Other / General Medicine
Natalie Nepa, MD
National Capital Consortium PM&R Resident
Walter Reed National Military Medical Center
Bethesda, Maryland, United States
Tawnee L. Sparling, MD
Medical Director, Amputee Care, Department of PM&R
Uniformed Services University of the Health Sciences
Bethesda, Maryland, United States
Edward Dolomisiewicz, MD
Program Director, National Capital Consortium PM&R Residency
Walter Reed National Military Medical Center
Bethesda, Maryland, United States
Natalie Nepa, MD
Walter Reed
Bethesda, Maryland, United States
Two patients with transtibial amputations from blast injuries over 15 years prior presented with new distal residual limb pain. A 49-year-old reported squeezing pain during ambulation, despite a normal physical exam and well-fitting prosthesis. Imaging and labs excluded infection or fracture. Vascular ultrasound revealed left superficial femoral and popliteal artery occlusion. Imaging also identified subsegmental pulmonary emboli. He underwent femoral thromboendarterectomy with patch angioplasty, was started on anticoagulation, and was referred for a hypercoagulability work-up due to a family history of Factor V Leiden. A 52-year-old developed throbbing, aching pain with activity, relieved by rest and prosthesis removal. Exam showed blanchable erythema with purple discoloration and reduced limb temperature. Point-of-care ultrasound identified a right popliteal occlusion, which was confirmed on subsequent vascular studies. Due to limited revascularization options, he underwent targeted muscle reinnervation and cryoneurolysis for pain management and was started on rivaroxaban and cilostazol.
Discussions: These cases highlight presentations of vascular claudication in transtibial amputees. Residual limb pain in amputees has a broad differential including prosthetic fit, infection, neuroma, fracture, radicular pain, myodesis instability, and neurogenic or vascular claudication. Both patients were evaluated by physiatry, prosthetists, and orthopedics to rule out common causes of amputee pain before ultrasound confirmed arterial occlusions. Notably, neither patient had prior peripheral arterial disease or hematologic diagnoses. Key retrospective features of vascular claudication were present: exertional onset, relief with rest, insidious course, and limb color/temperature changes. While pain descriptors varied (squeezing, tightness, throbbing/aching), localization was consistently vague.
Conclusions: Vascular claudication should be considered in amputees with exertional residual limb pain. Characterization of this pain is difficult to discern. Point-of-care ultrasound offers a rapid, accessible tool to evaluate for arterial occlusion in the outpatient setting.
