Peripheral pulses and the ankle–brachial index !

Exam technique

Feeling the pulses in arms and legs and comparing ankle and arm blood pressure uncovers blocked arteries.

Updated 2026-11-01

See it in 3D: Femoral artery · Popliteal artery · Dorsalis pedis artery · Posterior tibial artery · Brachial artery · Radial artery · Common carotid artery

What it is

Pulses are felt bilaterally and symmetrically, head to toe, and graded. The ankle–brachial index (ABI) compares systolic pressure at the ankle with that in the arm and is the bedside test for peripheral artery disease.

Landmark anatomy

The abdominal aorta divides into the iliacs; the femoral continues in the thigh, becomes the popliteal behind the knee and divides into the tibials; the dorsalis pedis continues the anterior tibial.
Claudication appears one level below the blockage: calves for femoropopliteal disease, buttocks and thighs for aortoiliac disease.
The dorsalis pedis is absent as an anatomical variant in a minority of healthy people.

Technique, step by step

Compare each pulse with the other side: carotid, brachial, radial, femoral, popliteal, posterior tibial and dorsalis pedis.
Femoral: below the inguinal ligament, midway between the anterior superior iliac spine and the pubic symphysis.
Popliteal: knee slightly flexed, fingertips of both hands deep in the popliteal fossa.
Posterior tibial: behind and below the medial malleolus. Dorsalis pedis: dorsum of the foot, lateral to the extensor hallucis longus tendon.
Grade: 0 absent, 1+ weak, 2+ normal, 3+ increased, 4+ bounding. Listen over the carotids, abdominal aorta and femorals for bruits.
ABI: supine and rested, use a cuff and Doppler to measure systolic pressure in both arms and at the dorsalis pedis and posterior tibial of each ankle.
ABI for each leg = the higher ankle pressure on that side divided by the higher brachial pressure.

Abnormal findings

Normal ABI: 1.00 to 1.40. 0.91 to 0.99: borderline. 0.90 or less: peripheral artery disease. Very low (below 0.40): severe ischemia.
ABI above 1.40: calcified, non-compressible arteries (diabetes, chronic kidney disease); unreliable, so the toe–brachial index is used.
Weak femoral pulse delayed against the radial: coarctation of the aorta. Pulse or pressure difference between arms: aortic dissection or subclavian stenosis.
Absent pulses with cool, pale, hairless skin and thick nails: chronic arterial insufficiency.

Common errors

Mistaking the examiner's own pulse for the patient's (use fingertips, never the thumb).
Wrong cuff size or measuring without prior rest.
Not using the higher brachial pressure of the two arms.

Test yourself

Think of the answer, then tap the question to see it.

How is the ankle–brachial index of one leg calculated?

The higher ankle systolic pressure of that leg (dorsalis pedis or posterior tibial) divided by the higher brachial systolic pressure.

Which ankle–brachial index value indicates peripheral artery disease?

0.90 or less.

Why is an index above 1.40 not reassuring in a patient with diabetes?

It means calcified, non-compressible arteries; the reading is falsely high and can hide arterial disease.

Where is the posterior tibial pulse felt?

Behind and below the medial malleolus.

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See it in 3D

The structures of Durgical's 3D anatomy where it is found.

← All of the clinical exam

Educational content on the clinical exam; it is learned and practised under supervision. It does not replace assessment by a health professional and is not for self-diagnosis.

Sources: 24.3 Nursing Assessment - Clinical Nursing Skills | OpenStax (OpenStax (Rice University), 2024); Peripheral artery disease - legs: MedlinePlus Medical Encyclopedia (MedlinePlus, U.S. National Library of Medicine, 2026); Pulse: MedlinePlus Medical Encyclopedia (MedlinePlus, U.S. National Library of Medicine, 2026).

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Representative model, for educational purposes only.