[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Clinical exam](https://durgical.com/en/clinical-exam/) › [Cardiovascular system](https://durgical.com/en/clinical-exam/#a-cardiovascular) › Peripheral pulses and the ankle–brachial index [Clinical exam](https://durgical.com/en/clinical-exam/) · [Cardiovascular system](https://durgical.com/en/clinical-exam/#a-cardiovascular) # 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](https://durgical.com/en/anatomy/femoral-artery/) · [Popliteal artery](https://durgical.com/en/anatomy/popliteal-artery/) · [Dorsalis pedis artery](https://durgical.com/en/anatomy/dorsalis-pedis-artery/) · [Posterior tibial artery](https://durgical.com/en/anatomy/posterior-tibial-artery/) · [Brachial artery](https://durgical.com/en/anatomy/brachial-artery/) · [Radial artery](https://durgical.com/en/anatomy/radial-artery/) · [Common carotid artery](https://durgical.com/en/anatomy/right-common-carotid-artery/) ## Key points - ABI = ankle systolic pressure / higher brachial systolic pressure. - ABI 0.90 or less = peripheral artery disease; above 1.40 = non-compressible arteries. - Dorsalis pedis: lateral to the extensor hallucis longus tendon; posterior tibial: behind the medial malleolus. - Pulse scale: 0 to 4+, normal 2+. ## 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. [Add to my cards (4)](https://durgical.app/estudiar/?add=/en/clinical-exam/peripheral-pulses-and-the-ankle-brachial-index/) ## See it in 3D The structures of Durgical's 3D anatomy where it is found. - [Femoral artery](https://durgical.com/en/anatomy/femoral-artery/) - [Popliteal artery](https://durgical.com/en/anatomy/popliteal-artery/) - [Dorsalis pedis artery](https://durgical.com/en/anatomy/dorsalis-pedis-artery/) - [Posterior tibial artery](https://durgical.com/en/anatomy/posterior-tibial-artery/) - [Brachial artery](https://durgical.com/en/anatomy/brachial-artery/) - [Radial artery](https://durgical.com/en/anatomy/radial-artery/) - [Common carotid artery](https://durgical.com/en/anatomy/right-common-carotid-artery/) ## Related - [Arterial pulse: rate, rhythm and amplitude](https://durgical.com/en/clinical-exam/arterial-pulse-rate-rhythm-and-amplitude/) - [Acute limb ischemia and chronic arterial insufficiency](https://durgical.com/en/clinical-exam/acute-limb-ischemia-and-chronic-arterial-insufficiency/) - [Allen test](https://durgical.com/en/clinical-exam/allen-test/) - [Capillary refill time](https://durgical.com/en/clinical-exam/capillary-refill-time/) - [Blood pressure measurement](https://durgical.com/en/clinical-exam/blood-pressure-measurement/) ## Related conditions - [Peripheral artery disease](https://durgical.com/en/conditions/peripheral-artery-disease/) - [Acute limb ischaemia](https://durgical.com/en/conditions/acute-limb-ischaemia/) - [Abdominal aortic aneurysm](https://durgical.com/en/conditions/abdominal-aortic-aneurysm/) - [Coarctation of the aorta](https://durgical.com/en/conditions/coarctation-of-the-aorta/) - [Aortic dissection](https://durgical.com/en/conditions/aortic-dissection/) [← All of the clinical exam](https://durgical.com/en/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](https://openstax.org/books/clinical-nursing-skills/pages/24-3-nursing-assessment) (OpenStax (Rice University), 2024); [Peripheral artery disease - legs: MedlinePlus Medical Encyclopedia](https://medlineplus.gov/ency/article/000170.htm) (MedlinePlus, U.S. National Library of Medicine, 2026); [Pulse: MedlinePlus Medical Encyclopedia](https://medlineplus.gov/ency/article/003399.htm) (MedlinePlus, U.S. National Library of Medicine, 2026). ## **Spotted a mistake?** We are always improving for the community. Tell us what is wrong and our team will review it. Report a mistake Representative model, for educational purposes only. --- Source: https://durgical.com/en/clinical-exam/peripheral-pulses-and-the-ankle-brachial-index/ License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/clinical-exam/peripheral-pulses-and-the-ankle-brachial-index/