Ischemic Rest Pain: Ischemic rest pain is a grave symptom caused by ischemic neuritis- indicates advanced aerial insufficiency that usually terminates in gangrene and amputation of the extremity if aerial reconstruction cannot be performed. In ischemic rest pain there is severe burning pain usually confined to the forefoot distal to the metatarsals. It may be localized to the vicinity of an ischemic ulcer or pre gangrenous toe. It is aggravated by the elevation of the extremity or by bringing the leg to the horizontal position. Thus, it appear at bed rest (hence the name) and may prevent sleep. Because gravity aids the delivery of aerial blood, classically, the patient with rest pain can obtain relief by simply hanging the leg over the side of the bed. This simple maneuver will not relieve the pain caused by peripheral neuropathy, the most common cause of foot pain at rest. If the foot is constantly kept dependant to relieve pain, the leg and foot may be swollen, causing some confusion in diagnosis. Ischemic neuritis pain is severe and resistant to opioid for relief. Rest pain occur when blood flow is inadequate to meet metabolic requirements. In the lower extremity, ischemic rest pain is localized to the forefoot and generally is easily distinguished from benign nocturnal muscle cramps in the calf, which are also common in old patients. Patients often have trophic changes, such as muscle wasting, thinning of skin, thickening of nails, and hair loss in the distal affected limb. Ref: L & B 25/e, page 909-10 ; Sabiston 18/e, page 1954-59 ; Textbook of Surgery By S. Das 5/e, page 180-82