[Case Studies] Differentiating peripheral artery disease from sciatica: a case study with Tom Jesson

Of course the most important thing is always the patient's background and the risk factors actually are really important and this is something I reflect on in the case study it's I didn't really dig enough into those but in terms of the tools we have in clinic once we suspect prefer to your disease people talk about capillary refill they talk about checking skin quality and all those things are useful and do no damage but really for us the king is pulses pulses of king for the physiotherapist welcome back to case studies from physiognet work in this episode we're tackling peripheral artery disease how to suspect it how to differentiate it and how to handle the work up and referrals all centered around a real life case study that brings these concepts to life I'm delighted to be joined by Tom Jessen if you haven't come across Tom before he's a physiotherapist and writer who specialises in making the complex world of lumber ridiculous pain and quarter acquire syndrome understandable is the author of essential guides like understanding sciatica and quarter acquire syndrome the MSK clinicians guide is currently finishing another major work on sciatica. Tom's known not just for his deep expertise but for his talent in turning confusing clinical concepts into clear and vivid insights today he's here to help us navigate peripheral artery disease through a real case study covering everything from how we spot it to the work up to making the right referrals stay tuned because by the end of this episode you'll never look at peripheral artery disease in the same way again I'm James Armstrong and this is case studies Tom it's great to have you back on the podcast and this time on a case studies podcast which is fantastic how have you been very well it's getting finally cool weather here in Houston so I'm happy the hot summers over how are you doing very well indeed yeah we're wetting wind in in the UK listeners of listening at the same time just getting released so we're talking today about peripheral artery disease and we're going to be covering all sorts in terms of his differentiation how you might suspect it how it's easily missed work up referrals and everything in between all wrapped around a case study which is going to be fantastic but I thought we'd start off with a good old fashioned definition so everyone we're all on the same page of what are we talking about when we talk about peripheral artery disease Tom so peripheral arterial disease is very common it's very common asymptomatically lots of people have atherosclerotic buildup in their arteries for various reasons which we can come on to when it comes to physios and carapractors and the like what we tend to think of as peripheral arterial disease is symptomatic peripheral arterial disease which tends to present as pain in the legs with exertion so when you go for walk James you're a physio so as you know your muscles move your calf muscles your thigh muscles and in order to work more your muscles need more blood they need blood to bring the oxygen and to take away all the metabolites of exercise usually that works very well if you have peripheral arterial disease then your heart is trying to pump that blood to your moving muscles but it can't get through because of all the atherosclerosis in your arteries so you do your exercise the muscles say we want oxygen and we want to get rid of all these metabolites let's get some more blood flow the heart is trying to get it there but it can't get past the narrowing of the arteries so the muscles begin to hurt you get essentially ischemic pain in the muscles so what this typically shows as is patients typically in the 50s and 60s will come to us and they'll say whatever I go for a walk it starts to hurt in my calf for example might be thigh but it starts to hurt in my calf after a certain amount of time and when I rest the pain subsides and all that's happening there is the patient is walking the muscles are working the heart is trying to get the blood there to support the muscles but because of the peripheral arterial disease the blood can't get there so you get this pain and the muscles as they're kind of gasping for oxygen and gasping for blood basically that's typically what we think of is peripheral arterial disease as I say it can be asymptomatic and it can also be much more symptomatic kind of critical limb ischemia and so on but what we're looking for like I say is that symptom pain and it's particularly important not only because those symptoms are bothersome because it's often a gateway or an early sign a warning sign let's say of more serious cardiovascular problems in the future for the patient really and I'm sure listen we're gonna talk about this in a minute but I'm just gonna say it anyway but listen to probably thinking potentially that those symptoms could sound just like someone's muscles fatiguing they could sound lots of other things as a physio we might think oh brilliant we can treat that we're gonna see you we're gonna set you these things and we're gonna see you again in two three four weeks and so on and so forth so we're gonna hopefully pick apart today how we might differentiate that so should we dive into the case tom should we get it started yeah as you say there can be confusing classic peripheral arterial disease textbook is actually quite clear and it it's often relatively unambiguous but in the case study that I presented physio network it was actually a mistake that I made thankfully a long time ago where I diagnosed a man in his late 50s with sciatica who the thought at me seeing sciatica everywhere but I diagnosed him with sciatica when in fact he did have peripheral arterial disease in the case study I go through all the details but the bottom line is that this chat turned up and he had what I just described which is whenever he walked 150 yards in this case he got this sort of vague cramping pain in his calf it forced him to stop and every time he stopped the pain went away so you get exertional and predictable pain of peripheral arterial disease those are the two key words for me exertional so it's not positional it's not based on stress it's just based on using the muscles typically walking of course and predictable so it's not like oh I have you know some days I can do great or you know some days it's fine while I'm exercising but it flares up afterwards no it's predictable most people will be able to say I can go three times around the block or I can get this far I'm a walk to work predictably comes on and predictably goes away when they stop so this chat described all the symptoms but what I was confused by was on top of those he also had some pretty normal symptoms of lower back pain in sciatica so we had the straight leg raised he had some loss of function signs and he himself said he thought he had sciatica because he'd had it in the past as well so I had my plastic sort of bias that we talk about I have my MSK hat on and I also was led by him mentioned not to bless and I am blaming him but he mentioned sciatica and I was like great I know what that is so we ran with that the upshot was that his musculoskeletal symptoms it took them fading away with time or maybe with my incredible treatment for it to be revealed that actually what was really bothering him was the calf pain that predictable exertional pattern and then we could go on with a bit more of an assessment to confirm that he had peripheral arterial disease. You lead us really nicely onto that and it is interesting to on this it took for the musculoskeletal symptoms to improve for them to be left with something else that became a little bit more clear so what when you went on to your objective or your assessment now so this is the point where these musculoskeletal sciatic-like symptoms have improved where did you go next with your assessment? Of course the most important thing is always the patient's background and the risk factors actually are really important and this is something I reflect on in the case study as I didn't really dig enough into those but in terms of the tools we have in clinic once we suspect peripheral arterial disease people talk about capillary refill they talk about checking skin quality and all those things are useful and do no damage but really for us the king is pulses pulses are king for the physiotherapist there's a million and one youtube videos on how to do those that I also always just kind of remember this four of them and the kind of vascular structure of the leg is there's one river and at the knee it splits into two rivers to the toes and you're you're testing at the top of the river the femoral pulse at the point where it splits for the popliteal pulse and then as you go to the toes you've got the dorsalis pedus and the tip post pulse there as well so I give a few kind of tips in the presentation about kind of how to find those and how to do them because for me it took a long time for that apparently quite simple confirmation to kind of click so that felt natural but check the pulses and confirm that these symptoms are exertional by bringing them on in clinic so go for a walk if you can but in this case we just did a heel raise test if your patient symptoms are sciatica just simply heel raising shouldn't really bring them on and especially if it does it they shouldn't the symptoms shouldn't subside immediately afterwards but in this case a heel raise test he said yep that's exactly what it is and the symptom subsided afterwards at that point you haven't really diagnosed prefer to your disease not always at your job most listeners won't do ankle, brachial, pressure index testing but that's really the next step whether via GP in this case sometimes will be a pathway to like a vascular specialist or clinic that will do it but that's what's going to call the shots it's still not perfectly sensitive or specific but that's going to call the shots if the blood pressure is lower in the legs relative to in the arms because that blood isn't getting through the only important exception there is diabetics who often they'll have calcified arteries so their blood pressure will actually be higher it's just always a neat thing to remember but the ABPI test is to check whether the blood pressure is indeed lower in the legs than it is in the arms 0.9 or below and then if the symptoms fit then the patient can be confirmed with that diagnosis and you can pat yourself on the back for doing a good job because actually this is one of those things that is quite consequential especially in the case study this was this chap's first inkling that he had any problems with his cardiovascular system and in fact knowing that making lifestyle changes getting treatment can be pretty consequential for the patient and prevent or delay pretty more serious events down the line. Are you struggling to keep up to date with new research? Let our research reviews do the hard work for you our team of experts summarise the latest and most clinically relevant research for instant application in your clinic so you can save time and effort keeping up to date click the link in the show notes to try physio networks research reviews for free today when you mentioned earlier Tom that you didn't dig deep enough into those risk factors talk through that walking hindsight now might have led you to today as the clincher you knew are today or has or recently what might have led you to suspect more to define what I mean there's obviously a long list of risk factors for peripheral or to your disease I always think try and limit it to what I call like the plaque five so it's like diabetes smoking high blood pressure high cholesterol and then like a previous cardiovascular event so like something going on with the brain or a schema car disease and those are maybe different lists but those if you can only remember five the five to remember but in the case study I kind of reflect on what was actually the problem was I just didn't really understand what I was asking about so I kind of it in the case study try to break down into more detail okay well I know that there was something called peripheral arterial disease but I didn't fully have the understanding of what it was and so what happened talking to this chap was I tried to do a checklist in my mind but I forgot to ask him if he was a smoker because I was doing a kind of bit of a naive checklist approach forgot to ask him if he was a smoker and in fact that should should have been the thing that the first appointment made me think okay there's definitely something potentially wrong with his vascular system because he'd been a heavy smoker since his teens right so in the case study I kind of argue that checklists are great but actually if we develop our understanding of these conditions then it's less likely that I would have forgotten such an obvious thing as to ask about smoking if I'd had a more holistic understanding of the vascular system really pretty so then going obviously there's those things there going back to that first presentation that first appointment what would you do differently now top apart from maybe switch onto that side of things a little bit maybe is there anything else do you think actually yeah this is this is how I play this one differently it was a case of the risk of repeating myself maybe putting on different kinds of hats a bit more of what they sometimes call systems thinking so at the time it was relatively new graduate and I was just thinking everything's MSK if it doesn't tick these red flag check checklists which of course isn't absolutely fine way to do things and everyone starts that way and I'm still some ways at that level and some with some aspects of practice but there's limits for example if you forget one of the boxes on the checklist because that's you're just trying to read in demonic in your head for example but also for example I would reflect that he had sent he did have symptoms of sciatica with the symptoms of pad but I didn't pause to discriminate between them okay so do these symptoms come on at different times do they have different acts in eases which is something I was kind of often think of this chap when I do that now I say okay so you're telling me about these two symptoms let's split them up and say what aggravates this one what eases this one and then the same questions for the other one and if I done that I didn't even need to have any knowledge really of vascular conditions to know that he was describing two quite different sets of eggs in eases quite two quite different symptom presentations and also ties is in essence when you did the objective assessment for your for the sciatica element side of it says yeah the positive straight leg raise would that symptom have been quite different to the one that he would have felt at so many minutes of walking good point yeah it would have been completely different if I'd asked him something like is that your pain is that why you have to see me today instead of again that kind of well it's technically positive which it was there's other things like so he had a loss of his Achilles reflex and some numbness on his knee which made me think okay nerve root but actually when you think about it the Achilles typically S1 knee sensation typically L4 that doesn't actually fit a picture of sciatica fits a picture of maybe he had sciatica in the past and maybe he's had any injury maybe should have picked up on those things so there's maybe it also his pain wasn't dermatoma so we talk a lot of rubbish about the dermatomes and how they're not perfect which they're not but actually it would have been useful to have thought at the time which I did not hang on this guy has just got like this kind of throbbing localized calf pain sciatica usually you'd think of it being a bit more dermatoma than that even if it doesn't look like it doesn't the textbook it's one of those case studies which I like it because there's quite a few things where you can look back and think hey actually I've got better at this job you do learn things that actually I'm just knowing these things about radiculopathy presentations dermatomes fast fuel system does make you a bit sharper thankfully in this case I delayed this chapscare by two or three weeks hopefully didn't do any harm in doing that but the other nice thing as I say about this particular area is it really helped him out I must admit I didn't follow it up with him but it at least put him in the right position to get care for potentially for hopefully preventing something more serious brilliant yeah it's I think it's great and I think a lot of the things you described there are things that we've probably always clinicians thought well actually that's exactly how I've done it in the past and actually I've done it more recently and I think everyone has been guilty of the straight leg raise being positive when the patient goes ow and not asking those those further questions I think something that's very very normal so new clinicians new grads listening to this this is part of the development of a clinician this is what we all go through so I think that's really important to highlight what do I need to gather what information is really important for me to get and who do I get it to and in what formats the best way of doing it I might sort of be repeating myself it's just about explaining why there's a reasonable suspicion with this chapter particularly the smoking explaining the symptoms in this case I was working in a GP practice so it was a fairly easy kind of referral to the GP for for that test the confirmed is his problem and from there he probably would have been referred to a fast killer specialist so I think it's just a case of summarizing summarizing everything I've said when the pulses as well being something that kind of proves you've done your work there and something for them to hang a hat on and and bring them in yeah so it's so intangible that's as useful for that that diagnosis so anything else I think in terms of leaving the listeners with things that you think this is real takeaway stuff what you'd say to some new grads or any clinician out there to that you've taken away from this how would you summarize your key key things some if I would go back and say myself rather than I don't know what advice to give everyone but if I say to myself it would be to learn your checklists for your red flags and use them because that's how to do your job but actually sit down and read some papers and textbooks about peripheral arterial disease and get to know it as a condition just like you kind of know what an ankle sprain is who knows what low back pain is but you kind of know what sciatica is get to know these red flag conditions because actually when you're going to make these decisions it's a case of saying hey this sounds like this thing that I know right because if you are going by a checklist it's never going to be quite right you need to kind of learn about this condition and how it works and how it presents and that's what I would say I think it's the same with a lot of things you know I was having to have a conversation at work today about quarter acquire for instance and not using just a checklist balance you understand what's going on therefore what you might see why you might see it rather than just thinking this this this must be that so I think understanding conditions understanding pathologies is quite important and useful and get you out of bind like with quarter acquire syndrome of you wondering all this person said that they they've got this problem when they're peeing that means they've got urinary dysfunction so what do I do but if you actually kind of have read a lot of case studies and maybe read a certain book about quarter acquire syndrome then you can say oh it actually doesn't sound anything like quarter acquire syndrome it just it sounds like they've got a UTI basically I don't try to be too preachy and but the last because the only thing I would say is all this stuff is actually very interesting too it's a very interesting and fun to learn about it and kind of enrich your day-to-day life too definitely definitely I think it genuinely makes our lives easier the better understanding we have of things allows us to be more investigative and potentially have a little bit more dare say fun with with our patients and and really think and get kind of our teeth into our patients so this has been brilliant really interesting and obviously listeners you can all get far more detail on this case study with with Tom's case study with physio network also mentioned the great master class that Tom's also done some time ago now but is still an absolute corker and I can't have Tom Jessen on the podcast without mentioning the great books that Tom's done on quarter acquire syndrome and sciatica they really are fantastic and have helped me a lot in my practice and help my team on a weekly basis for sure so I can't not say that Tom thank you so much for your time we're sure have you on the podcast and all the best and we'll speak to you soon thanks James appreciate it