A 65-year-old computer programmer came to my office for an examination to clear him for spinal surgery the following week. He’d been experiencing leg pain while walking, and his orthopedist had scheduled surgery after an MRI showed lumbar spinal stenosis, or an overgrowth of arthritic bone in the spine. Seemed straightforward enough, I thought.

But his case provided a powerful example of why it’s rarely a good idea to rush into surgery, and why it’s wise to remember that very different health problems can sometimes look remarkably alike.

Step on the Surgery Brakes

My patient told me that his symptoms had started about a year earlier and slowly worsened. He described sharp pain in both calves that began after walking about a block and eased within a few minutes of stopping. He had no pain sitting or at night.

That, I thought, sounded like another problem: peripheral artery disease (PAD), or reduced blood flow to the legs.

The referring orthopedist had also considered that possibility. He had ordered an ankle-brachial index (ABI) test, which compares blood pressure in the upper arm with blood pressure in the ankle. Usually those readings should be the same or a little higher in the legs. In my patient, they were borderline—not clearly low in the legs, but suggestive of PAD.

So I decided to repeat the ABI test, with a tweak: First I had the patient walk rapidly on a treadmill to the point of pain. The pressure in his legs decreased significantly.

That convinced me that his pain stemmed mainly from PAD, not spinal stenosis. I called the orthopedist to have the surgery canceled. 

Subtle Symptoms Matter

What about that MRI showing spinal stenosis? Experience shows that imaging tests sometimes reveal evidence of that condition even in people without pain while walking or any other symptoms. So opting for surgery or other treatment depends on carefully matching symptoms with test results.

And though stenosis and PAD can cause similar symptoms, there are subtle but key differences. Pain from spinal stenosis is more likely to be achy, radiating to the buttocks and thighs in addition to the calves. It usually doesn’t ease when you stop walking, but leaning forward—as when pushing a shopping cart—can reduce discomfort.

Peripheral artery disease, on the other hand, can be described as “angina” of the leg. During exercise, which increases the muscles’ need for oxygen, plaque buildup in the leg arteries can impede oxygen-rich blood flow, triggering pain—similar to blocked heart arteries that can cause chest pain, or angina, during exertion. The leg pain caused by PAD is usually sharp, like a muscle cramp, and eases with rest when blood flow is restored to the muscles.

The condition is often related to smoking and is commonly accompanied by the usual suspects that can cause the formation of plaque in the arteries—diabetes, hypertension, and elevated levels of LDL (bad) cholesterol

On the Road to Recovery

Additional examination showed that my patient had all of those risk factors. He was a pack-a-day smoker and prediabetic, with a fasting blood sugar level that was elevated but not yet at the cutoff for full-blown type 2 diabetes. His blood pressure was borderline, at 140/90. And he had high LDL cholesterol.

Fearing that he might meet the same fate as his diabetic father, who had died of a heart attack in his 60s, he immediately gave up smoking.

A registered dietician instructed him on following a diet low in saturated fat, and a physiotherapist outlined an exercise program that consisted mainly of walking to the point of pain at least seven to eight times twice per day.

I started him on a daily regimen of baby aspirin as a deterrent to clotting. He also began taking a statin to lower his elevated LDL cholesterol level.

Within six months his exercise tolerance had increased from one block to two. And in a year he was walking six blocks without pain—no surgery required.