Poor Circulation in the Extremities

Circulation is blood pumping through the body. The heart is the main pump that pushes the blood. The heart is controlled by the Autonomic Nervous System (ANS), the part of the nervous system that keeps the internal workings of the body going, automatically. You cannot consciously control your heart beating or pumping blood through your arteries and veins.

Blood flow works best in the body areas closest to the heart. The further away from the heart, the less efficient blood flow can be. Toes are the farthest body part from the heart which is why they are at the most risk for poor circulation. Fingers are also more distant from the heart, although not as far as the toes.

Although the heart pumps blood, there is some help along the way. Little shelf like formations are inside the blood vessels which holds blood in place between the lub dub of heart beats. Your muscles also help blood flow by massaging the blood vessels when muscles are activated.

Decreased blood flow in the legs and arms is something that can happen to anyone. Internally, there can be a decrease in blood pressure unable to keep the tiny vessels open. Externally, too much pressure on the skin over boney prominences crushes small blood vessels and blood flow leading to pressure injury.

Detriments to blood flow include some diseases such as diabetes which affects arteries and veins, peripheral vascular disease, coronary artery disease, blood clots and, atherosclerosis or plaque or calcification in the blood vessels. Some medications also play a part in restricting blood flow.

Today, let’s look at decreased blood pressure in the legs from another point of view than pressure injury. Too weak of blood flow from any cause can lead to pain or venous stasis ulcers better known as leg sores. These ulcerations appear anywhere on the legs and even occasionally on the arms. Since the toes and fingers are the farthest points of the body away from the heart, blood flow is slowest in these areas (the least amount of blood pressure).

Just because you have a spinal cord injury does not mean that you will develop venous status ulcers. In fact, most individuals with SCI do not develop this problem. However, having knowledge about a condition is a good step in ensuring you do not develop it. Like many conditions, the earlier treatment begins, the easier the problem is to correct.

A combination of issues can lead to poor circulation. Sedentary lifestyle or not moving your extremities much is one factor. Chronic conditions especially diabetes atherosclerosis, heart disease and obesity are others. Smoking constricts blood vessels. Constriction of blood vessels from a mechanical point of view decreases circulation. This can be from too tight clothing or leg bags, too tight restraints such as seatbelts and spasm fasteners, crossing your legs, ‘hooking’ your arm around the back of your chair and lack of mobility.

Signs and symptoms of poor circulation might include things a person with spinal cord injury may not sense such as cold hands and feet, pain, joint and muscle cramping, and numbness and tingling in the hands and feet. An individual with a spinal cord injury might notice these symptoms: swelling in the feet, ankles, legs, hands and arms, skin color changes, ulcers, varicose veins, digestive issues, tiredness, memory loss and difficulty concentrating. In particular, you might have sensations of spasms or episodes of Autonomic Dysreflexia.

There are ways you can check for poor circulation. First look at your extremities for changes in skin color. Your feet or hands may look mottled or splotchy.

Second, feel your extremities for temperature. An ever so slight coolness to your feet and lower legs, hands and lower arms can be room temperature differences. A noticeable difference to one or both of your extremities could be indicative of poor circulation.

Third, check your pulses. The pedal (foot) pulses can be hard to find. One is on the top of the foot and one behind the inner ankle. The picture below will show you where they are. You will have to feel around to find your pulses as everyone’s are not in the exact same location. Use a light touch when finding the pedal pulse as even a slight pressure can occlude them. Feet pulses can be very hard to find. The wrist pulse is on the inner wrist just below the line of the thumb. You have had this checked by health professionals many times. There is also a faint pulse on the inside of the elbow toward the side of the body. Pulses should be equal on each side and rhythmic.

Arm pulses are assessed by using the index and middle finger together on the areas marked with an X.arm diagram

Pedal (foot) pulses are assessed using the index and middle finger together on the areas marked with an X. Generally, the top of the feet are assessed at one time with the examiner using both hands, fingers on each foot to compare similarity.

Edema can make feeling your feet or arm pulses difficult. A healthcare professional might want to assess your pulses if they are difficult to locate. Blood flow is assessed with a doppler test which is a device that is placed on the skin over the pulse area. A special transmitting lubricant (not catheterization or bowel program lubricant) is used to enhance the pulse location. If further studies are needed, blood flow studies, CT or MRI tests might be done.foot diagram


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You can assist with improving your blood flow by wearing compression stockings or gloves. These apply a slight tension to the skin which creates a very light compression internally making the inside of the body tighter. The resistance then improves blood flow. Elevating your legs and arms to reduce edema and facilitate return blood flow by using gravity is also helpful. Drink fluid, especially water, according to your catheterization needs, to increase overall blood volume. Check your medications to see if any of your prescriptions constrict blood flow. Keep chronic disease under control such as following a healthy diet and taking prescribed medications, especially if you are diabetic or have chronic heart disease. Provide movement to your extremities through range of motion exercises to activate your muscles for the pumping action to the blood vessels. If you have a genetic family history of poor circulation or other health problems that can lead to poor blood flow, attempt a preventative program to avoid or delay onset.

Massage is not recommended for stimulation of blood flow as it is not long lasting, increases constriction through pressure and can release an undiagnosed blood clot.

Poor circulation can become quite a serious problem. If poor blood flow develops, there are surgeries to re-route blood flow to the extremities. This is typically performed much later in vascular disease. Should the problem become such that re-routing blood flow does not help, amputation may be needed. Amputation is performed at the level where your circulation is still effective, not just at the site of the issue.

Some will suggest amputation early on especially if you have a spinal cord injury. Regardless of your SCI, amputation should only be done as a last resort. If someone does not want to offer another solution first, and there is still time for another option to work, it is appropriate to look for less radical medical treatments. If the limb can be saved, you do not have to have an amputation just because you have a spinal cord injury. Amputation may be necessary for your condition but not as an excuse.

As stated, poor circulation leading to vascular issues can be an issue in individuals with spinal cord injury. The risk factors are enhanced due to spinal cord injury. Being educated and aware can help you in noticing a problem that could be lurking in your health history. Nurse Linda

Pediatric Consideration: Children typically have great body function, healthier skin, better circulation, just better functioning body systems because they have not been exposed to the excesses of life. However, diseases that have been noted in the elderly are creeping down the chronology of humans. Problems relegated to the elderly are now in the pediatric population. Adding the issue of spinal cord injury, adds risks as well.

You can help your child maintain good health by providing a healthy environment and diet for your child and role modeling a healthy lifestyle yourself. Following care guidelines for healthy living with a spinal cord injury will maintain your child’s wellbeing. 

About the Author - Nurse Linda

Linda Schultz, Ph.D., CRRN is a leader, teacher, and provider of rehabilitation nursing for over 30 years. In fact, Nurse Linda worked closely with Christopher Reeve on his recovery and has been advocating for the Reeve Foundation ever since.

Nurse Linda

The opinions expressed in these blogs are the author's own and do not necessarily reflect the views of the Christopher & Dana Reeve Foundation.