Popliteal Pulse

See Table 14-3, Common Ulcers of the Feet and Ankles (p. 463).

Palpate the pulses in order to assess the arterial circulation.

■ The femoral pulse. Press deeply, below the inguinal ligament and about midway between the anterior superior iliac spine and the symphysis pubis. As in deep abdominal palpation, the use of two hands, one on top of the other, may facilitate this examination, especially in obese patients.

Physical Examination Obese

See Table 14-2, Chronic Insufficiency of Arteries and Veins (p. 462).

See Table 14-3, Common Ulcers of the Feet and Ankles (p. 463).

Lymphadenopathy refers to enlargement of the nodes, with or without tenderness. Try to distinguish between local and generalized lymphadenopathy, respectively, by finding either (1) a causative lesion in the drainage area, or (2) enlarged nodes in at least two other noncontiguous lymph node regions.

A diminished or absent pulse indicates partial or complete occlusion proximally; for example, at the aortic or iliac level, all pulses distal to the occlusion are typically affected. Chronic arterial occlusion, usually from atherosclerosis, causes intermittent claudication, (pp. 460-461), postural color changes (p. 458), and trophic changes in the skin (p. 462)

An exaggerated, widened femoral pulse suggests a femoral aneurysm, a pathologic dilatation of the artery.

■ The popliteal pulse. The patient's knee should be somewhat flexed, the leg relaxed. Place the fingertips of both hands so that they just meet in the midline behind the knee and press them deeply into the popliteal fossa. The popliteal pulse is often more difficult to find than other pulses. It is deeper and feels more diffuse.

Pulse Examination

An exaggerated, widened popliteal pulse suggests an aneurysm of the popliteal artery. Neither popliteal nor femoral aneurysms are common. They are usually due to atherosclerosis, and occur primarily in men over age 50.

If you cannot feel the popliteal pulse with this approach, try with the patient prone. Flex the patient's knee to about 90°, let the lower leg relax against your shoulder or upper arm, and press your two thumbs deeply into the popliteal fossa.

Femoral Popliteal PulsesFemoral Pulse

Atherosclerosis (arteriosclerosis obliterans) most commonly obstructs arterial circulation in the thigh. The femoral pulse is then normal, the popliteal decreased or absent.

■ The dorsalis pedis pulse. Feel the dorsum of the foot (not the ankle) just lateral to the extensor tendon of the great toe. If you cannot feel a pulse, explore the dorsum of the foot more laterally.

Dorsalis Pedis Pulse

The dorsalis pedis artery may be congenitally absent or may branch higher in the ankle. Search for a pulse more laterally.

Decreased or absent foot pulses (assuming a warm environment) with normal femoral and popliteal pulses suggest occlusive disease in the lower popliteal artery or its branches— a pattern often associated with diabetes mellitus.

■ The posterior tibial pulse. Curve your fingers behind and slightly below the medial malleolus of the ankle. (This pulse may be hard to feel in a fat or edematous ankle.)

■ The posterior tibial pulse. Curve your fingers behind and slightly below the medial malleolus of the ankle. (This pulse may be hard to feel in a fat or edematous ankle.)

Posterior Tibial Pulse Point

Sudden arterial occlusion, as by embolism or thrombosis, causes pain and numbness or tingling. The limb distal to the occlusion becomes cold, pale, and pulseless. Emergency treatment is required. If collateral circulation is good, only numbness and coolness may result.

Tips on feeling difficult pulses: (1) Position your own body and examining hand comfortably; awkward positions decrease your tactile sensitivity. (2) Place your hand properly and linger there, varying the pressure of your fingers to pick up a weak pulsation. If unsuccessful, then explore the area deliberately. (3) Do not confuse the patient's pulse with your own pulsating fingertips. If you are unsure, count your own heart rate and compare it with the patient's. The rates are usually different. Your carotid pulse is convenient for this comparison.

Note the temperature of the feet and legs with the backs of your fingers. Compare one side with the other. Bilateral coldness is most often due to a cold environment or anxiety.

Coldness, especially when unilateral or associated with other signs, suggests arterial insufficiency from inadequate arterial circulation.

Look for edema. Compare one foot and leg with the other, noting their rel- Edema causes swelling that may ative size and the prominence of veins, tendons, and bones. obscure the veins, tendons, and bony prominences.

Thrombosed Vein Finger

Check for pitting edema. Press firmly but gently with your thumb for at least See Table 14-4, Some Peripheral 5 seconds (1) over the dorsum of each foot, (2) behind each medial malle- Causes of Edema (p. 464). olus, and (3) over the shins. Look for pitting—a depression caused by pressure from your thumb. Normally there is none. The severity of edema is Shown below is 3+ pitting edema. graded on a four-point scale, from slight to very marked.

Pitting Edema Scale

If you suspect edema, measurement of the legs may help you to identify it and to follow its course. With a flexible tape, measure (1) the forefoot, (2) the smallest possible circumference above the ankle, (3) the largest circumference at the calf, and (4) the midthigh a measured distance above the patella with the knee extended. Compare one side with the other. A difference of more than 1 cm just above the ankle or 2 cm at the calf is unusual in normal people and suggests edema.

If edema is present, look for possible causes in the peripheral vascular system. These include (1) recent deep venous thrombosis, (2) chronic venous insufficiency due to previous deep venous thrombosis or to incompetence of the venous valves, and (3) lymphedema. Note the extent of the swelling. How far up the leg does it go?

Is the swelling unilateral or bilateral? Are the veins unusually prominent?

Try to identify any venous tenderness that may accompany deep venous thrombosis. Palpate the groin just medial to the femoral pulse for tenderness of the femoral vein. Next, with the patient's leg flexed at the knee and relaxed, palpate the calf. With your fingerpads, gently compress the calf muscles against the tibia, and search for any tenderness or cords. Deep venous thrombosis, however, may have no demonstrable signs, and diagnosis often depends on high clinical suspicion and other testing.

Note the color of the skin.

■ Is there a local area of redness? If so, note its temperature, and gently try to feel the firm cord of a thrombosed vein in the area. The calf is most often involved.

■ Are there brownish areas near the ankles?

■ Note any ulcers in the skin. Where are they?

■ Feel the thickness of the skin.

Ask the patient to stand, and inspect the saphenous system for varicosities. The standing posture allows any varicosities to fill with blood and makes them visible. You can easily miss them when the patient is in a supine position. Feel for any varicosities, noting any signs of thrombophlebitis.

Conditions such as muscular atrophy can also cause different circumferences in the legs.

In deep venous thrombosis, the extent of edema suggests the location of the occlusion: the calf when the lower leg or the ankle is swollen, the iliofemoral veins when the entire leg is swollen.

Venous distention suggests a venous cause of edema.

A painful, pale swollen leg, together with tenderness in the groin over the femoral vein, suggests deep iliofemoral thrombosis. Approximately half of patients with deep venous thrombosis in the calf have tenderness and cords deep in the calf. Calf tenderness is nonspecific, however, and may be present without thrombosis.

Local swelling, redness, warmth, and a subcutaneous cord suggest superficial thrombophlebitis.

A brownish color or ulcers just above the ankle suggest chronic venous insufficiency.

Thickened brawny skin occurs in lymphedema and advanced venous insufficiency.

Varicose veins are dilated and tortuous. Their walls may feel somewhat thickened. Many varicose veins can be seen in the leg on p. 459.

■ Special Techniques_

Evaluating the Arterial Supply to the Hand. If you suspect arterial insufficiency in the arm or hand, try to feel the ulnar pulse as well as the radial and brachial pulses. Feel for it deeply on the flexor surface of the wrist medially. Partially flexing the patient's wrist may help you. The pulse of a normal ulnar artery, however, may not be palpable.

Thromboangiitis Obliterans

Arterial occlusive disease is much less common in the arms than in the legs. Absent or diminished pulses at the wrist in acute embolic occlusion and in Buerger's disease, or thromboangiitis obliterans.

The Allen test gives further information. This test is also useful to assure the patency of the ulnar artery before puncturing the radial artery for blood samples. The patient should rest with hands in lap, palms up.

Ask the patient to make a tight fist with one hand; then compress both radial and ulnar arteries firmly between your thumbs and fingers. Next, ask the patient to open the hand into a relaxed, slightly flexed position. The palm is pale.

Release your pressure over the ulnar artery. If the ulnar artery is patent, the palm flushes within about 3 to 5 seconds.

Extending the hand fully may cause pallor and a falsely positive test.

Persisting pallor indicates occlusion of the ulnar artery or its distal branches.

Patency of the radial artery may be tested by releasing the radial artery while still compressing the ulnar.

Arterial Insufficiency

Postural Color Changes of Chronic Arterial Insufficiency.

If pain or diminished pulses suggest arterial insufficiency, look for postural color changes. Raise both legs, as shown at the right, to about 60° until maximal pallor of the feet develops—usually within a minute. In light-skinned persons, either maintenance of normal color, as seen in this right foot, or slight pallor is normal.

Marked pallor on elevation suggests arterial insufficiency.

Then ask the patient to sit up with legs dangling down. Compare both feet, noting the time required for:

■ Return of pinkness to the skin, normally about 10 seconds or less

■ Filling of the veins of the feet and ankles, normally about 15 seconds.

This right foot has normal color and the veins on the foot have filled. These normal responses suggest an adequate circulation.

The foot below is still pale and the veins are just starting to fill—signs of arterial insufficiency.

Look for any unusual rubor (dusky redness) to replace the pallor of the dependent foot. Rubor may take a minute or more to appear.

Normal responses accompanied by diminished arterial pulses suggest that a good collateral circulation has developed around an arterial occlusion.

Color changes may be difficult to see in darker-skinned persons. Inspect the soles of the feet for these changes, and use tangential lighting to see the veins.

Persisting rubor on dependency suggests arterial insufficiency (see p. 462). When veins are incompetent, dependent rubor and the timing of color return and venous filling are not reliable tests of arterial insufficiency.

(Source of foot photos: Kappert A, Winsor T: Diagnosis of Peripheral Vascular Disease. Philadelphia, FA Davis, 1972).

Mapping Varicose Veins. You can map out the course and connections of varicose veins by transmitting pressure waves along the blood-filled veins. With the patient standing, place your palpating fingers gently on a vein and, with your other hand below it, compress the vein sharply. Feel for a pressure wave transmitted to the fingers of your upper hand. A palpable pressure wave indicates that the two parts of the vein are connected.

A wave may also be transmitted downward, but not as easily.

Trendelenburg Test

Evaluating the Competency of Venous Valves. By the retrograde filling (Trendelenburg) test, you can assess the valvular competency in both the communicating veins and the saphenous system. Start with the patient supine. Elevate one leg to about 90° to empty it of venous blood.

Next, occlude the great saphenous vein in the upper thigh by manual compression, using enough pressure to occlude this vein but not the deeper vessels. Ask the patient to stand. While you keep the vein occluded, watch for venous filling in the leg. Normally the saphenous vein fills from below, taking about 35 seconds as blood flows through the capillary bed into the venous system.

After the patient has stood for 20 seconds, release the compression and look for any sudden additional venous filling. Normally there is none: competent valves in the saphenous vein block retrograde flow. Slow venous filling continues.

When both steps of this test are normal, the response is termed negativenegative. Negative-positive and positive-negative responses may also occur.

Rapid filling of the superficial veins while the saphenous vein is occluded indicates incompetent valves in the communicating veins. Blood flows quickly in a retrograde direction from the deep to the saphenous system.

Sudden additional filling of superficial veins after release of compression indicates incompetent valves in the saphenous vein.

When both steps are abnormal, the test is positive-positive.

TABLE 14-1 ■ Painful Peripheral Vascular Disorders and Their Mimics

Problem

Process

Location of Pain

Arterial Disorders

Atherosclerosis (arteriosclerosis obliterans)

■ Intermittent claudication

Rest pain

Episodic muscular ischemia induced by exercise, due to obstruction of large or middle-sized arteries by atherosclerosis

Ischemia even at rest

Usually the calf, but also may be in the buttock, hip, thigh, or foot, depending on the level of obstruction

Distal pain, in the toes or forefoot

Acute Arterial Occlusion

Embolism or thrombosis, possibly superimposed on arteriosclerosis obliterans

Distal pain, usually involving the foot and leg

Raynaud's Disease and Phenomenon

Venous Disorders

Superficial Thrombophlebitis

Deep Venous Thrombosis

Chronic Venous Insufficiency (deep)

Thromboangiitis Obliterans (Buerger's disease)

Raynaud's disease: Episodic spasm of the small arteries and arterioles; no vascular occlusion. Raynaud's phenomenon: Syndrome is secondary to other conditions such as collagen vascular disease, arterial occlusion, trauma, drugs

Clot formation and acute inflammation in a superficial vein

Clot formation in a deep vein

Chronic venous engorgement secondary to venous occlusion or incompetency of venous valves

Inflammatory and thrombotic occlusions of small arteries and also of veins, occurring in smokers

Distal portions of one or more fingers. Pain is usually not prominent unless fingertip ulcers develop. Numbness and tingling are common.

Pain in a local area along the course of a superficial vein, most often in the saphenous system

Pain, if present, is usually in the calf, but the process more often is painless.

Diffuse aching of the leg(s)

■ Intermittent claudication, particularly in the arch of the foot

■ Rest pain in the fingers or toes

Acute Lymphangitis

Mimics*

Acute Cellulitis

Acute bacterial infection (usually streptococcal) spreading up the lymphatic channels from a portal of entry such as an injured area or an ulcer

Acute bacterial infection of the skin and subcutaneous tissues

An arm or a leg

Arms, legs, or elsewhere

Erythema Nodosum

Subcutaneous inflammatory lesions associated with Anterior surfaces of both lower legs a variety of systemic conditions such as pregnancy, sarcoidosis, tuberculosis, and streptococcal infections

* Mistaken primarily for acute superficial thrombophlebitis.

Timing

Factors That Aggravate

Factors That Relieve

Associated Manifestations

Fairly brief; pain usually forces the patient to rest.

Persistent, often worse at night

Sudden onset; associated symptoms may occur without pain.

Relatively brief (minutes) but recurrent

Exercise such as walking Rest usually stops the pain in 1-3 min.

Elevation of the feet, as Sitting with legs dependent in bed

Exposure to cold, emotional upset

Warm environment

Local fatigue, numbness, diminished pulses, often signs of arterial insufficiency (see p. 462)

Numbness, tingling, trophic signs and color changes of arterial insufficiency (see p. 462)

Coldness, numbness, weakness, absent distal pulses

Color changes in the distal fingers: severe pallor (essential for the diagnosis) followed by cyanosis and then redness

An acute episode lasting days or longer

Local redness, swelling, tenderness, a palpable cord, possibly fever

Often hard to determine because of lack of symptoms

Chronic, increasing as the day wears on

■ Fairly brief but recurrent

■ Chronic, persistent, may be worse at night

An acute episode lasting days or longer

Prolonged standing ■ Exercise

Elevation of the leg(s)

■ Permanent cessation of smoking helps both kinds of pain (but patients seldom stop)

Possibly swelling of the foot and calf and local calf tenderness; often nothing

Chronic edema, pigmentation, possibly ulceration (see pp. 462, 463)

Distal coldness, sweating, numbness, and cyanosis; ulceration and gangrene at the tips of fingers or toes; migratory thrombophlebitis

Red streak(s) on the skin, with tenderness, enlarged, tender lymph nodes, and fever

An acute episode lasting days or longer

Pain associated with a series of lesions over several weeks

A local area of diffuse swelling, redness, and tenderness with enlarged, tender lymph nodes and fever; no palpable cord

Raised, red, tender swellings recurring in crops; often malaise, joint pains, and fever

TABLE 14-2 ■ Chronic Insufficiency of Arteries and Veins

Chronic Arterial Insufficiency (Advanced)

Chronic Venous Insufficiency (Advanced)

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Responses

  • dina
    Can you feel popliteal lymph nodes?
    7 years ago
  • kaarina
    How to palpate the popliteal pulse?
    7 years ago
  • ronnie craig
    Where to check for the popliteal pulse?
    7 years ago
  • Henri
    How to check for swelling in ankles?
    4 years ago
  • karolin
    Why should we flex leg to feel popliteal artrey?
    3 years ago
  • Alexander Grunwald
    Can you feel your own popliteal pulse?
    3 years ago
  • reginard lightfoot
    Can you feel a pedal pulse with venous insufficiency?
    3 years ago
  • Lalli
    WHY POPLITEAL PULSE SWELL?
    3 years ago
  • TOINI
    Why is the popliteal artery hard to palpate?
    3 years ago
  • prisca
    How should one position his leg so as to feel popliteal pulse?
    2 years ago
  • Peony
    How to feel popliteal artery?
    2 years ago
  • brhane
    What color on the feet and legs change to with arteriosclerosis?
    2 years ago
  • phil
    How to assess popliteal pulse?
    2 years ago
  • amina
    What treatment you can use when you have pulse?
    2 years ago
  • Tekle
    How to palpate popliteal lymph nodes?
    2 years ago
  • Tricia
    What does weakness of popliteal pulse indicate for?
    1 year ago
  • annett
    Why are we looking for poplital pulse?
    1 year ago
  • libera
    Why use the popliteal artery to assess pulse?
    11 months ago
  • TEIJA
    Can dorsalis pedis pulse be felt on oedema?
    9 months ago
  • cleo
    Does all patients have a popliteal pulse?
    4 months ago
  • bryan
    Why is poplitea puse weak in diabetic patients?
    2 months ago
  • AMAN
    How to assas poplital pulse?
    5 days ago

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