If you have diabetes, you already know the condition affects your body in ways that go far beyond blood sugar. You monitor your eyes. You check your kidney function. You watch your feet for sores. But there’s one complication that often goes undetected until it’s advanced—and it’s the one most likely to cost you a limb.
Peripheral artery disease (PAD) affects approximately 6.5 million Americans, and people with diabetes are at dramatically higher risk. The intersection is so dangerous that a landmark 2025 ACC Scientific Statement (Das et al., JACC 2025) was published specifically to address the unique challenges of diagnosing and managing PAD in diabetic patients—challenges that the broader 2024 ACC/AHA PAD Guideline only briefly touched on.
The core problem is deceptively simple: diabetes can mask the very symptoms that would otherwise alert you to PAD. And by the time the disease becomes obvious—a wound that won’t heal, pain at rest, discolored toes—you may already be facing chronic limb-threatening ischemia (CLTI), where the one-year amputation rate runs 15–20%.
At Surgical Associates (SACMD), our vascular team screens for and treats PAD in diabetic patients across Maryland, DC, and Northern Virginia. This article is about what happens before treatment—the screening and early detection that can change your trajectory entirely.
Why Diabetes and PAD Are Such a Dangerous Combination
To understand why early screening matters, you need to understand how diabetes attacks your blood vessels from two directions simultaneously.
Accelerated atherosclerosis. Diabetes speeds up the process by which plaque builds up inside your arteries. In non-diabetic PAD patients, disease tends to concentrate in the larger arteries of the thigh and pelvis (the femoral and iliac arteries). In diabetic patients, the disease is more likely to also involve the smaller arteries below the knee—the tibial and peroneal arteries—which are the vessels that supply blood to the foot. This pattern of below-the-knee disease is particularly dangerous because it directly threatens foot perfusion, wound healing, and limb viability.
Diabetic neuropathy masks symptoms. Here is the critical clinical problem. The classic symptom of PAD is claudication—cramping or aching pain in the calves, thighs, or buttocks when walking, which goes away with rest. This pain is the body’s alarm system: it tells you that your muscles aren’t getting enough blood. But diabetic neuropathy—nerve damage caused by chronically elevated blood sugar—can destroy that alarm system. When you can’t feel the pain, you don’t know the blood flow is compromised. The disease progresses silently. As the 2025 ACC Scientific Statement puts it: PAD is underdiagnosed in people with diabetes, leading to missed opportunities to implement intensive preventive therapies.
Microvascular disease adds to the problem. Beyond the large arteries, diabetes also damages the tiny blood vessels (the microvasculature) that supply the skin, nerves, and tissues of the foot. This microvascular damage compounds the effects of large-vessel PAD, making wounds slower to heal and infections more likely to take hold. Other markers of microvascular disease—diabetic kidney disease, diabetic retinopathy, and neuropathy—are strongly associated with worse outcomes in patients who also have PAD.
PAD may be the first sign of broader cardiovascular disease. The 2025 ACC statement notes that PAD may be the most frequent first manifestation of cardiovascular disease in patients with diabetes. Detecting PAD early doesn’t just protect your limbs—it identifies you as someone at elevated risk for heart attack and stroke, opening the door to preventive therapies (including the rivaroxaban-aspirin combination discussed in the 2024 PAD guideline).
The Screening Test: ABI — And Why It Can Mislead in Diabetes
The ankle-brachial index (ABI) is the standard screening test for PAD. It’s painless, takes about 15 minutes, and compares blood pressure at your ankle to blood pressure in your arm. A normal ABI is 1.00 to 1.40. An ABI below 0.90 indicates PAD.
For most patients, the ABI is reliable and accurate. But for diabetic patients, there’s an important caveat: arterial calcification can produce falsely normal or even falsely elevated ABI readings.
Diabetes accelerates medial arterial calcification—a process in which calcium deposits stiffen the walls of the arteries, making them less compressible. When the blood pressure cuff squeezes the ankle during an ABI test, a calcified artery resists compression and gives an artificially high pressure reading. The result? A “normal” ABI in a patient who actually has significant arterial disease.
This is why the 2025 ACC Scientific Statement and the 2024 PAD guideline both emphasize the importance of alternative diagnostic tests when the ABI is unreliable in diabetic patients.
Toe-brachial index (TBI). The small arteries in the toes are less susceptible to calcification. A TBI test uses a small cuff on the toe to measure pressure, providing a more accurate assessment. A TBI below 0.70 suggests PAD.
Pulse volume recordings (PVR). These tests measure changes in the volume of blood flowing through the legs and feet at different levels, providing a functional assessment of blood flow that isn’t affected by vessel calcification.
Arterial duplex ultrasound. This imaging test uses sound waves to directly visualize blood flow through the leg arteries and can identify areas of narrowing or blockage.
What to ask your doctor: “Given my diabetes, is a standard ABI reliable for me, or should we also check a toe-brachial index?”
Who Should Be Screened — And When
The 2025 ACC Scientific Statement provides specific consensus recommendations for PAD screening in diabetic patients:
Patients with diabetes should have ABI measurements performed when they reach age 50. This is regardless of whether they have symptoms. For patients with additional risk factors—smoking history, hypertension, high cholesterol, chronic kidney disease, or a family history of PAD—screening may be appropriate even earlier.
Patients under 50 with diabetes AND at least one additional atherosclerotic risk factor should also be considered for screening.
Any diabetic patient with foot complications—including neuropathy, history of foot ulcers, or structural foot deformities—should be evaluated for PAD, as these patients are at the highest risk for limb-threatening complications.
Routine foot examination and pulse palpation should be performed consistently in routine care. The ACC statement emphasizes that careful physical examination—checking for pedal pulses, skin temperature changes, hair loss on the legs, and slow-healing wounds—should be a standard part of every diabetic patient’s regular visit.
What to ask your doctor: “I’m over 50 with diabetes. Have I ever had an ABI test? If not, can we schedule one?”
The DMV Context: Why This Matters Locally
The diabetes-PAD connection is not an abstract public health issue in our region. It’s a daily clinical reality.
Prince George’s County, Maryland—home to Surgical Associates’ Camp Springs and Waldorf offices—has some of the highest diabetes prevalence rates in the state. Southeast Washington, DC, which our DC office serves, has among the highest rates of diabetes-related hospitalizations and amputations in the District. These communities also experience documented disparities in access to vascular care and revascularization procedures.
The 2024 ACC/AHA PAD Guideline explicitly acknowledges that racial and ethnic disparities in PAD detection, management, and outcomes are a major public health issue. Amputation rates are significantly higher among Black patients compared to White patients—a disparity driven in part by later diagnosis, less access to vascular specialists, and lower rates of limb-saving revascularization procedures.
Early screening is one of the most effective tools we have to close this gap. An ABI test costs very little, takes minutes, and can identify disease years before it becomes limb-threatening. The challenge is making sure that every patient who needs this test actually gets it.
At Surgical Associates, we offer ABI and vascular screening at all five locations: Camp Springs, Waldorf, and Silver Spring in Maryland; Washington, DC; and Reston, Virginia. No referral is required to schedule a vascular evaluation.
What Happens If PAD Is Detected Early
The entire point of early screening is that PAD caught early is far more manageable than PAD caught late. When disease is identified in the asymptomatic or early symptomatic stage, the treatment plan focuses on medical therapy and lifestyle intervention that can dramatically slow progression and reduce the risk of major cardiovascular and limb events.
This includes high-intensity statin therapy for cholesterol management, blood pressure optimization (the 2024 guideline recommends ACE inhibitors or ARBs for PAD patients), glycemic control (A1C targets tailored to the individual patient), smoking cessation (the single most impactful modifiable risk factor), structured exercise therapy (a Class 1 recommendation in the 2024 guideline for symptomatic patients), antithrombotic therapy including the rivaroxaban-aspirin combination for eligible patients, and preventive foot care coordinated with podiatry.
When caught early, many PAD patients never progress to the point where they need a procedure. And for those who do eventually need revascularization—angioplasty, stenting, or atherectomy—the outcomes are dramatically better when intervention happens before tissue loss occurs.
What to ask your doctor: “What is my current PAD risk profile, and what medical therapies should I be on to protect my limbs and my heart?”
The Bottom Line
Diabetes doesn’t just raise your risk of PAD—it actively hides the disease from you by destroying the nerve signals that would otherwise sound the alarm. By the time you notice a problem, the disease may already be advanced.
That’s why screening matters. A simple, painless ABI test—sometimes supplemented with a toe-brachial index for accuracy in calcified arteries—can detect PAD years before it threatens your limb. And early detection opens the door to the full range of evidence-based therapies that can prevent progression.
If you have diabetes and you’ve never had a vascular screening, this is your signal. Don’t wait for a wound that won’t heal or pain that wakes you up at night. Get screened.
Schedule a PAD screening: Call (240) 427-1630 or visit www.sacmd.com
Related reading on Surgical Associates:
Disclaimer: This article is for informational purposes only and does not constitute medical advice. Screening recommendations should be discussed with your physician based on your individual risk factors and medical history.
References:
- Das SR, Bonaca MP, Creager MA, et al. Management of Peripheral Artery Disease in Adults With Diabetes: 2025 ACC Scientific Statement. J Am Coll Cardiol. 2025. doi:10.1016/j.jacc.2025.11.027.
- Gornik HL, et al. 2024 ACC/AHA/Multisociety Guideline for the Management of Lower Extremity Peripheral Artery Disease. J Am Coll Cardiol. 2024;83(24):2497-2604.
- Allison MA, et al. Health Disparities in Peripheral Artery Disease: A Scientific Statement From the American Heart Association. Circulation. 2023;148:286-296.
- ACC Scientific Statement Provides Guidance For Managing PAD in Patients With Diabetes. American College of Cardiology. December 17, 2025.
Dr. Rahbar is an esteemed vascular surgeon at Surgical Associates, known for their exceptional contributions to the field of vascular surgery. As a board-certified vascular surgeon with over 20 years of invaluable experience, Dr. Rahbar is a respected authority in the medical community serving Camp Spring, Maryland and the whole community of Maryland. Their unwavering dedication to providing advanced care for patients with diseases of the arteries and veins has earned them a reputation for excellence. Dr. Rahbar’s work embodies a passion for precision and compassion, improving the lives of those they serve, one procedure at a time.