Rehabilitation guide
Does a cramp-like pain start in your calf, thigh or buttock when you walk, and ease after a few minutes’ rest? Narrowing of the leg arteries can reduce the blood reaching your working muscles. This is called peripheral arterial disease, and the pain that comes on with walking is called intermittent claudication. Regular walking exercise clearly increases the distance you can walk without pain, and guidelines list it among the first steps of treatment.
Many people with the condition have no symptoms at all. Recurring leg pain during exercise is not a normal part of ageing for someone who is otherwise healthy; you can see your doctor about it.
The narrowing is usually caused by fatty deposits building up in the artery wall (atherosclerosis). Because the same process can affect other arteries, people with peripheral arterial disease are also more likely to develop other cardiovascular diseases such as coronary heart disease, heart attack and stroke.
Your doctor will first ask about your symptoms and examine your legs and foot pulses. The most common test is the ankle–brachial pressure index (ABPI or ABI), which compares the blood pressure at your ankle with the blood pressure in your arm. According to the referral guidance of a Scottish health board, 0.9–1.4 is considered normal; below 0.9 suggests narrowed arteries and below 0.5 suggests severe narrowing. In people with diabetes or advanced kidney disease and in the very elderly, stiff artery walls can make the value misleadingly high.
Arteries are not the only cause of leg pain when walking. Lumbar spinal stenosis can also cause leg pain on walking, but this pain usually eases when you sit down or lean forward, and even standing can bring it on. For short cramps that wake you at night, see the night leg cramps guide.
A 2017 Cochrane review looked at 32 randomised controlled trials involving 1,835 people. Compared with usual care, exercise increased pain-free walking distance by an average of 82 metres and maximum walking distance by an average of 120 metres; these results are based on high-quality evidence, and the gains lasted for up to 2 years. Exercise did not change the ankle–brachial pressure index; no effect on death or amputation could be shown, while quality of life may improve.
How hard you walk also seems to matter. In the LITE trial of 305 people in the USA, participants walked at home 5 times a week for 12 months, for up to 50 minutes per session. Those who walked at a pace that caused moderate to severe leg pain increased their 6-minute walk distance by 34.5 metres; those who walked at a comfortable pace that caused no pain did not improve, and their results did not differ from the group that did no exercise.
The European Society of Cardiology’s 2024 consensus document sees supervised walking exercise as first-line treatment: at least 3 sessions a week, at least 30 minutes per session, for at least 3 months. Because pain can make it hard to keep going, the document recommends a flexible, person-centred approach: start at a light-to-moderate intensity and increase it as tolerated.
To set your steps to a steady pace, you can use the brisk walking metronome.
Exercises at home
Interval walking is the core of the programme. The other movements are for strengthening your leg muscles, warming up or for days when you cannot go out for a walk; the choice of strength exercises and the numbers of repetitions are general recommendations. Stop at once if you get chest pain, dizziness or unusual shortness of breath.
Warm up at a slow pace for a few minutes. Then walk until the pain in your leg reaches a moderate to severe level, stop and rest until the pain goes, then walk again. Repeat the walk–rest cycle until your total time is up.
Start with 20–30 minutes, aim for 30–60 minutes; at least 3 days a weekWhen the weather is bad, or to warm up before a walk: sit upright on a sturdy chair, lift and lower your knees in turn and swing your arms as well.
2–3 minutesHold lightly on to a kitchen worktop. Lift both heels together to rise up on to your toes, then lower slowly. This strengthens your calf muscles.
10–15 reps, 2 setsSit at the front of a sturdy chair. Stand up as you breathe out, and sit down slowly as you breathe in. Use your hands for support if you need to.
10 reps, 2 setsSit upright on a chair. Slowly straighten your knee and tighten the muscle at the front of your thigh, hold for 3 seconds and lower. As it gets easier, you can add a light weight at your ankle.
10 reps with each leg, 2 setsHolding the banister, climb a few stairs and come down slowly. If pain starts, stop and rest, then carry on once it has passed.
1–3 flights, a few times a dayNo. This pain comes from the working muscles not getting enough blood, and it eases with rest. England’s NICE guideline recommends walking to the point of maximal pain, and the European Society of Cardiology’s consensus document recommends walking until the pain is moderate to severe; pain-free walking also improves walking to some extent, but the evidence for it is weaker. Pain that continues at rest, or a sudden change in the leg, is a different matter; see the warning signs below.
In studies, exercise did not change the ankle–brachial pressure index (a measure of arterial narrowing). The gain is in how far you can walk and in daily life. Stopping smoking and the medicines your doctor recommends are also important for slowing the narrowing.
NICE recommends a supervised exercise programme for everyone with intermittent claudication: about 2 hours a week for 3 months. If you cannot find such a programme, a structured home programme is a good option. According to the European Society of Cardiology’s document, home programmes monitored with a step counter, a walking diary or regular phone calls give results close to supervised programmes, while unmonitored programmes are less effective. The US guideline also recommends structured programmes that include support for behaviour change; the benefit of unplanned, casual walking is uncertain.
Programmes usually last at least 12 weeks. In the studies in the Cochrane review, exercise programmes were mostly done at least twice a week for 3 to 12 months, and the gains lasted up to 2 years. The benefit fades when you stop exercising, so it is important to keep walking regularly after the programme ends.
According to the European and US guidelines, walking is the first choice; if walking is not possible, cycling, arm cycling (arm ergometry) or strength exercises can also be used. Walking usually increases walking distance more than strength exercises do, while cycling and arm cycling stand out for improving heart and lung fitness.
Smoking is the most important risk factor for peripheral arterial disease. Stopping reduces the risk of the condition getting worse and of other serious cardiovascular events such as heart attack. People who keep smoking after diagnosis have a much higher risk of heart attack.
For exercise after a heart attack or bypass surgery, see the cardiac rehabilitation guide; for nerve damage in the feet from diabetes, see the diabetic neuropathy guide.
For the situations marked “emergency”, call 112 or go to the nearest emergency department:
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