of the skin (dermatitis) and the connective tissue underneath (cellulitis), and ulcerated, open wounds on the bony bumps of the ankle. Legs may feel achy or heavy. And when people walk, they may feel a tight, “bursting” pain, most often in the groin or thigh. The pain will stop with rest but may take longer to ease up than pain from peripheral artery disease.

The symptoms from a mild case of chronic venous insufficiency can be helped by lying on your back and using a pillow to elevate your legs so blood flows downhill to your heart. If you’re sitting for long periods, pointing your toes up and down several times can flex the vein-pumping leg muscles.

More serious cases needed to be treated with compression stockings, There aren’t really any medications for chronic venous insufficiency per se. Surgical treatments are reserved for the most serious. They include removing damaged veins or tying them off (venous ligation).

3. Lumbar canal stenosis. Stenosis is a medical term for any kind of narrowing. Spinal stenosis can occur anywhere along the spine as a result of the vertebrae, the disks between them, or their supporting structures impinging on the tube-like spinal canal that holds the spinal cord and the roots of the nerves that branch off it. Pain comes from the mechanical pressure, and perhaps also from the pinching off of the blood supply that nerves (like other kind of tissue) need.

The lumbar region of the spine consists of the five large vertebrae that form the small of the back. When spinal stenosis occurs in the lumbar region, lower back pain can be a symptom but often, it’s the legs that are affected. The pain can resemble that caused by peripheral artery disease: cramping tightness that increases with walking, although it’s often felt in the thigh rather than the calf. The legs may also feel weak and numb.

The diagnosis starts with discussions of symptoms and medical history. One important clue is whether the pain eases when the back is curved forward, or flexed. That posture tends to take pressure off the lumbar region, and it’s the reason some people with lumbar stenosis find it easier to walk when leaning on a grocery cart or a walker. An MRI or CT scan will often be ordered to confirm a diagnosis, but imaging studies shouldn’t be used to make one. Many people have spinal stenosis that show up on an imaging study but doesn’t cause any symptoms.

Treatment usually begins with physical therapy and exercises aimed at strengthening back and abdominal muscles. Pain relievers may help. Growing numbers of older people are getting corticosteroid injections into the spine, which worries some experts. Evidence that the shots are effective is mixed. If the pain persists, surgery is an option. The most common procedure is a laminectomy, which involves cutting away part of a vertebra to create more space for the spinal cord and nerves. Bone spurs and portions of the disks and facet joints can also be removed to relieve pressure. Study results for surgery are murky. The majority of patients seem to feel better for the first year or so, but the advantage over a nonsurgical approach seems to wear off after several years. A second operation is sometimes needed. On the other hand, for some, surgery greatly reduces the pain and discomfort.

4. Diabetic neuropathy. People with diabetes are prone to nerve damage. Exactly why is uncertain. High blood sugar levels may damage the tiny blood vessels that supply nerves, creating “nerve strokes”: nerves starved for oxygen (ischemia) because of damaged blood vessels. Diabetes may also deplete the body’s store of neurotrophic peptides, chemicals that normally repair and regenerate nervous tissue.

Diabetic neuropathy affects the upper and lower legs in different ways. In the upper leg, the pain from ischemic nerves can come on suddenly and be felt in just one leg. In the lower legs and feet, where it is more common, the symptoms are typically numbness or tingling, and are usually felt about equally in both legs. The numbness often dulls painful sensations, so sores on the feet go unnoticed and get worse. Diabetic neuropathy can make walking difficult, but symptoms may improve with exercise.

People with diabetes can reduce their chances of developing neuropathy by keeping their blood sugar down. It’s less certain that tight blood sugar control is helping once nerves have been damaged. Still, it’s an important goal for many reasons. Pain relievers, tricyclic antidepressants (amitriptyline, desipramine), and anticonvulsants (gabapentin, pregabalin, duloxetine) are used to control the burning and tingling sensations from the neuropathy.