Assessing the Lower Extremities in the Geriatric Patient

Mark E. Williams, MD


November 08, 2010

In This Article

Assessment of Lower Extremity Circulation

General Evaluation of Lower Extremity Circulation

Inspect the legs from the groin to the feet noting any asymmetry, skin changes, hair distribution, varicosities, or edema. Signs of vascular insufficiency include pallor, coolness, cyanosis, atrophy, loss of hair, pigmentation along the shin or ankles, or ulcers. Check the capillary refill by pinching the great toes and noting the time that it takes for the color of the nail beds to return to normal (should be less than 3 seconds).

Arteries in the Legs

Assessing the femoral artery. Palpate the right femoral artery pulse by placing the index and middle fingers of your left hand over the patient's right inguinal ligament about midway between the right anterior superior iliac spine and the right symphysis pubis. Feel the opposite side with your right hand at the left inguinal ligament appreciating both pulses. Inequality of the pulse suggests vascular disease.

Now check the radial and femoral pulses on the right side. The femoral pulse should be felt before the radial pulse; if it is not, suspect aortoiliac disease. Listen for a vascular bruit. If one is present, observe whether it increases when the patient flexes and extends the ankle rapidly. Then, compress the femoral artery high in the femoral triangle near the inguinal ligament in the anterior and medial thigh. If the bruit increases, consider occlusion of the profunda artery. If the bruit decreases, consider occlusion of the common femoral artery or the proximal femoral artery. If the patient has a femoral popliteal bypass graft, hearing the bruit decrease with compression suggests that occlusion of the graft is eminent.

Popliteal artery. With the patient supine, place both hands around the knee and feel in the popliteal space. Slowly lift the knee until it is about 90°. If you cannot detect a pulse, then stop at that point. Feel the skin temperature over the shin. Normally, you would detect a point of warmth at the upper portion of the anterior thigh. Coolness in this area suggests acute vascular insufficiency. Note, however, that in chronic popliteal disease, vascular collaterals may cause the involved knee to feel warmer rather than cooler.

Dorsalis pedis and posterior tibial arteries. The dorsalis pedis pulse is usually felt along the dorsum of the foot just lateral to the extensor tendon of the great toe. The posterior tibial pulse is usually just behind and slightly below the medial malleolus.

Deep Venous Obstruction

With the patient supine, check the veins over the tibial plateau. Dilated veins that do not collapse with leg elevation suggest deep venous obstruction (Pratt's sign). If the skin on 1 leg is warm and stiff to a pinch (secondary to edema), then deep venous thrombosis is also indicated (Rose's sign). Measure the difference in circumference between the normal and distended leg -- both thighs and calves. Greater than 2.5 cm difference between the calves and greater than 2 cm between the thighs suggest deep venous thrombosis. Deep venous thrombosis is also suggested by the following:

  • Tenderness to percussion of the medial surface of the tibia (Lisker's sign);

  • Cough-induced pain that disappears when the proximal vein is compressed (Louvel's sign); and

  • Asymmetric tenderness to blood pressure cuff inflation at less than half the pressure of the opposite side (Löwenberg's sign).

Varicose Veins

Varicose veins with pulsations suggest tricuspid insufficiency. Hearing a murmur over the veins suggests tricuspid insufficiency. Dark purple discoloration of the skin with varicose veins suggests arteriovenous fistula.

Inspect the saphenous system for varicosities that will appear as large wormlike, tortuous vessels. Perform the manual compression test by having the patient stand and placing your right hand over the distal lower part of the varicose vein and your left hand over the proximal vein. Your hands will be about 15-20 cm apart. Compress the proximal portion of the varicose vein. If you feel a palpable pulsation in your distal hand, the test is positive.

Now perform Trendelenburg's test. Have the supine patient elevate the leg to 90° until the venous blood has drained from the great saphenous vein. Now place a tourniquet around the upper thigh of the patient's leg tightly enough to occlude the great saphenous vein but not the arterial pressure. Help the patient stand and look for venous filling. Slow filling (over 30 seconds) below the superficial veins while the tourniquet is applied is normal. Rapid filling of the superficial veins while the tourniquet is applied is abnormal, as is sudden additional filling of the superficial veins after the tourniquet has been released.

Additional Lower Extremity Circulation Pearls

  • Aneurysms of the abdominal aorta are associated with distal peripheral aneurysm.

  • Atherosclerosis, although a generalized metabolic disorder, tends to build up at bifurcations of major vessels. In the lower extremity, the superficial femoral artery becomes occluded at the adductor hiatus.

  • Patients with diabetes tend to have femoral-tibial occlusions, whereas nondiabetic patients tend to have ileal-femoral occlusions.


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