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Smoker’s Leg: Symptoms & Treatment

by Josephine Andrews
Published: Last Updated on 400 views

Smoker ‘s leg is a colloquial term for peripheral arterial disease (PAD) in the legs. Smoking is the most important risk factor for PAD. In the case of PAD, constrictions form in the arteries due to hardening of the arteries (arteriosclerosis), which leads to a lack of oxygen in the tissue. Find out here how to recognize a smoker’s leg and how the disease progresses.

ICD codes for this disease:

ICD codes are internationally valid codes for medical diagnoses. They can be found, for example, in doctor’s letters or on certificates of incapacity for work.

I73 I70

quick overview

  • Symptoms: No complaints for a long time, then mainly pain, possibly pale and cool legs
  • Treatment: Treatment of the causes, walking training, blood thinning medication, possibly operations
  • Causes and risk factors: smoking, calcified arteries and high blood pressure, diabetes mellitus, chronically high blood lipid levels, obesity
  • Diagnostics: consultation with the doctor, physical examination, walking test, ultrasound , magnetic resonance imaging
  • Prognosis and course of the disease: Depending on the elimination of the cause, the prognosis can be positively influenced by a healthy lifestyle
  • Prevention: Not smoking and a healthy lifestyle reduce the risk of PAD

What is smoker’s leg (PAD)?

Smoker’s leg is defined as the abnormal narrowing of arteries in the leg. The medically correct term is “peripheral arterial occlusive disease” (PAD). This causes constrictions (stenoses) to form in the arteries, which impede the flow of blood into the tissue and, in the worst case, completely prevent it. The expression “smoker’s leg” came about because the effects are particularly common in the leg first and smoking is the main risk factor for the development of PAD. Smokers are therefore particularly often affected.

Smoker’s leg accounts for about 90 percent of all PAD cases. The constriction is in about a third of patients in the iliac arteries, 50 percent in the femoral arteries and about 15 percent in the lower leg arteries. In the remaining ten percent of PAD patients, the bottlenecks are in the upper arms, forearms or hands.

Around three to ten percent of the general population have PAD. The incidence of the disease increases with age and is 15 to 20 percent over the age of 70. Regardless of age, however, the majority of those affected do not experience any symptoms. Gender also plays a role: men are more likely to be affected by a smoker’s leg than women in a ratio of 4:1. The main cause of PAD in men is smoking.

In many cases, patients with a smoker’s leg also suffer from other chronic diseases such as diabetes mellitus, high blood pressure or elevated cholesterol and blood lipid levels. All of these diseases are also risk factors for the development of what is known as hardening of the arteries (arteriosclerosis), which is the main cause of PAD.

How do you recognize a smoker’s leg and what are the stages?

There are several stages during the development of a smoker’s leg. In the early stages, those affected usually do not even notice that they are suffering from the smoker’s leg. As the disease progresses, the most important symptom of PAD is the stress-dependent pain in the affected body region and later cool and pale feet as well as poorly healing wounds. Sensory disturbances such as numbness may also occur. The symptoms and related complications show up in stages depending on the severity of the smoker’s leg.

Depending on the occurrence and severity of the symptoms, physicians divide PAD into four different PAD stages according to Fontaine-Ratschow:

  • Stage 1: No complaints, although a bottleneck can be detected
  • Stage 2a: Pain occurs with a walking distance of more than 200 meters, which disappears again when standing still or at rest.
  • Stage 2b: The pain in the leg starts when you walk less than 200 meters.
  • Stage 3: The leg already hurts at rest.
  • Stage 4: Ulcers and inflammation develop on the smoker’s leg as a sign that the undersupplied tissue is slowly dying.

While those affected in stage 1 sometimes do not notice any symptoms, from stage 2 onwards the typical stress-related pain occurs when walking. Doctors also refer to this stress-related pain as intermittent claudication or intermittent claudication. The term comes from the fact that people with PAD keep stopping because of the pain when walking, like window shopping. As a result, the pain temporarily subsides and those affected are able to walk a short distance again.

From stage 3, those affected also have pain during physical rest due to one or more narrowings in the arteries. Everyday stresses such as short walking distances are then often no longer possible or only possible with severe pain. In stage 4, typical changes in the skin appear due to the chronic lack of oxygen in the tissue.

For example, ulcers (ulcers) develop. Finally, in the final stages of the disease, the tissue dies from the lack of oxygen and begins to literally rot – with the possibility that it also becomes infected. The dead tissue (necrosis and gangrene) takes on a blackish color.

Basically, smoker’s leg or PAD is a chronic disease that develops over years. In some cases, however, an artery also occludes suddenly (acutely). If so, this is a medical emergency that can become life-threatening. Immediate medical treatment is then absolutely necessary.

How does an acute arterial occlusion occur? This occurs when a blood clot (thrombus) or the torn fragment of arteriosclerotic plaque gets stuck in the constriction. An acute occlusion is noticeable through severe pain in the leg, which does not subside even when resting. There is also weakness or complete paralysis of the affected extremity, a feeling of cold, the skin is pale and even the doctor can no longer feel a pulse in the arteries in the back of the knee or in the inner ankle.

Smoker’s leg symptoms depend on the location and degree of constriction

The pain occurs in the smoker’s leg below the constriction, since this is the only place where there is a reduced supply of blood and oxygen. A vasoconstriction in the right thigh is shown, for example, by pain in the right lower leg, while a narrowing in the pelvic area triggers the typical smoker’s leg symptoms in the thigh.

Depending on the degree and location of the narrowing, numbness also develops in the buttocks or thighs. In almost all cases, a smoker’s leg is indicated by cold limbs below the constriction.

The extent of smoker’s leg symptoms also depends on where exactly the stenosis is located: the closer it is to the trunk of the body, the more pronounced the symptoms are, as the entire subsequent blood supply is impaired. A stenosis in the iliac arteries causes more serious problems than one in the lower leg.

Why does a smoker’s leg often not cause any symptoms for a long time?

A smoker’s leg often goes undetected for a long time. The reason for this is that vasoconstriction only causes symptoms at a very advanced stage. Because the constriction develops slowly and the body has time to form bypass circuits (collateral circuits) in order to compensate for the bottleneck in the blood vessels. The tissue below the constriction is then partially supplied via other, non-pathologically altered blood vessels .

However, such collateral circulations are only able to take over a certain proportion of the blood flow. The smoker’s leg causes symptoms at the latest when there is a narrowing of more than 90 percent of the inner diameter of the vessel.

Other diseases also sometimes lead to those affected noticing symptoms of peripheral arterial occlusive disease until late. People with diabetes mellitus and nerve damage (diabetic polyneuropathy), for example, have a disturbed perception of pain and therefore often do not feel any symptoms, even with advanced smoker’s leg. Doctors therefore often only diagnose smoker’s leg or PAD at a particularly late stage .

How is smoker’s leg treated?

The therapy of PAD primarily depends on the personal requirements of the patient and the stage of the smoker’s leg. It is also important to treat other diseases such as diabetes or cardiovascular diseases.

Stage 1 PAD therapy

If the smoker’s leg is recognized in the first stage, it is particularly important to combat the causes. The most important measures are to stop smoking, exercise regularly and eat a healthy diet. It is also important to normalize cholesterol levels, blood lipid levels and blood pressure. If a change in lifestyle with more exercise and a healthier diet is not enough, medication may be necessary.

Usually, the doctor will also prescribe exercise therapy . This is recommended in all stages, but especially for stages 1 and 2. Whether it is prescribed in stage 3 or 4 depends heavily on the patient’s condition. The doctor determines the distance that the patient can cover without pain despite having a smoker’s leg. In daily walking training, it is important to complete at least half of this walking distance. This stimulates the body to form bypass circuits (collaterals).

In principle, good foot care is important from stage one . Those affected are encouraged to apply lotion to their feet regularly and to avoid injuries during pedicures and to ensure that they wear comfortable shoes. If there are pressure points or injuries on the affected feet, it is important to have the wound treated carefully and to observe the healing.

Stage 2 PAD therapy

In addition to the measures already mentioned and regular walking training for PAD therapy, the doctor also prescribes medication from stage two onwards. The so-called platelet aggregation inhibitors improve the fluidity of the blood and prevent the accumulation of blood platelets (thrombocytes), thereby preventing blood clots. The drug of choice is acetylsalicylic acid (ASA). In case of intolerance, the doctor may prescribe other platelet inhibitors, such as clopidogrel.

PAD therapy in stages 3 and 4

Careful foot care is essential, especially from the third stage. It is also advisable to keep your legs low to support the blood supply. If the person concerned is physically restricted, it is very important to avoid pressure points. This is mainly achieved through regular repositioning and cotton bandages. The heel is particularly prone to pressure sores, which is why skin care is particularly important here. In addition, the heel should be supported as freely as possible with the help of cushions in the knee/lower leg area.

Surgical interventions are usually used from the third stage of PAD. However, this decision depends on several factors, such as the location of the constriction, the wishes of the person concerned and the possibilities of the practitioner. It is therefore quite possible that PAD from stage two onwards is treated, for example, with a catheter-based intervention.

The type of operation depends on the length and exact location of the constriction. If the vascular constriction in the thigh or pelvic area is only a few millimeters long, the constriction can often be expanded simply with a minimally invasive procedure.

This is done using a catheter (percutaneous transluminal angioplasty, PTA) through a small incision, usually in the groin. The doctor inserts a balloon catheter from the groin into the constriction and lets it inflate with pressure. In order to avoid narrowing again, it may be necessary to implant a vascular support ( stent ).

If expansion is not possible because the constriction is too rigid or extends over a longer section of the vessel, a larger incision is usually necessary. In thromboendarterectomy, the doctor peels the debris out of the artery.

If necessary, a bypass operation is also an option. The doctor uses either a vein or a Teflon tube to redirect the narrowed vessel. If the circulatory disturbance in a smoker’s leg is so severe that the limb dies, the last resort is amputation of the affected limb.

In principle, doctors who specialize in vascular diseases reassess the smoker’s leg before a possible amputation and weigh up whether there are other treatment options.

How is a smoker’s leg formed?

Over 95 percent of all cases of PAD (smoker’s leg) are due to hardening of the arteries. Doctors refer to this as “arteriosclerosis”. This is a deposit (plaque) of fat , calcium and connective tissue in the inner layer of blood vessels. Hardening of the arteries usually affects all arteries in the body, including the coronary arteries and cervical arteries. The arteries in the neck supply blood to the brain.

In some places, however, the bottlenecks are particularly pronounced. The blood flow is so severely impaired there that too little blood flows through the subsequent tissue and there is a lack of oxygen. This ultimately leads to the pain and other smoker’s leg symptoms.

Studies have confirmed several causes and risk factors for the development of arteriosclerosis. Smoking is considered a particular risk factor for arteriosclerosis. It is therefore a main reason for the development of PAD. Certain ingredients in cigarettes promote calcification of the arteries, especially in the legs. Overall, smokers develop arterial circulatory disorders about three times more often than non-smokers and about 85 percent of people with a smoker’s leg are or were smokers.

In addition, other risk factors promote peripheral arterial occlusive disease. This includes:

  • high blood pressure (hypertension)
  • Diabetes (diabetes mellitus)
  • Increased blood cholesterol (hyperlipoproteinemia: increased LDL cholesterol, decreased HDL cholesterol)
  • Elevated blood fats (hypertriglyceridemia)
  • Cardiovascular disease in blood relatives
  • overweight

Very rare causes are special forms of vasculitis , such as thromboangiitis obliterans or Takayasu syndrome.

How is a smoker’s leg diagnosed?

The first point of contact when suspecting a smoker’s leg is usually the family doctor. This first records the medical history (anamnesis). Here you have the opportunity to describe your symptoms and the changes you have noticed in detail. The presence of certain risk factors and typical smoker’s leg symptoms often gives the doctor decisive indications of peripheral arterial occlusive disease. During the anamnesis interview, the doctor asks the following questions, for example:

  • Do you get increasing pain in your leg muscles after walking longer distances, which improves immediately when you take a break?
  • Do you smoke or have you smoked in the past? If so, how long and how much?
  • Do you have diabetes, high cholesterol and/or blood fat levels?
  • Have you been diagnosed with high blood pressure?
  • Does your family have or have you had cardiovascular diseases such as a smoker’s leg or a heart attack?


During the examination, the doctor first looks at the skin on the legs. Pale or bluish skin is a first indication of a possible smoker’s leg. Signs that sometimes indicate PAD include bulging nails (watch glass nails), small, poorly healing skin defects, and dead (necrotic) tissue.

Now the doctor feels the pulse in the groin or on the thigh, in the back of the knee, the inner ankle area and on the back of the foot. In the case of severe PAD, the pulse in the affected limb is hardly or not at all palpable. A temperature comparison of both legs also provides an indication of PAD: The affected leg is noticeably cooler than the healthy one. In the case of a one-sided smoker’s leg, the musculature is often visibly slimmer than on the healthy leg due to the gradual lack of oxygen.

With a stethoscope, the doctor often hears a typical flow noise over the constriction (stenosis), which is caused by turbulence at the constriction. In this way, the vessel or the region in which the narrowing is located can be roughly determined. A special ultrasound examination (duplex sonography) measures the blood flow in the vessels, doctors giving additional information about possible bottlenecks.

If the doctor suspects a smoker’s leg, the calculation of the so-called ankle-brachial index (ankle-brachial index, ABI) also provides important information. In this simple examination, the examiner puts a blood pressure cuff on the upper arm and lower leg and determines the pressure at which the pulse can no longer be felt in the arteries below.

This measured pressure corresponds to the systolic blood pressure. The ABI is now calculated from the quotient of the two systolic blood pressure values. That is, the blood pressure measured on the lower leg is divided by the blood pressure measured on the upper arm.

Normally, the pressure in the lower leg is slightly higher than in the upper arm, resulting in a quotient between 0.9 and 1.2. If the pressure in the lower leg is significantly lower than in the upper arm because the blood supply is reduced there, the quotient falls. The following assessment standard applies to the ankle-brachial index:

  • 0.75-0.9: mild PAD
  • 0.5–0.75: moderate PAD
  • < 0.5: severe PAD

In order to obtain even more precise information on the localization of the constriction (stenosis), imaging procedures such as so-called contrast medium angiography are usually necessary. This examination is absolutely necessary, especially before a planned operation on the constriction. Patients are injected with a contrast agent that makes the vessels visible in the image, and at the same time the examiner prepares an X-ray image (digital subtraction angiography) .

The X-ray contrast agent and any bottlenecks in the vessels are shown in the computer-aided image. Alternatively, the vessel display can be performed as computer tomography (CT) or as magnetic resonance imaging (MRI).

To determine the extent of the disease according to the PAD stages (see above), the doctor performs a stress test. To do this, the patient runs on a special treadmill for a certain amount of time. The doctor measures the walking distance from which symptoms occur.

How does smoker’s leg disease progress?

People who suffer from a smoker’s leg (peripheral arterial disease, PAD) have a major impact on the disease and its course. Those affected first find support from their family doctor, but also in self-help groups. First and foremost, the prognosis depends on whether the cause can be eliminated or significantly minimized.

Quitting smoking completely and permanently is the most important measure in the treatment of PAD. If those affected cannot stop smoking on their own, it is advisable to seek professional help. The first point of contact for this is the general practitioner.

Smoking and poorly controlled diabetes mellitus increase the risk that vessels will close again after the operation and an amputation may become necessary. If there are other diseases such as high blood pressure, it is important to have these checked regularly by a doctor.

An active lifestyle with a varied diet and regular physical exercise also has a favorable prognostic effect. A daily walk of about half an hour is enough. Endurance sports such as swimming , jogging or cycling are particularly recommended.

Make sure you eat as little fat as possible and eat a varied diet with a high proportion of vegetables. It is advisable to avoid saturated fats in particular, such as those found in chips, crisps or biscuits. If a patient with a smoker’s leg is overweight, weight reduction is also recommended.

People with stage two PAD often also have arteriosclerosis in other parts of the body, such as the coronary arteries or the carotid arteries. They therefore usually also have a significantly increased risk of a heart attack or stroke. Life expectancy decreases by about 10 years as a result of PAD.

Severe disability and PAD

Peripheral arterial disease is one of the diseases associated with chronic pain. For this reason, it is possible for the pension office to determine the degree of disability and for the person concerned to receive a corresponding disabled person’s pass.

How high the degree of disability (GdB) or the degree of damage consequences (GdS) is and whether it is a severe disability depends on the present stage and the symptoms caused by the disease. A severe disability is defined as a GdS of 50 or more.

Those affected can access the table in the supply medicine regulation of the Federal Ministry of Labor and Social Affairs .

How do you prevent a smoker’s leg?

Smoker’s leg or PAD can be prevented by avoiding active or passive smoking and reducing risk factors through an active and healthy lifestyle. If there are underlying diseases that increase the risk of arterial circulatory disorders or calcification of the arteries, it is advisable to treat them and have them checked regularly by a doctor.

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