How High Cholesterol Can Affect Your Legs and Feet

High cholesterol can increase your risk of peripheral artery disease, causing symptoms to develop in your legs and feet.

Anonymous grey-haired senior man stretching his legs before jogging.
Aleksandra Jankovic/Stocksy

Cholesterol is essential for your health.1 It is a waxy substance that is important to many functions in the body and travels through your bloodstream.2

Usually, healthy arteries, which are blood vessels that carry blood from your heart, nourish the tissues of your body.3 But cholesterol, along with other fats and substances, can form plaque on the walls of your arteries—this process is called atherosclerosis. People with high cholesterol are at risk of atherosclerosis, which can narrow the arteries and reduce blood flow to the tissues.1,4

Although this plaque buildup is most known for causing heart attacks and strokes (blood clots in the brain), atherosclerosis can affect blood vessels anywhere in the body. Buildup in the arteries of your legs and feet can cause a condition called peripheral artery disease (PAD).4

In the U.S., PAD affects more than 6.5 million people over the age of 40.5 Having PAD raises your risk for heart attack, stroke, and other serious health conditions.6 Speak with your healthcare provider if you have high cholesterol or symptoms of PAD. Lifestyle changes to prevent PAD, as well as early diagnosis and treatment are important.7

Symptoms in the Legs and Feet Due to PAD

Peripheral artery disease can reduce or block blood flow in your limbs (extremities), such as the arms and legs, as well as your pelvis (hip area).8 The most common type of PAD is lower extremity PAD, which affects the legs and feet.3

Leg pain during physical exercise is a common symptom of PAD.9 Other symptoms include physical changes of your legs and feet, which most often occur in the nails and skin.10

Typically, PAD starts slowly and worsens over time, but the symptoms vary widely.11 Over half of the people with PAD do not have symptoms.12 People who report no symptoms may likely be physically inactive or mistake any muscle discomfort to be a sign of aging (the risk of PAD increases with older age).13 In turn, PAD is often underdiagnosed.7,14

Some people at risk for PAD have no symptoms but show plaque buildup in their leg arteries with ultrasound screening. One small study revealed that many of these people go on to develop leg pain and more plaque buildup within a year of screening.11

In some cases, people might only be diagnosed with PAD when they have symptoms severe enough to cause a medical emergency.8

A healthcare provider can help identify the following symptoms of PAD.

Muscle pain during exercise

A common sign of PAD is a type of muscle pain known as claudication, which can include aching, cramping, numbness, and fatigue.10 This pain occurs with walking or other physical activity. It is often located in the legs, but can also occur in the butt, hip, thigh, calf, or foot.10,15 The pain usually occurs in the muscles where arteries are affected by cholesterol and fat buildup.7,10

With physical activity, muscles need extra blood to support exercise, but the narrowed arteries prevent enough blood flow.7 Your body uses pain as a warning that the muscle is under stress from insufficient blood flow.13 Standing still and resting requires less blood flow to the muscles, reducing pain.13

Generally, pain that starts with exercising can go away after resting the affected muscle.7 But with continued physical activity, the pain can return—this is known as intermittent claudication.12 For example, the pain can start after walking a certain distance, go away with sitting for some time, and then return after walking the same distance.

Muscle pain at rest

In severe cases of PAD, muscle pain may not go away even when resting—and it can persist. Some people with PAD find that they have pain, coldness, or numbness in their feet and toes, usually at night or whenever their legs are elevated.10

Lowering the foot below the level of the heart or dangling it off the bed may help reduce the pain.10 When the legs are downward, gravity helps to pull more blood toward the feet, which can temporarily lessen the pain.13

Skin and hair changes

People with PAD may develop smooth, shiny skin.15 You may lose your leg hair, or it may grow much more slowly.7,15 You may also notice that the color of your skin changes. It may be darker (hyperpigmented) than usual.16 Other times, it may become a bluish color (called cyanosis).17

Over time, poor blood flow to the skin and hair cells in your legs causes these changes.18

In one study of over 540 adults at risk of PAD—who either have high blood pressure or diabetes—about a third (182 adults) were diagnosed with PAD.15,16 And of those with PAD, about 1 in 3 adults (65 people) had skin changes, which were more common among cases of moderate or severe PAD.16

Cold feet

If you have PAD, you may find that your feet are cool or cold to the touch.15 Blood flow helps keep your legs and feet warm. When your arteries are partly blocked by cholesterol and fat, it becomes hard for your body to get blood to areas far from the heart, to maintain a stable temperature.18

Weak or missing pulses

If you have enough circulation, your pulse can commonly be felt on your feet from the pumping action of your heart.19 As your blood flow decreases, your healthcare provider may be able to detect changes when checking your pulses.20 With PAD, pulses may be weak or missing, especially the pulses of the feet (such as the dorsalis pedis or posterior tibial arteries).20

To examine blood flow in your body, a provider uses a test called the ankle-brachial index (ABI), which compares blood pressure in your legs to the pressure in your arms. A healthy ABI score is between 1.00 and 1.40. However, a score below 0.9 may suggest PAD, though further tests are needed for a diagnosis.7

Thick toenails

With PAD, you might notice toenail changes. Toenails may grow more slowly or become thickened, deformed, or discolored (dystrophic nails).7,16 Chronic poor circulation due to narrow or blocked arteries that supply blood to the feet can lead to nail changes over time.16

Muscle wasting

Decreased amount of muscle, or muscle atrophy, can be a consequence of PAD. Some people with PAD show an overall decrease in calf or other leg muscles. Sometimes a muscle biopsy may show wasting within the muscle fibers at a microscopic level. Reduced blood flow to the muscles also decreases the delivery of oxygen and energy. This can lead to changes in the muscle structure and is associated with decreased mobility for people with PAD.21

Leg sores

Lack of blood flow from the arteries to the legs and feet may increase your risk of developing sores called arterial ulcers.18 These ulcers typically happen far away from the heart on the legs, feet, ankles, or toes.22

Poor blood flow can damage cells, tissues, and nerves, which can cause wounds (ulcers) to form on the skin, especially if there is a small injury. These wounds can also be slow and difficult to heal and can form in areas affected by PAD.22

If someone has PAD with leg ulcers, the wound can turn pale, ashen, or cold when the leg is raised.18,22 When the leg is in a sitting position, the skin can turn red.18

Tissue death

If left untreated, PAD can progress to tissue death.4 Severe lack of blood flow can cause tissue death (gangrene) of the leg. Over time, as arteries narrow, you may develop pain even when resting or ulcers that do not heal. This stage of PAD is known as critical limb ischemia (CLI).23

Typically, about 30% to 50% of people with PAD may have a risk of heart attack or stroke within five years, but that risk is raised to within a year for people with CLI.23

Critical limb ischemia may require bypass surgery to the affected arteries to correct blood flow.23 If circulation is not improved, these areas become black and there is no cure once the tissue dies.13 If the wounds become infected or it is not possible to improve blood flow, amputation may be necessary.5

Fewer than 5% of people with muscle pain due to PAD may have a major limb amputation (at or above the ankle) after five years. However, about 30% to 50% of people with CLI that does not improve in the first year may have this type of amputation.23

When to See a Healthcare Provider

If you have leg pain when walking or other PAD symptoms, speak with your healthcare provider right away for diagnosis.13 Since some cases of PAD may have no symptoms, keep up with regular annual medical checkups, which include blood tests for blood pressure and cholesterol.13,24

Talk to your healthcare provider if you have an increased risk of developing PAD. It is more likely to occur in people with high cholesterol, high blood pressure, diabetes, a history of smoking, and older age. Because blockages can occur in any blood vessel, PAD is also associated with an increased risk of heart disease or stroke.4

Treatment and diagnosis

For treatment and diagnosis, your doctor may consult a radiologist, endocrinologist (specialist in hormones), or a vascular surgeon (specialist in blood vessels aside from the heart or brain).13

A provider can give you treatments for PAD or similar conditions associated with atherosclerosis. This may include medications to prevent blood clots (antiplatelet drugs like aspirin), as well as to reduce cholesterol.15

Prevention

For preventing high cholesterol, PAD, or worsening PAD, a provider may also recommend that you:15,25

  • Regularly exercise
  • Maintain a healthy weight
  • Limit your alcohol consumption
  • Quit smoking
  • Eat foods that are high in fiber or low in saturated fat, salt, and added sugars (whole grains, fruits, vegetables, lean meat)

If a provider diagnoses you with PAD, you will need to have regular followup visits. While there is no cure for PAD, lifestyle changes and treatment can help prevent worsening of your condition.13

Summary

High cholesterol is one of several factors that can lead to plaque buildup in the blood vessels.13 Narrowed or blocked arteries in your legs can cause reduced blood flow, poor circulation, and symptoms of peripheral artery disease. This condition can potentially cause pain with walking, decreased pulses, skin changes, or coldness in the legs and feet.15

Be sure to check with your health care provider for early diagnosis, symptom management, and treatment to prevent serious complications.

Sources

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  3. National Heart, Lung, and Blood Institute. What is peripheral artery disease?
  4. American Heart Association. About peripheral artery disease (PAD).
  5. Virani SS, Alonso A, Aparicio HJ, et al. Heart disease and stroke statistics—2021 update: A report from the American Heart Association. Circulation. 2021;143(8). doi:10.1161/cir.0000000000000950
  6. Morley RL, Sharma A, Horsch AD, Hinchliffe RJ. Peripheral artery disease. BMJ. 2018;360. doi:10.1136/bmj.j5842
  7. American Heart Association. Symptoms and diagnosis of PAD.
  8. MedlinePlus. Atherosclerosis.
  9. Bevan GH, White Solaru KT. Evidence-based medical management of peripheral artery disease. Arteriosclerosis, Thrombosis, and Vascular Biology. 2020;40(3):541-553. doi:10.1161/atvbaha.119.312142
  10. Creager MA, Loscalzo J. Chapter 275: Arterial diseases of the extremities. In: Jameson JL, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J, eds. Harrison's Principles of Internal Medicine. 20th ed. McGraw-Hill Education; 2018.
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  12. Shu J, Santulli G. Update on peripheral artery disease: Epidemiology and evidence-based facts. Atherosclerosis. 2018;275:379-381. doi:10.1016/j.atherosclerosis.2018.05.033
  13. Zemaitis MR, Boll JM, Dreyer MA. Peripheral arterial disease. StatPearls. 2022.
  14. Aday AW, Matsushita K. Epidemiology of peripheral artery disease and polyvascular disease. Circulation Research. 2021;128(12):1818-1832. doi:10.1161/circresaha.121.318535
  15. Centers for Disease Control and Prevention. Peripheral arterial disease (PAD).
  16. Umuerri EM. Skin manifestations of peripheral artery disease: Prevalence and diagnostic utility. Journal of Clinical and Preventive Cardiology. 2019;8(3):121. doi:10.4103/jcpc.jcpc_11_19
  17. National Heart, Lung, and Blood Institute. Peripheral artery disease - Symptoms.
  18. Star A. Differentiating lower extremity wounds: Arterial, venous, neurotrophic. Seminars in Interventional Radiology. 2018;35(05):399-405. doi:10.1055/s-0038-1676362
  19. Zimmerman B, Williams D. Peripheral pulse. StatPearls. 2022.
  20. Mohler III ER. Peripheral arterial disease. Archives of Internal Medicine. 2003;163(19):2306. doi:10.1001/archinte.163.19.2306
  21. McDermott MM, Ferrucci L, Gonzalez-Freire M, et al. Skeletal muscle pathology in peripheral artery disease. Arteriosclerosis, Thrombosis, and Vascular Biology. 2020;40(11):2577-2585. doi:10.1161/atvbaha.120.313831
  22. MedlinePlus. Ischemic ulcers - self-care.
  23. Kinlay S. Management of critical limb ischemia. Circulation: Cardiovascular Interventions. 2016;9(2). doi:10.1161/circinterventions.115.001946
  24. MedlinePlus. Physical exam frequency.
  25. Centers of Disease Control and Prevention. Preventing high cholesterol.
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