Exercise guide
If your legs ache when you walk and the pain goes when you stop, walking is also the treatment. The National Institute for Health and Care Excellence (NICE) recommends a supervised exercise programme for everyone with this leg pain (intermittent claudication) from peripheral arterial disease (PAD). In trials, regular walking added about 82 metres before the pain started and 120 metres to the furthest people could walk.
This guide explains the walk-rest-walk method, how much pain to walk into (the guidelines differ a little), how often and for how long, what to do if you can't get to a class, other exercise if walking isn't possible, looking after your feet, and the red flags that need urgent help. It includes a follow-along walking session.
NICE says to "offer a supervised exercise programme to all people with intermittent claudication", and the European Society of Cardiology (ESC) gives supervised exercise training its strongest recommendation. The NHS calls walking one of the best exercises you can do.
In 32 trials with 1,835 people, exercise programmes added about 82 metres to how far people could walk before the pain started, and about 120 metres to how far they could walk in total, with gains seen for up to 2 years. Supervised programmes did better than exercising at home without support.
Walk until the pain is close to as bad as you can bear, rest until it goes, then walk again. Keep going until you've walked for at least 30 minutes in total, several times a week.
NICE and the NHS say walk to near-maximal pain. The ESC says moderate to severe pain gives the best results, but milder pain also helps, so it recommends a flexible approach. Walking only at a comfortable, pain-free pace didn't help in one large trial.
An NHS physiotherapy service's advice is that exercising with the pain won't make your circulation worse. Exercise doesn't clear the narrowing itself: the gains come from your leg muscles and the small blood vessels around it.
A leg or foot that suddenly turns cold, pale or blue, numb, weak or very painful is an emergency: call 999 (911 in the US). Pain in your foot at rest, wounds that won't heal, or toes that turn cold and numb, then red or black, need a GP immediately.
PAD is a common condition where a build-up of fatty deposits in the arteries restricts the blood supply to the leg muscles. Many people have no symptoms. It's a form of cardiovascular disease, the same process that narrows the arteries to the heart and brain.
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The commonest symptom is an ache in the legs when you walk that goes after a few minutes' rest. It's usually in the calf, but can be in the thigh, hip or buttock, in one or both legs.
Hair loss on the legs and feet, numbness or weakness, brittle toenails that grow slowly, sores that don't heal, skin turning paler or blue, shiny skin, erectile dysfunction in men, and shrinking leg muscles. Symptoms that come on quickly or suddenly get worse can be a sign of a serious problem that needs treating straight away.
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About 113 million people aged 40 and over worldwide have PAD, and it becomes much more common with age, reaching about 15% of people in their early 80s. Claudication affects about 4.5% of people over 40.
Smoking is the most significant risk factor, along with diabetes, high blood pressure, high cholesterol and getting older. PAD makes heart attacks and strokes more likely: each year, about 1 in 20 people with PAD has a heart attack or stroke or dies, which is why treatment protects your heart and brain as well as your legs.
Most people's claudication stays the same or improves (about 75%). About 1 to 2 in 100 people with PAD a year develop critical limb ischaemia, where the leg doesn't get enough blood even at rest.
The ankle blood pressure test didn't change in trials, so exercise doesn't unblock the artery. The gains are thought to come from the leg muscles using oxygen better, and from smaller blood vessels around the narrowing enlarging to carry more blood.
Leg pain on walking has other causes, such as a narrowed spinal canal (spinal stenosis), which is managed differently. See a GP if you get recurring leg pain when you exercise, and see our spinal stenosis guide for the difference.
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In the oldest age groups, PAD is more common in women. Women more often have PAD without typical claudication, and some studies found women gained less from supervised exercise, but others didn't; the ESC calls the data scarce. Women benefit from exercise too.
A Cochrane review of 32 trials (1,835 people) found exercise programmes increased pain-free walking distance by about 82 metres and maximum walking distance by about 120 metres (high-quality evidence), with gains for up to 2 years. They didn't change the ankle blood pressure test, and showed no effect on amputation or death. Quality of life improved modestly.
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Across 21 trials (1,400 people), supervised exercise added about 120 metres more than home exercise (moderate quality) and about 210 metres more than walking advice (high quality). Home exercise without close structure did no better than advice. About 80% of people kept to their programmes, and no deaths were caused by the exercise.
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Home walking works better with structure and support. A group-supported home walking programme added 53.5 metres to the 6-minute walk in 194 people, and a UK programme run by physiotherapists added 16.7 metres in 190 people. The ESC's exercise experts report that monitored home training can match supervised training, while a programme of activity tracking and phone coaching alone didn't help.
In a trial of 305 people walking at home for a year, walking that brought on moderate to severe leg symptoms added 34.5 metres to the 6-minute walk, while walking at a comfortable pace without symptoms didn't help. But in the only 2 small trials that compared supervised programmes directly, pain-free and moderate-pain walking gave similar gains. That's why the ESC now recommends a flexible approach.
The ESC says vigorous training (77% to 95% of maximum heart rate, or 14 to 17 on the 6 to 20 Borg scale of effort) gives the best gains in walking and fitness, starting at a low to moderate effort and building up if you manage it well.
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In 10 trials (527 people), cycling, leg strength training, arm cranking and Nordic walking did about as well as supervised walking, though the certainty is low. The ESC recommends them when walking isn't an option.
In a Cochrane review of 10 trials, angioplasty or stenting gave no clear advantage over supervised exercise for walking or quality of life. Adding a procedure to exercise reduced the need for repeat procedures.
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The NHS: "walk as far and as long as you can before the symptoms of pain become intolerable. Then rest until the pain goes. Begin walking again until the pain returns. Keep using this 'stop-start' method until you've spent at least 30 minutes walking in total. Do this several times a week." The Circulation Foundation calls it walk-rest-walk.
The ESC recommends at least 3 sessions a week of at least 30 minutes, for at least 12 weeks. NICE's supervised programmes are about 2 hours a week for 3 months. After that, the NHS says aim to exercise every day for the rest of your life, because the benefits are quickly lost if exercise isn't frequent and regular.
Exercise specialists use a claudication pain scale from 0 (no pain) to 4 (severe pain). The wording for the steps between is ours: 1, the pain is just starting; 2, mild; 3, moderate. Our editorial target, which reconciles the guidelines, is to walk until the pain reaches 3 or 4, then rest until it's back to 0.
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The ESC suggests increasing the challenge every 1 to 2 weeks, as you can manage it. How is up to you: walk a little faster, add a gentle slope, or walk for longer before you stop (our suggestion).
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NHS physiotherapists suggest keeping a record of your exercise. Note how far or how long you walk before the pain starts, and your total walking time, so you can see your progress.
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Choose a flat, safe route with places to stop, or use a treadmill. Wear comfortable, well-fitting shoes, and if you have diabetes, check your feet afterwards.
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NICE says to encourage exercise "to the point of maximal pain", and the NHS says to walk until the pain becomes intolerable. The ESC guideline says exercising to moderate to severe pain "may be considered", that improvements can also come with milder pain, and that a flexible approach is recommended, partly because a lot of pain can put people off.
Walking into moderate to severe leg symptoms improved walking in a large home trial, and walking with no symptoms didn't. Two small supervised trials found pain-free and moderate-pain walking about as good as each other. No trial has compared walking to maximal pain with walking to moderate pain.
Walk until the pain is close to the worst you can bear (3 or 4 on the 0 to 4 scale), as the UK guidance says. If you can't face that, walking into a moderate level of pain still helps. Walking at a comfortable pace without any pain still counts as exercise for your heart, but may not improve how far you can walk.
"Exercising with pain will not make your arterial circulation worse", say NHS physiotherapists. In supervised programmes, no deaths were caused by the exercise. Claudication pain eases within a few minutes when you stop.
Walk-rest-walk: walk until the pain reaches 3 or 4 out of 4, rest until it has gone, and repeat until you've walked for 30 minutes in total, at least 3 times a week. On a treadmill, use the handrails only to step on and off; a slope makes it harder.
Start with 1 minute of each and build up as you can (NHS Ayrshire & Arran physiotherapy). Hold the calf stretch for 20 seconds and repeat.
3D demoSlow calf raiseBeginner · A wall
3D demoAnkle circlesBeginner · No equipment
3D demoLow step-upBeginner · A step
3D demoTandem stance and heel-to-toe walkBeginner · A wall
3D demoStanding marchBeginner · No equipment
3D demoSit to stand from a chairBeginner · A bench or box
3D demoWall calf stretch (gastrocnemius)Beginner · A wallWhen supervised classes aren't available, the ESC recommends a structured home programme that is monitored, for example with phone calls, a logbook or an activity tracker. Its exercise experts add that home programmes work best with support to change habits.
Walking 5 days a week for up to 50 minutes, into moderate to severe leg symptoms, with an activity monitor and weekly coaching calls; weekly group meetings on keeping track, coping with leg pain during exercise and getting past barriers; and a physiotherapist using a motivational approach.
Ask your GP, practice nurse or vascular team. Scotland's NHS pathway says nurse-led claudication clinics should offer access to supervised exercise, and some NHS physiotherapy services refer people to structured classes at leisure centres.
When walking isn't an option, for example with a foot wound or joint problems, the ESC recommends strength training, arm cranking (an arm-pedalling machine in a gym or rehabilitation unit), cycling or a mix. These did about as well as walking in trials, though the evidence is low certainty.
According to the ESC's exercise experts, heavier leg strength training (about 80% of the most you can lift once) improved walking more than lighter training. At home, the NHS circuit of heel raises, step-ups and sit-to-stands is a good start.
Diabetes UK advises taking the weight off a foot with a new problem until it's been seen. Our editorial advice: avoid walking for exercise on a foot wound until your foot team agrees, and use a bike or arm exercise instead.
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Cycle for 30 minutes or more, at least 3 times a week, as with walking. For strength, start with 2 sets of 8 to 12 (our editorial starting point), breathing out on the effort.
3D demoStationary cyclingBeginner · Cardio machine
3D demoLeg pressBeginner · Strength machine
3D demoDumbbell goblet squatIntermediate · A dumbbell
3D demoSeated bent-knee calf raise (soleus raise)Beginner · A bench or box
3D demoSingle-leg calf raise from a stepIntermediate · A step + A wall
3D demoSingle-leg standBeginner · A wallUse the claudication walking workout for your main walking sessions, at least 3 times a week. The leg and balance workouts build strength on other days, and the chair workout is for days when walking isn't possible.
The walk-rest-walk session for leg pain from narrowed arteries: walk until the pain is close to the most you can bear, rest until it goes, repeat to 30 minutes.
45 minBeginner8 movesA wall, Cardio machineA gentle leg strength routine with no jumping: sit-to-stands, step-ups, wall sits, bridges and calf raises.
20 minBeginner7 movesA bench or box, A stepA 40-minute strength and balance session for over-65s, built from the Otago home programme and NHS exercises, using a chair, a counter and a step.
40 minBeginner18 movesA bench or box, Something with weightA 10-minute routine for straight after a meal: an easy walk, a few simple standing moves from blood sugar trials, then a short walk to finish.
10 minBeginner6 movesCardio machine, A bench or boxA 45-minute home session built like a UK cardiac rehab class: a 15-minute warm-up, 20 minutes of cardio mixed with light strength, and a 10-minute cool-down.
45 minBeginner14 movesA wall, A bench or boxA 20-minute seated workout for older adults who cannot stand for long: marching, leg and arm strength, posture, and sit-to-stands that lead back to standing.
20 minBeginner11 movesA bench or box, Something with weightSwap the plan's walks for the claudication walking workout.
The Circulation Foundation calls stopping smoking the most important treatment for PAD: after 5 years, people who stop are twice as likely to be alive, and less likely to need an amputation, than people who carry on. People who keep smoking are very unlikely to be offered surgery for claudication. Your GP or a stop smoking service can help you quit.
People with PAD are usually offered a statin to lower cholesterol and a medicine to prevent clots, such as aspirin or clopidogrel, with high blood pressure and diabetes treated too. These protect your heart and brain as well as your legs. Exercise and medicines work together.
Supervised programmes start with a health check. Slow down or stop, and talk to your doctor, nurse or physiotherapist before exercising again, if you get very short of breath or dizzy, a pounding or racing heart, extreme tiredness, chest pain or blurred vision, and don't exercise with a cold, flu, sore throat, infection or temperature. Call 999 for chest pain that feels tight or spreads to your arms, neck or jaw.
NICE offers angioplasty for claudication only when supervised exercise hasn't helped enough and scans show it's suitable. If you do have a procedure, the ESC recommends supervised exercise afterwards too.
People with PAD and diabetes tend to have more severe disease and are 5 to 10 times more likely to need a major amputation. With diabetes, a normal ankle test doesn't rule PAD out.
Check your feet every day, morning and bedtime, using a mirror or asking someone to help. Wear shoes that fit well (wide, deep and rounded at the toes, with a flat or low heel and laces or a buckle), check inside them before you put them on, and break new shoes in at home for 20 to 30 minutes at a time. Moisturise, but not between your toes, cut your nails carefully, don't use corn plasters or blades, and go to your yearly foot check.
A new cut, blister or wound, a red, hot or swollen foot, or new foot pain needs seeing by your foot protection team or GP within 24 hours: the full list is in the warning signs below.
If you think you're developing critical limb ischaemia:
See your foot protection team or GP within 24 hours, or an out-of-hours service if they're closed, and keep the weight off the foot meanwhile, if you notice:
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See a GP if you get recurring leg pain when you exercise. The NHS says many people mistakenly think this is just part of getting older. Symptoms that come on quickly or suddenly get worse can be serious and need treating straight away.
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Slow down or stop, and speak to your doctor, nurse or physiotherapist before exercising again, if you get:
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"Exercising with pain will not make your arterial circulation worse." Walking to near-maximal pain is what NICE recommends, and no deaths in supervised programmes were caused by the exercise.
Rest eases the pain at the time, but walking is the treatment: programmes added about 82 metres of pain-free walking and 120 metres of total walking in trials. The NHS says aim to exercise every day for life.
It doesn't: the ankle blood pressure test didn't change in trials. The gains come from your leg muscles and the circulation around the narrowing adapting.
In a 305-person trial, walking at a comfortable pace without leg symptoms didn't improve walking, while walking into moderate to severe symptoms did. Two small trials found pain-free supervised walking about as good as moderate-pain walking, so the ESC recommends a flexible approach: some pain is better than none if you can manage it.
For claudication, angioplasty or stenting gave no clear advantage over supervised exercise for walking or quality of life. NICE offers angioplasty only when exercise hasn't helped enough, and exercise is still recommended after a procedure.
The NHS says many people mistakenly think so. Recurring leg pain on exercise needs a GP check: PAD is a sign of narrowed arteries, and about 1 in 20 people with it has a heart attack or stroke or dies each year.
Trials found gains for up to 2 years, but the NHS says the benefits are quickly lost if exercise isn't frequent and regular. Keep walking for life.
Walking. NICE recommends a supervised exercise programme for everyone with intermittent claudication, and the European Society of Cardiology gives supervised exercise training its strongest recommendation. In 32 trials, exercise added about 82 metres of pain-free walking and about 120 metres to the total distance people could walk.
Walk until the leg pain is close to the worst you can bear, stop and rest until it has gone completely, then walk again. Keep repeating until you've walked for at least 30 minutes in total, and do it several times a week.
At least 3 sessions a week of 30 to 60 minutes, for at least 12 weeks; NICE's supervised programmes are about 2 hours a week for 3 months. After that, the NHS says aim to exercise every day for life, because the benefits are quickly lost if you stop.
The guidelines differ. NICE and the NHS say walk until the pain is close to the most you can bear, while the European Society of Cardiology says moderate to severe pain works best but milder pain still helps, and recommends a flexible approach. Walking only at a comfortable pace with no symptoms didn't improve walking in one large trial.
No. NHS physiotherapists say exercising with the pain won't make your circulation worse, and no deaths in supervised programmes were caused by the exercise. Pain in your foot at rest, wounds that won't heal or toes changing colour are different: contact a GP immediately.
NICE's supervised programmes run for 3 months, and the European Society of Cardiology recommends at least 12 weeks, making the walks a little harder every 1 to 2 weeks. In trials, gains in walking distance were seen for up to 2 years.
Usually: supervised exercise added about 120 metres more than home exercise and about 210 metres more than walking advice alone. If you can't get to a class, a structured home programme with monitoring, such as a diary, an activity tracker or regular calls, is the next best option. Ask your GP or vascular team about local classes.
Cycling, arm cranking and leg strength training did about as well as walking in a Cochrane review, though the evidence is low certainty, and the European Society of Cardiology recommends them when walking isn't an option. With a foot wound, avoid walking for exercise until your foot team agrees, and use a bike or arm exercise instead.
No. The ankle blood pressure test didn't change in trials. Exercise helps your leg muscles use oxygen better and helps smaller blood vessels around the narrowing carry more blood.
For claudication, angioplasty or stenting didn't give clearly better walking or quality of life than supervised exercise, and NICE offers angioplasty only when supervised exercise hasn't helped enough. Severe symptoms and critical limb ischaemia are different and need a vascular team.
Check your feet every day, wear well-fitting shoes, and get any new wound, blister, colour change or swelling seen by your foot team or GP within 24 hours. With diabetes, PAD tends to be more severe and major amputation is 5 to 10 times more likely, and a normal ankle test doesn't rule PAD out.
A leg or foot that suddenly turns cold, pale or blue, numb, weak or very painful needs 999 (911 in the US) or A&E. Pain in your foot or toes at rest, wounds that won't heal, or toes that go cold and numb, then red or black, mean contacting a GP immediately, or NHS 111.
Exercise education, not a diagnosis or treatment plan, and clinical review of these guides is pending. Stop and get advice for chest pain, unusual breathlessness, dizziness or fainting, or new pain, and check with your doctor or midwife first if they have told you to limit activity. Health disclaimer.
