Why Your Legs Hurt When You Walk: Neurogenic Claudication Explained

The Pattern That Matters

A common scenario I see is someone who used to walk a mile without thinking about it. Now they can barely make it two blocks before their legs start to ache, feel heavy, or go numb. They stop, sit on a bench for a minute, and the symptoms fade. They stand up and walk another block or two before it happens again.

Here's what changes the plan: if sitting or leaning forward relieves the symptoms, the problem is almost certainly coming from your spine, not your circulation.

When you stand upright or walk, your lower spine extends slightly, which narrows the spinal canal. When you sit or lean forward (like over a shopping cart), your spine flexes, the canal opens up, and the pressure on the nerves decreases. That's why people with spinal stenosis often say they can walk farther in the grocery store than on the sidewalk—they're leaning on the cart.

Neurogenic vs Vascular Claudication

Both conditions cause leg pain with walking, but the patterns are different. Here's what I'm listening for:

Common Causes

Lumbar spinal stenosis is the most common cause—narrowing of the spinal canal from arthritis, thickened ligaments, or bulging discs. It's a wear-and-tear condition that typically develops after age 50.

Spondylolisthesis (when one vertebra slips forward on another) can also narrow the canal and cause similar symptoms.

Large disc herniations can compress multiple nerve roots at once, though this usually causes more acute, severe pain rather than the gradual, activity-related pattern of stenosis.

Occasionally, hip arthritis mimics neurogenic claudication—pain with walking that improves with rest. The exam and imaging help sort this out.

What I Look for on Exam

The neurologic exam is usually normal or near-normal at rest. That's part of the pattern—symptoms are activity-related.

I check strength in your ankles and toes, reflexes at the knees and ankles, and sensation in your legs and feet. Sometimes there's subtle weakness or diminished reflexes, but often everything looks fine in the exam room.

I watch you walk. Gait changes—shorter steps, wider base, slower speed—tell me how much the problem is affecting function.

I check pulses in your feet. If they're weak or absent, we need vascular studies before assuming the spine is the only problem.

The straight-leg raise test is usually negative in stenosis (it's more useful for disc herniations). Extension-based maneuvers—having you lean backward—sometimes reproduce the leg symptoms.

Imaging and Tests

MRI is the best test for evaluating the spinal canal and nerve roots. It shows the degree of stenosis, whether there's disc involvement, and whether there's any instability or spondylolisthesis.

Standing X-rays (including flexion-extension views) help assess alignment and whether there's any movement between vertebrae that might require fusion in addition to decompression.

CT scan is occasionally useful if MRI isn't possible or if we need better detail of the bone anatomy for surgical planning.

Vascular studies (ankle-brachial index, arterial Doppler) are needed if pulses are diminished or if the pattern doesn't quite fit neurogenic claudication. Sometimes people have both spine and circulation problems.

What You Can Try First

Conservative treatment makes sense for most people, especially if symptoms are mild to moderate and not rapidly worsening.

Walking strategy: Walk until symptoms start, rest briefly (sitting or leaning forward), then continue. This interval approach can help maintain fitness without overdoing it. Using a shopping cart, walking poles, or a walker encourages the forward-leaning posture that opens the canal.

Physical therapy: Focus on core strengthening and flexion-based exercises. PT won't reverse the stenosis, but it can improve your functional capacity and may delay or eliminate the need for surgery.

Medications: NSAIDs can help with inflammation. Gabapentin or pregabalin sometimes help with nerve-related symptoms, though they don't work for everyone. Muscle relaxants occasionally help if there's a spasm component.

Activity modification: Biking, swimming, and other flexion-based activities are usually better tolerated than prolonged standing or walking.

Give conservative treatment 2-8 weeks. If you're improving, keep going. If you're not, it's time to reassess.

When Injections Help

Epidural steroid injections can be useful when there's an inflammatory component to the nerve compression. They won't fix the stenosis, but they can reduce inflammation and buy you time—sometimes months, occasionally longer.

Here's what success looks like: significant improvement in walking tolerance and leg symptoms for at least several weeks. Even if the relief is temporary, it confirms the diagnosis and suggests that decompression surgery would likely help.

Here's what failure looks like: no improvement at all, or relief that lasts only a few days. This makes me reconsider whether stenosis is the primary problem, or whether there's something else going on (hip arthritis, peripheral neuropathy, vascular disease).

I don't recommend more than 2-3 injections in a year. If they're not providing meaningful, sustained relief, it's time to talk about surgery.

When Surgery Becomes Reasonable

Surgery isn't about "fixing" the MRI. It's about improving function and quality of life when conservative treatment hasn't worked.

Here are the decision points I use:

• Conservative treatment (PT, activity modification, medications) hasn't helped after 2-3 months
• Your walking distance is significantly limited (can't walk more than a block or two)
• The symptoms are affecting your quality of life in a meaningful way
• The MRI shows stenosis that matches your symptoms
• You're medically fit for surgery

Decompression vs fusion: Most people with stenosis need only decompression—removing bone and ligament to create more space for the nerves. Fusion is added only if there's instability (spondylolisthesis with movement on flexion-extension X-rays) or if we need to remove so much bone that the spine might become unstable.

Modern decompression techniques are minimally invasive—smaller incisions, less muscle disruption, faster recovery. Most patients walk the same day and go home the next day.

Realistic outcomes: Most people experience significant improvement in walking tolerance and leg pain. The leg pain often improves immediately. Numbness may take weeks to months to fully resolve, and sometimes doesn't completely go away. Back pain may or may not improve—decompression is primarily for leg symptoms.

Who should pause before surgery: Uncontrolled diabetes, active smoking, severe obesity, and significant medical comorbidities all increase surgical risk and reduce the likelihood of a good outcome. Addressing these factors first—when possible—improves results.

Red Flags — Seek Urgent Care

Most neurogenic claudication develops gradually and isn't an emergency. But certain symptoms require immediate evaluation:

• New weakness in your legs (foot drop, difficulty standing from a chair)
• Loss of bowel or bladder control
• Numbness in the saddle area (groin, inner thighs, buttocks)
• Severe pain at rest that doesn't improve with position changes
• Fever with back pain (possible infection)
• Leg pain after significant trauma
• History of cancer with new or worsening back/leg pain

These symptoms suggest cauda equina syndrome, infection, fracture, or tumor—all of which need urgent imaging and treatment.

Simple Decision Pathway

Frequently Asked Questions