In peripheral arterial disease (PAD), the arteries that supply your legs with blood are narrowed or blocked. The cause is usually atherosclerosis — deposits of fat, calcium and connective tissue in the artery wall, often called “hardening of the arteries”.¹,²
While you are sitting or standing, the blood supply is usually enough. When you walk, the muscles need considerably more oxygen — and that is exactly when the narrowing makes itself felt: the calf (less often the thigh, buttock or sole of the foot) starts to hurt, you have to stop, and after one or two minutes' rest you can carry on. Because people used to disguise these stops by pausing in front of shop windows, PAD is popularly known in German as the “shop-window disease”; the medical term is intermittent claudication (intermittent limping).²,³
PAD is more common than many people think: depending on the age group, around 3 to 10 per cent of adults are affected, and according to current knowledge roughly one in five people over 65. A large proportion of them have no typical symptoms — either because they unconsciously move less, or because nerve damage (polyneuropathy) dulls the pain.¹,²
Normal or a sign of disease? Muscle soreness comes the day after exertion and is tender to the touch. PAD pain, by contrast, is reproducible: it almost always appears after roughly the same walking distance, forces you to stop and goes away within a few minutes at rest — without you having to sit or lie down. This pattern is the most important distinguishing feature.¹,³
PAD is a warning sign for the entire vascular system. Anyone with hardened leg arteries very often also has narrowed coronary and neck arteries. The risk of a heart attack and stroke is clearly increased. That is why treatment is never just about the legs, but always about your overall cardiovascular risk.¹,⁴
2. Stages: from no symptoms to critical ischaemia
In German-speaking countries, PAD is divided into four stages according to Fontaine, and internationally also according to Rutherford. The classification helps determine how urgently treatment is needed.¹,³
Stage I — no symptoms: The arteries are measurably narrowed, but you notice nothing. It is usually discovered by chance, for example through a poor ankle-brachial index. Treatment is still needed — because of the cardiovascular risk.
Stage II — pain on exertion (claudication): Pain when walking that eases at rest. Subdivided into IIa (pain-free walking distance over 200 metres) and IIb (under 200 metres). More important than the number of metres, however, is how much it limits you in everyday life.
Stage III — pain at rest: Pain even without exertion, typically at night when lying down, in the forefoot or toes. Many people let the leg hang out of bed because gravity improves the blood flow.
Stage IV — wounds or dead tissue: Poorly healing wounds, black toes or open sores on the foot.
Today, stages III and IV are grouped together as chronic limb-threatening ischaemia (CLTI). They are not simply an “advanced version” but an emergency in their own right with a high risk to the leg — here a vascular centre promptly assesses whether the artery can be reopened.¹,⁴
Not to be confused with: acute arterial occlusion. If a leg suddenly becomes painful, pale, cold, weak or numb, an artery may have become acutely blocked — for example by a clot from the heart in atrial fibrillation. This is an emergency: call 112 (emergency number in Germany) immediately. To save the leg, hours count, not days.¹,³
3. Symptoms and consequences
Typical symptoms
Cramping, pulling or burning calf pain when walking, especially uphill or at a brisk pace
The pain disappears after one to three minutes of standing still — you do not need to sit down
Cold feet, pale or bluish skin, a temperature difference between the two sides
Thin, shiny skin, slower nail growth, less hair on the lower leg
Wounds on the foot or lower leg that do not heal for weeks
Where it hurts reveals the level
The pain is usually felt one level below the narrowing:¹,³
Pelvic type: Pain in the buttock, hip or thigh. In men, erectile dysfunction can also occur.
Thigh type: Calf pain — the most common variant.
Lower-leg type: Pain in the sole of the foot and the foot. Particularly common in type 2 diabetes.
Possible consequences
Without treatment, the walking distance often shrinks slowly over years — many people adapt their everyday life without noticing and think they have “just got out of shape”. The serious consequences are poorly healing wounds, in the worst case the loss of toes or the foot, and a loss of independence due to restricted mobility. Statistically, however, the heart matters more than the leg: most people with PAD are more likely to have a cardiovascular event over time than an amputation.¹,²,⁴
4. Causes and risk factors
Smoking: by far the strongest risk factor. Smoking speeds up atherosclerosis, worsens the walking distance and clearly increases the risk that a bypass or stent will close up again.¹,⁴
Diabetes mellitus: damages small and large blood vessels. The lower-leg arteries are affected particularly often; in addition, nerve damage can suppress the warning pain.¹,²
High blood pressure: puts the inner lining of the arteries under constant mechanical stress. See also high blood pressure.
Lipid metabolism disorder: above all high LDL cholesterol and lipoprotein(a). More on this under lipid metabolism disorder.
Age and family history: The risk rises noticeably from around the age of 50; relatives affected at a young age increase it further.
Chronic kidney disease: encourages vascular calcification, often with marked calcification of the artery wall (medial sclerosis). See chronic kidney disease.
Lack of exercise and excess weight: amplify all the other risk factors and hinder the formation of collaterals — the body's natural bypass circuits.
Rare causes: inflammation of the blood vessels, thromboangiitis obliterans (almost exclusively in young smokers) or mechanical compression of the artery behind the knee. These are considered above all when the person is young and classic risk factors are missing.¹,³
Medicines as a contributing factor: PAD is practically never caused by medicines alone, but some can worsen or mask the symptoms. These include vasoconstricting ergot preparations (ergotamine) for migraine, excessive fluid removal with high-dose diuretics, and painkillers that mask beginning rest pain or a pressure sore on the foot. So mention new leg symptoms after a change in medication — background in the guide Medication side effects.³,⁵
5. Diagnosis: how PAD is detected
In most cases the diagnosis can be made without elaborate equipment — a conversation, a physical examination and a simple blood pressure measurement on the arm and ankle are often enough.¹,²
Medical history: How far can you walk without pain? Where exactly is the pain? Does it go away when you stand still? Are there risk factors, wounds or pain at night?
Examination: Feeling the foot pulses on both sides, listening to the groin and knee arteries for flow noises, assessing skin colour, temperature, hair growth and wounds — including between the toes.
Ankle-brachial index (ABI): the central basic test. The blood pressure at the ankle is divided by that at the upper arm. Values below 0.9 indicate PAD, values below 0.5 a critical reduction in blood flow.
Exercise test: treadmill test or standardised walking test. It measures the walking distance objectively and reveals PAD that does not show up at rest.
Duplex ultrasound: ultrasound with flow measurement. Shows the location, length and severity of the narrowing — without radiation and without contrast agent.
Imaging with contrast agent (MR, CT or catheter angiography): usually only once a procedure is actually being planned.
Laboratory tests: LDL cholesterol, long-term blood sugar HbA1c, kidney values and blood count — as the basis for treating risk factors. Help with interpreting them in the guide Understanding blood values.
A normal ABI does not reliably rule out PAD. In long-standing diabetes or kidney disease, the artery walls are often so stiff that they can hardly be compressed. The value is then falsely high — values above 1.3 are considered unusable. In this case, toe pressure measurement, ultrasound or a measurement after exercise help.¹,⁴
What else can be behind leg pain: narrowing of the spinal canal or a herniated disc (here the pain typically only eases when you bend forward or sit down, not when you stand still), osteoarthritis of the hip or knee, varicose veins with a feeling of heaviness, or thrombosis with swelling on one side.²,³
6. Treatment: what really helps
Treatment rests on three pillars: reducing risk factors, walking exercise and medicines to protect the blood vessels. For pain on exertion, a procedure is only considered once this foundation has been followed consistently for several months and everyday life is still severely restricted. It is different with pain at rest or wounds — here it is checked immediately whether the artery can be reopened.¹,⁴
FoundationNon-drug treatment — the basis of every treatment
Stopping smoking
The single most effective measure of all. It slows progression, improves the walking distance and clearly lowers the risk of re-occlusion after a stent or bypass. Support through counselling, behavioural therapy programmes and — after discussion with your doctor — nicotine replacement or medicines noticeably increases the success rate.¹,⁴
Structured walking exercise
First-line treatment in stage II. According to current knowledge, training on at least three days a week for 30 to 60 minutes is recommended, consistently for at least three months. You walk until you are close to the pain threshold, rest until it subsides, then carry on. Supervised programmes work better than advice alone — in many regions there are vascular exercise groups.¹,²
Diet and weight
A Mediterranean diet with plenty of vegetables, pulses, olive oil, nuts and fish, and little processed meat and sugar. It works mainly through blood pressure, blood sugar and blood lipids — practical tips in the guide Lowering cholesterol.
Foot care and footwear
Check your feet and the spaces between your toes every day, wear well-fitting shoes that do not rub, trim your nails carefully, and with diabetes ideally have professional medical foot care. With poor blood flow, small injuries heal badly and quickly turn into a bigger problem.¹,⁶
The most common mistake in walking exercise: stopping too early. The stimulus for new bypass vessels to form arises precisely in the phase just before the pain threshold. So the aim is not to avoid the pain, but to allow it in a controlled way and then take a short break. What to bear in mind when exercising while taking medicines is covered in the guide Medications and exercise.
7. Medicines for PAD
Important to understand: most medicines for PAD do not directly lengthen your walking distance. They stabilise the deposits in the arteries and lower the risk of heart attack, stroke and leg complications. That is why they are usually taken long term — even when you feel well.¹,⁴
First lineVascular protection — for practically everyone affected
Statins
For example atorvastatin or rosuvastatin. PAD counts as a condition with very high vascular risk; according to the guideline, the aim is an LDL cholesterol below 55 mg/dl and at least a halving of the starting value. If the statin is not enough, ezetimibe can be added.⁴,⁷
Antiplatelet medicines
Aspirin 100 mg or clopidogrel 75 mg daily — in symptomatic PAD, current guidelines often favour clopidogrel. Both are given long term and on their own; a combination is only intended in special situations and for a limited time.¹,⁴
Blood pressure medicines
ACE inhibitors such as ramipril or sartans such as candesartan are considered the preferred drug classes in PAD with high blood pressure. The target value is set individually and is usually below 140/90 mmHg.¹,⁴
Diabetes treatment
In type 2 diabetes, alongside metformin, active substances with a proven vascular benefit are increasingly used, such as empagliflozin or semaglutide. The choice is made by the treating practice based on kidney function, heart health and weight.⁴
Second lineWhen the risk remains high despite basic treatment
Low-dose rivaroxaban plus aspirin
Rivaroxaban 2.5 mg twice daily in addition to aspirin 100 mg can lower leg complications and cardiovascular events in selected people at high risk — for example after vascular surgery or with extensive disease. The price is a higher risk of bleeding, which is why benefit and risk are weighed up individually.⁴
Cilostazol
The only medicine for which a relevant increase in walking distance has been shown — but with clear restrictions and contraindications. Details in the next section.¹,²
Painkillers in critical ischaemia
With pain at rest, effective pain relief is part of the treatment — but it never replaces checking whether the artery can be reopened. Newly occurring pain at rest should always be assessed by a doctor promptly.¹
Never stop vascular medicines on your own. After stopping antiplatelet medicines or statins, the risk of heart attack, stroke and arterial occlusion rises measurably — often within a few weeks. Before operations or dental procedures, too: do not pause them yourself, discuss the approach first. How a planned discontinuation works safely is explained in the guide Stopping medications; for procedures, see Medications before surgery.¹,⁴
Watch out for signs of bleeding. Small wounds that keep bleeding for an unusually long time, bruises for no reason, black stools or reddish urine should be checked by a doctor. This applies especially in combination with painkillers from the NSAID group such as ibuprofen. Everyday tips in the guide Living with blood thinners.
Long-term protection only works without gaps
brite reminds you to take your vascular medicines at the right time — even on days when you feel completely well.
8. Cilostazol, naftidrofuryl & ginkgo: what circulation boosters achieve
Hardly any area of PAD treatment is as shaped by expectations as the question of a “medicine for better circulation”. An honest look at the evidence:
Cilostazol: blocks an enzyme (phosphodiesterase 3), widens blood vessels and inhibits the platelets. Studies show a moderate increase in pain-free walking distance. Common side effects are headache, palpitations and diarrhoea; it must not be used in heart failure. It is broken down by liver enzymes, which is why interactions are possible with omeprazole, some antibiotics and antifungals, among others. In Germany it tends to be prescribed cautiously, and usually only once walking exercise has been fully exploited.¹,²
Naftidrofuryl: used in some European countries to increase walking distance. The evidence is limited and the effects are smaller than those of structured walking exercise.²
Pentoxifylline: widely used for a long time, but by today's evidence the benefit is small at best. Guidelines no longer recommend it routinely.¹,²
Ginkgo and dietary supplements: The evidence on walking distance is weak and inconsistent. More relevant is an often overlooked risk: ginkgo, high-dose fish oil, vitamin E or garlic preparations can increase the tendency to bleed when combined with antiplatelet medicines. Background in the guide Supplements and medications.²,⁵
Infusions with prostanoids: reserved for special situations in critical ischaemia when the artery cannot be reopened.¹
The honest comparison. No medicine achieves for walking distance what consistent walking exercise plus stopping smoking achieve over three months. Medicines complement this foundation — according to current knowledge, they do not replace it.¹,⁴
The beta-blocker myth. For a long time there was a warning that beta-blockers such as metoprolol or bisoprolol would worsen blood flow to the legs. According to current evidence, this no longer applies across the board: if you also have coronary heart disease or heart failure, the benefit usually clearly outweighs the risk. So do not stop a beta-blocker because of your PAD — mention any symptoms instead.³,⁴
9. Catheter, stent or bypass: when a procedure is needed
Reopening the artery (revascularisation) is usually considered if:¹,⁴
everyday life remains severely restricted despite several months of consistent basic treatment,
there is pain at rest or wounds are not healing (critical ischaemia — here without waiting),
the narrowing is technically easy to reach and a realistic benefit can be expected.
The options are widening the artery with a balloon catheter, if necessary with a stent or a drug-coated balloon, and bypass surgery using one of your own veins or a synthetic graft. Which procedure is suitable depends on the location and length of the blockage, the condition of the arteries further down and any other conditions.¹,⁴
After a procedure, antiplatelet treatment is often stepped up for a limited period — for example as a combination of two medicines for a few weeks to months. This time window is crucial, but it often gets muddled in everyday life because the plan changes several times between hospital and practice. So write down which medicine applies for how long, and compare it at every appointment. A template is provided in the guide Create a medication plan.¹,⁵
A stent does not fix the cause. Without stopping smoking, a statin, antiplatelet medicine and exercise, widened sections close up again considerably more often. The procedure buys quality of life — the basic treatment preserves it.¹,⁴
10. Everyday life with PAD
Fixed walking times instead of good intentions: Three fixed slots a week in your calendar work better than “a little more every day”. A route with familiar benches makes the breaks plannable.
Daily foot check: Look at the soles of your feet and between your toes — with a hand mirror if necessary. Any new wound, blister or discolouration should be seen by your practice promptly, especially with diabetes.¹,⁶
No direct heat: Hot-water bottles, heating pads or hot foot baths are risky with poor blood flow and reduced sensation — burns are noticed too late. Better: warm socks.³,⁶
Keep your legs low at night: With pain at rest, slightly lowering the foot end or raising the head end of the bed a little often eases the symptoms more than raising the legs.³
Watch out for interactions: Over-the-counter painkillers and cold remedies as well as supplements can affect blood pressure and the risk of bleeding. Check briefly before you buy — see Drug interactions.
Sorting out many medicines: Statin, antiplatelet, blood pressure and diabetes medicines quickly add up. Help is available in the guide Polypharmacy.
Prepare for travel: Take enough supply, keep your medicines in your hand luggage, and get up regularly on long flights. Details in the guide Medications when travelling.
Make good use of appointments: Note down your current pain-free walking distance, any changes and open questions beforehand — this makes the course comparable. Preparation tips in the guide Prepare for a doctor's appointment.
11. How brite helps you with PAD
With PAD, long-term treatment decides what happens to your heart, brain and legs — and it consists of several tablets that work quietly in the background. Because you feel no effect, taking them can easily slip. brite keeps your plan together, reminds you reliably and makes changes visible.
Pill reminder — statins, antiplatelet medicines and blood pressure medicines only work if you take them without gaps. brite reminds you at the right time, even when you feel completely free of symptoms. Set up a reminder
Interaction check — painkillers, ginkgo or fish oil on top of an antiplatelet medicine can increase the tendency to bleed. Check new products before you take them. Check now
Health journey — record your walking distance, blood pressure and LDL values over time. At your next appointment you will see in black and white whether exercise and treatment are working. Track your progress
Digital medication plan — after a stent or bypass, antiplatelet treatment often changes for a limited time. Your current plan is always at hand for the vascular practice, GP practice and hospital. Go to the medication plan
Walking distance, blood pressure and LDL in one record
Note your progress over time and take it to your next appointment — free with brite.
The underlying atherosclerosis does not regress, but its progression can be slowed effectively. Many people improve their walking distance so much through exercise and treatment of risk factors that they are hardly restricted in everyday life any more. So the goal is not a cure, but stability and mobility.¹,²
The first progress usually shows after four to eight weeks, the full effect after about three months of regular training. Consistency is what matters: three sessions a week achieve more than one long walk at the weekend. After a break, the gains are lost again fairly quickly.¹
With pain on exertion in stage II, controlled walking until you are close to the pain threshold is expressly encouraged and does not harm the tissue. It is different with pain at rest or open wounds — here you should rest the leg until the situation has been assessed by a doctor. If you are unsure, ask your practice to explain the approach.¹,²
With existing PAD, stricter target values apply than for healthy people, because the vascular risk is already very high. According to the guideline, the aim is an LDL cholesterol below 55 mg/dl. Statins also stabilise the deposits in the artery wall — this effect is independent of the starting value.⁴,⁷
Values between 0.75 and 0.9 are considered a mild reduction in blood flow, values of around 0.5 to 0.75 a moderate one. A value of 0.7 therefore indicates confirmed PAD with a relevant narrowing, but without any acute danger to the leg. Your symptoms and the ultrasound findings are also decisive for the next steps.¹
No, according to current knowledge this once widespread rule no longer applies across the board. In heart disease, the benefit of beta-blocker treatment usually clearly outweighs the risk. If you notice a markedly shorter walking distance while taking one, mention it instead of stopping the medicine yourself.³,⁴
The evidence is limited, and the measured effects on walking distance are small and inconsistent. At the same time, ginkgo can increase the tendency to bleed when combined with antiplatelet medicines or anticoagulants. So discuss herbal products with your practice or pharmacy before taking them.²,⁵
Statins and antiplatelet medicines are usually intended to be taken permanently, because their protection only lasts as long as you take them. After stopping, the risk of heart attack, stroke and arterial occlusion rises again. Dose and choice may change over time — this decision is always made by the treating practice.¹,⁴
German S3 guideline on the diagnosis, treatment and follow-up care of peripheral arterial disease (Deutsche Gesellschaft für Angiologie – Gesellschaft für Gefäßmedizin, AWMF reg. no. 065-003, 2015 version; revision announced) — German source. awmf.org
Gesundheitsinformation.de, German Institute for Quality and Efficiency in Health Care (IQWiG): Peripheral arterial disease (PAD) — German source. gesundheitsinformation.de
ESC Guidelines for the management of peripheral arterial and aortic diseases (European Society of Cardiology, 2024). escardio.org
Deutsche Gesellschaft für Angiologie (DGA, German Society of Angiology): Patient information on vascular diseases — German source. dga-gefaessmedizin.de
gesund.bund.de, the national health portal of the German Federal Ministry of Health: Peripheral arterial disease — German source. gesund.bund.de
ESC/EAS Guidelines for the management of dyslipidaemias (European Society of Cardiology / European Atherosclerosis Society, 2019). escardio.org
Living with PAD, with your plan always up to date — with brite
Reminders, interaction check and your current medication plan in one place. Free.
Medical disclaimer: This article is for general information and does not replace medical advice, diagnosis or treatment. A suddenly painful, pale, cold or weak leg is an emergency — in this case, call 112 (emergency number in Germany) immediately. Newly occurring pain at rest and wounds on the foot that do not heal should be assessed by a doctor straight away; antiplatelet medicines and statins must not be stopped on your own. The choice of medicine and its dose is always set individually by the treating practice. Last updated: October 2026.
