Popliteal Artery Occlusive Disease Clinical Presentation

Updated: Feb 03, 2022
  • Author: Cynthia K Shortell, MD; Chief Editor: Vincent Lopez Rowe, MD  more...
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History and Physical Examination

With the exceptions of acute thrombosis, emboli, and trauma, the course of disease culminating in popliteal artery occlusion is insidious. Most commonly, patients present with intermittent claudication. [11] Patients experience cramping pain distal to the level of obstruction. Symptoms are highly reproducible and disappear with rest.

Other conditions involving the lower extremity should be differentiated from intermittent claudication. These include pseudoclaudication, lumbar disk disease, and spinal stenosis. In most cases, the differential diagnosis between true claudication and pseudoclaudication can be made on the basis of careful history taking. The mortality associated with patients who present with claudication is 50% at 5 years.

Rest pain represents the next clinical step in the progression of peripheral artery disease (PAD) and is a pathognomonic sign of critical limb ischemia (CLI; or chronic limb-threatening ischemia [CTLI]). Rest pain characteristically presents as a burning in the toes, forefoot, and instep. It is aggravated by elevation and frequently awakens the patient at night. The pain is relieved by dependency (dangling the feet or a brief walk). When taking the patient’s history, distinguishing true rest pain from other causes (eg, arthritis and neuropathy) is important.

Mortality for patients presenting with rest pain reaches 75% at 5 years and 85% at 10 years and is inversely proportional to the ankle-brachial index (ABI) at the time of presentation. Patients with the most severe manifestations of PAD present with ischemic ulcerations and gangrene. Lesions are typically located at the tips of toes and over pressure points. Patients with rest pain and gangrene should undergo revascularization for limb salvage and preservation of function if they are ambulatory and do not have prohibitive comorbidities.


These patients are older (sixth and seventh decades of life) and may be asymptomatic or have claudication, rest pain, or tissue ischemia or loss below the knee. Chronic decreased blood supply also manifests as loss of hair on the affected limb, thickened toenails, dependent rubor, and pallor upon elevation.

Popliteal artery aneurysm

At the time of presentation, approximately two thirds of patients with popliteal artery aneurysms (PAAs) are symptomatic. The most common presenting symptoms are lower-extremity ischemia and compression of adjacent anatomic structures, notably nerves (causing paresthesias) and veins (leading to deep vein thrombosis and edema). Patients typically present in their sixth or seventh decade of life, with a pulsatile mass in the subsartorial or popliteal area, as observed upon physical examination.

The major complications of PAA result from thrombosis and embolism. Thrombosis occurs in as many as 55% of patients, and 6-25% of patients have evidence of distal emboli. Many patients with acute PAA thrombosis present on an emergency basis with limb-threatening ischemia. Rarely, these aneurysms can rupture, causing a threat to leg viability. Limb-threatening ischemia associated with PAA rupture results in a 50-70% amputation rate.

Rupture of a PAA is uncommon, occurring in approximately 2-7% of cases. This occurs much less frequently than thrombosis of the aneurysm. By contrast, an AAA is more likely to rupture than to thrombose.

Emphasizing that 33-43% of PAAs are associated with a coexisting AAA is important. A high index of suspicion in these patients should result in a careful evaluation of the aorta and the iliac, femoral, and contralateral popliteal arteries. Patients with bilateral PAA extrapopliteal aneurysm are even more common, with a reported incidence as high as 78%.

Popliteal entrapment syndrome

These patients are young, otherwise healthy, athletic males who present with symptoms of calf claudication. In rare cases, paresthesia, rest pain, or ulcer might be present. The symptoms most commonly described include aching and cramping in the calf or foot and coldness, blanching, and numbness in the foot associated with walking and relived by rest. The resting ABI is normal. Findings from Doppler examinations at rest are normal; abnormal findings with dorsiflexion of the foot are diagnostic of popliteal entrapment syndrome.

Cystic adventitial disease

Patients are usually healthy, nonsmoking, middle-aged men with a sudden onset and rapid progression of intermittent claudication. The important physical examination sign is a loss of foot pulses with knee flexion (Ishizawa sign). This demonstrates that cystic disease has resulted in stenosis of the popliteal artery with preservation of patency.

With progressive narrowing of the arterial lumen, blood flow may possibly occur only during the peak of a systole. The altered blood flow can be auscultated as a bruit in the popliteal fossa. Symptoms are predominately unilateral. In time, enlargement of the cyst can cause total occlusion of the popliteal artery. Given the slow progressive nature of the occlusion caused by cystic adventitial disease and healthy proximal and distal arteries, acute limb threat is unlikely to occur.



The Rutherford and Fontaine classifications were developed in an effort to categorize the extent of PAD on the basis of presenting clinical symptoms and thus to facilitate standardization of treatment outcomes reporting. (See Table 2 below.)

Table 1. Rutherford and Fontaine Classifications for Evaluating Extent of Peripheral Artery Disease (Open Table in a new window)

Rutherford Classification

Fontaine Classification













Mild claudication


Mild claudication



Moderate claudication


Moderate to severe claudication



Severe claudication


Ischemic rest pain



Ischemic rest pain


Ischemic rest pain



Minor tissue loss


Ulceration or gangrene



Major tissue loss