Emergency: Sudden severe leg pain, a pale or cold leg, numbness or being unable to move the leg can mean an acute blockage of an artery. Any one of these signs is enough: call the emergency number at once (112 in Germany and the EU).
Peripheral artery disease (PAD) is a circulation problem caused by narrowed arteries in the legs. The typical sign is cramping pain in the calf, thigh or foot when walking that eases after a short rest standing still. In German it is called "Schaufensterkrankheit", window-shopping disease, because people keep stopping as if looking into shop windows. The cause is almost always hardening of the arteries (atherosclerosis). In the early stages the most important treatment is structured walking training, together with stopping smoking and treating risk factors. Having PAD also means a higher risk of heart attack and stroke.
As of October 2026. Sources are linked below. They are German: the S3 guideline of the German Society for Vascular Medicine and the health portal of the German Federal Ministry of Health.
Key Takeaways
- What is PAD? Narrowed or blocked arteries in the legs, in about 95 out of 100 people caused by atherosclerosis.
- Typical sign: pain when walking that eases after a short rest. For a long time there are often no symptoms at all.
- Who is affected? An estimated 15 to 25 percent of people aged 65 and over.
- Most important risk factor: smoking. Also diabetes, high blood pressure, high blood lipids, severe kidney disease, lack of exercise and severe overweight.
- Diagnosis: blood pressure at the arm and ankle (ankle-brachial index), a walking test, ultrasound.
- Treatment: structured walking training, stopping smoking, treating risk factors, medicines, and in later stages a catheter procedure or surgery.
- Emergency: sudden severe leg pain, a pale or cold leg, numbness or paralysis: call 112 at once.
What Is Peripheral Artery Disease?
In PAD, the arteries that supply the legs with blood are narrowed or blocked. Usually calcium, blood fats, blood clots and connective tissue build up on the artery wall. During exercise not enough blood then reaches the muscle, and it hurts. When you stand still, the muscle recovers and the pain eases.
PAD is a chronic disease, because the atherosclerosis behind it cannot be cured. It can stay stable for many years, but it can also get worse. Because atherosclerosis usually affects other blood vessels too, PAD is a warning sign for the heart and brain: according to the German Federal Ministry of Health, about 3 in 100 people with PAD die each year, mostly from a heart attack or stroke.
PAD is something quite different from varicose veins or chronic venous insufficiency: those affect the veins, which carry blood back to the heart; PAD affects the arteries, which carry blood to the legs.
Calf Pain When Walking: PAD or Something Else?
Calf pain has many causes. The German guideline compares PAD with conditions that can feel similar (differential diagnosis of claudication, table 3-7). Some of them:
| Cause | Where it hurts | What gives it away |
|---|---|---|
| PAD in the calf | calf muscle | cramping pain that starts at a similar walking distance and eases quickly when you stand still, posture makes no difference |
| PAD in the thigh and buttock | buttock, hip, thigh | same pattern, higher up |
| Chronic compartment syndrome | calf muscles | tight, cutting pain after heavy exercise such as jogging, eases very slowly, better when the leg is raised, mainly in very muscular athletes |
| Venous claudication | whole leg, strongest in the calf | tight, cutting pain after walking, eases quickly when the leg is raised, history of a deep vein thrombosis in the pelvis or thigh, signs of a blocked vein, swelling |
| Nerve root compression | radiates down the leg | sharp pain triggered by sitting, standing or walking, often present at rest, better with a change of position, back problems |
| Spinal stenosis | often both sides, buttock, back of the leg | pain and weakness, worse when standing with the back straight, better when bending the lower back forward |
| Baker's cyst | back of the knee, down the calf | swelling and tenderness, present at rest too |
| Hip osteoarthritis | outer hip, thigh | pain after varying activity, eases slowly, better when the hip is rested |
A deep vein thrombosis can also cause calf pain, for example with swelling of one leg. That needs a doctor at once.
Symptoms
For a long time PAD causes no or only mild symptoms. Signs of poor circulation, according to the German Federal Ministry of Health, can include:
- pale, bluish-mottled, thin skin
- a cold leg or foot
- tingling or numbness
- slower hair growth or hair loss on the leg
The typical symptom is cramping pain in the calf, thigh or foot when walking, sometimes only after a longer distance, sometimes after just a few steps. As PAD progresses, the leg eventually hurts at rest too, especially when it is raised. Wounds on the foot heal more slowly, and ulcers can form. If tissue gets too little oxygen, areas turn blue to black, often starting at the toes. In men, PAD in the pelvis can also cause erection problems.
Leg pain at night and sleeping position
In advanced PAD, pain at rest usually affects the front of the foot. According to the guideline, it often eases when the leg hangs down, so some people let the affected leg hang out of bed at night or find that a few steps help. This is not a sleeping tip but a warning sign: in PAD, pain at rest means the leg is not getting enough blood even without exercise. Have it checked by a doctor the same day.
Stages
In Germany PAD is usually classified by the Fontaine stages. The pain-free walking distance separates stage IIa from IIb:
| Stage | What happens |
|---|---|
| I | no symptoms |
| IIa | pain when walking, pain-free walking distance over 200 metres |
| IIb | pain when walking, pain-free walking distance under 200 metres |
| III | pain at rest |
| IV | an open wound (ulcer) or dead tissue (gangrene) |
The guideline groups stages III and IV as chronic limb-threatening ischaemia (CLTI), the late stage in which the leg is at risk. A decision on restoring blood flow shall then be made as quickly as possible, by a team of specialists (recommendation 4.2). The Rutherford classification is also used internationally.
Diagnosis
Your doctor asks about symptoms, smoking, exercise and family history and examines your legs: cool, pale or bluish skin and weak or absent foot pulses point to poor circulation.
The most important simple test is the ankle-brachial index (ABI): the blood pressure at the ankle, measured at the dorsalis pedis and posterior tibial arteries (and sometimes the peroneal artery), compared with the blood pressure at the arm. According to the S3 guideline, a value of 0.9 or below proves relevant PAD (recommendation 3.6).
| ABI | Meaning according to the guideline |
|---|---|
| above 1.3 | falsely high values possible, for example with stiff, calcified arteries |
| above 0.9 | normal |
| 0.75 to 0.9 | mild PAD |
| 0.5 to under 0.75 | moderate PAD |
| under 0.5 | severe PAD, a sign of critical circulation problems |
A treadmill walking test and an ultrasound of the arteries (duplex ultrasound), which shows where and how badly they are narrowed, can add to this. Because atherosclerosis usually affects more than the legs, the heart, blood pressure and blood sugar are checked too.
People at higher risk, for example those who smoke, have diabetes or have PAD in the family, are advised by the German Federal Ministry of Health to get checked even without symptoms.
Treatment
According to the guideline, treatment has three aims depending on the stage: in all stages, lowering the risk of heart attack and stroke; in stage II, improving walking distance and quality of life; in stages III and IV, saving the leg.
The basis of treatment
The basic treatment according to the guideline includes walking training, losing weight if overweight, stopping smoking and treating high blood pressure, high cholesterol and diabetes. Cholesterol-lowering medicines are part of treatment at every stage, and once there are symptoms usually also medicines that stop blood platelets from clumping. They reduce the risk of further deposits and complications. Which medicines you need is your doctor's decision.
Structured walking training
Walking training is for stages I and II and, according to the guideline, the most important non-drug treatment in stage II. Supervised, structured walking training is more effective than walking without a plan and shall be offered to everyone with intermittent claudication as part of the basic treatment (recommendation 4.23), in stage II as the first treatment. According to the guideline, several Cochrane reviews show that walking training increases both the pain-free and the maximum walking distance.
If supervised training is not possible, home training with clear goals and close, goal-oriented monitoring, for example of the step count with a step counter, is equivalent for walking distance according to the guideline and should then be considered (recommendation 4.25). Advice alone or a diary without step counts is not enough. Conservative treatment shall last at least 3 to 6 months and then be reassessed.
Catheter procedure or surgery
If symptoms do not improve despite training and treatment, restoring blood flow can be considered: the narrowed artery is widened with a catheter or bypassed in an operation. At the claudication stage, the benefits and risks must be explained in detail beforehand. In stages III and IV, such a procedure is often needed to save the leg.
Protect your feet
According to the German Federal Ministry of Health, comfortable shoes, checking your feet regularly and professional foot care are important even in the early stage, so that no wounds develop. Any wound needs professional treatment.
Compression Stockings and PAD
Be careful. Compression stockings press on the leg and can make poor circulation worse. The German compression guideline (AWMF 037-005, 2026) names advanced PAD as a contraindication, for example an ankle-brachial index below 0.5 or an ankle artery pressure below 60 mmHg (recommendation 31). With less pronounced PAD, adapted compression with lower pressure may be possible under medical supervision if there is a clear reason, such as a coexisting vein problem.
If you have PAD or weak foot pulses, ask your doctor before using any compression, including over-the-counter support stockings. If you notice blue or white discolouration, tingling, numbness, weakness or pain in the foot or toes while wearing compression, take the stockings off at once and get checked.
What You Can Do
- Stop smoking. Smoking is the most important risk factor and makes a severe course more likely. Counselling, courses, nicotine replacement or medicines can help.
- Walk every day, ideally to a plan and with a step counter, even if it hurts at first. Agree how far and how often with your doctor. If you have pain at rest or an open wound on your foot, do not train on your own: see a doctor first.
- Check your feet every day for pressure marks, injuries and discolouration.
- Have blood pressure, blood sugar and cholesterol treated and take the medicines you are prescribed.
- Aim for a healthy weight.
When to See a Doctor
| Situation | What to do |
|---|---|
| Sudden severe leg pain, a pale or cold leg, numbness or paralysis | Call 112 at once, suspected acute arterial blockage |
| Leg pain even at rest, especially at night or when the leg is raised | The same day: your practice or a vascular clinic, out of hours the on-call service (116117 in Germany) or an emergency department; possible sign of a dangerous circulation problem |
| A foot wound that does not heal, or dark discolouration of the toes | The same day, as above |
| Calf pain when walking that eases when you stand still | Appointment with your family doctor, referral to vascular medicine if needed |
| You smoke, have diabetes or PAD in the family, but no symptoms | Ask about a check-up at your next appointment |
Frequently Asked Questions
What causes calf pain when walking? A common cause is PAD: the narrowed arteries cannot supply the calf muscle with enough blood during exercise, and the pain eases when you stand still. Other causes include nerve root compression, spinal stenosis, a Baker's cyst, a compartment syndrome in athletes or vein problems. If one calf is suddenly swollen and painful, it can be a deep vein thrombosis and needs a doctor at once.
What is the pain-free walking distance? The distance you can walk before the pain starts. It separates stages IIa (over 200 metres) and IIb (under 200 metres) and is often measured on a treadmill. According to the guideline, walking training can increase it.
Does walking really help when it hurts? Yes, in stages I and II. According to the guideline, structured walking training is the most important non-drug treatment in stage II and increases the pain-free and maximum walking distance. It does not apply if you have pain at rest or open wounds on your feet; see a doctor first in that case. It works best supervised, or at home with clear goals and a step counter. Agree on your training with your doctor.
What is the best sleeping position with PAD? If your leg hurts at night and feels better hanging over the edge of the bed, this can be a warning sign of advanced PAD, not a question of position. In PAD, pain at rest means the leg does not get enough blood even without exercise. Have it checked by a doctor the same day.
What does end stage mean in PAD? Stages III and IV: pain at rest, or open wounds and dead tissue. The leg is then at risk, and according to the guideline a team of specialists shall decide as quickly as possible on a procedure to restore blood flow.
Are varicose veins and PAD the same thing? No. Varicose veins affect the veins, PAD affects the arteries. Both can occur together but are treated differently. In advanced PAD, for example, compression, which helps with vein problems, can cause harm.
Can PAD be cured? No, the atherosclerosis behind it cannot be cured. But walking training, stopping smoking, medicines and, if needed, a procedure can relieve symptoms, often halt progression and prevent complications.
Does PAD increase the risk of heart attack and stroke? Yes, because atherosclerosis usually also affects the heart and brain. According to the German Federal Ministry of Health, about 3 in 100 people with PAD die each year, mostly from a heart attack or stroke. That is why treating blood pressure, cholesterol and blood sugar and stopping smoking are part of every stage.
Can I wear compression stockings with PAD? Only after a medical check. In advanced PAD, compression is a contraindication according to the guideline. With less pronounced PAD, adapted compression with lower pressure may be possible under medical supervision if there is a clear reason.
How LEVANA Can Help
LEVANA does not replace a check of your circulation. If your doctor has recommended walking training, the app can support you with reminders to move in daily life. For sudden severe leg pain, a pale or cold leg, numbness or paralysis, only the emergency number 112 counts.
Sources
All accessed on 6 October 2026.
- AWMF S3 guideline on the diagnosis, treatment and follow-up of peripheral arterial disease (065-003), version 4.3 of 25 November 2024: Fontaine stages (table 3-1), rest pain, ABI (recommendation 3.6, table 3-4), differential diagnosis of claudication (table 3-7), basic treatment and stage-based approach (chapter 4.1), recommendation 4.2, walking training (recommendations 4.23 to 4.25), duration of conservative treatment
- German Federal Ministry of Health, gesund.bund.de: Periphere arterielle Verschlusskrankheit (PAVK): signs, cause, risk factors, frequency, course, mortality, foot care, emergency
- AWMF S2k guideline on compression therapy of the limbs (037-005), version 5.1 of 16 July 2026: contraindications (recommendation 31), adapted compression in PAD without critical ischaemia
- AWMF S2k guideline on venous thrombosis and pulmonary embolism (065-002), version 5.0, 2023: compression in PAD only with a clear indication, warning signs under compression
Related Articles
- Varicose veins
- Chronic venous insufficiency
- Cold feet: causes and what helps
- Restless legs syndrome
- Heavy legs: understanding the causes
Disclaimer
This article is for general information only and does not replace medical advice, diagnosis or treatment. For sudden severe leg pain, a pale or cold leg, numbness or paralysis, call the emergency number 112 at once.
Take the next step in the app
Start with the free Leg Check for a structured overview, or register to follow a guided programme.