Leg pain Flashcards
Probability diagnosis
Muscle cramps
Nerve root ‘sciatica’
Varicose veins
Osteoarthritis (hip, knee)
Exercise-related pain (e.g. Achilles tendonitis)
Muscular injury (e.g. hamstring)
Serious disorders not to be missed
Vascular:
- peripheral vascular disease
- arterial occlusion (embolism)
- thrombosis popliteal aneurysm
- deep venous thrombosis
- iliofemoral thrombophlebitis
Neoplasia/cancer:
- primary (e.g. myeloma)
- metastases (e.g. breast to femur)
Infection:
- osteomyelitis
- septic arthritis
- erysipelas/cellulitis
- lymphangitis
- gas gangrene
Pitfalls (often missed)
- Osteoarthritis hip
- Osgood–Schlatter disorder
- Spinal canal stenosis → neurogenic claudication
- Herpes zoster (early)
- Greater trochanteric pain syndrome
- Nerve entrapment (e.g. meralgia paraesthetica)
- ‘Hip pocket nerve’
- Iatrogenic: injection into nerve
- Sacroiliac disorders
- Complex regional pain syndrome I
- Peripheral neuropathy
Rarities:
- osteoid osteoma
- polymyalgia rheumatica (isolated)
- Paget disease
- popliteal artery entrapment
- tabes dorsalis
- ruptured Baker cyst
Masquerades checklist
Depression
Diabetes
Drugs (indirect)
Anaemia (indirect)
Spinal dysfunction
Is the patient trying to tell me something?
Quite possible. Common with work-related injuries.
Key history
Is the pain acute or chronic onset?
Did it follow trauma or activity?
Is it ‘mechanical’ (related to movement)?
Is it postural?
Is it related to walking?
Is the pain arising from bone or from a joint?
PMHx, esp CVD, back pain, trauma history.
Key examination
Watch the walk and assess the nature of any limp.
Note the posture of the back and examine the lumbar spine.
Have both legs well exposed for inspection
Palpate for local causes of pain and if no cause is evident examine the spine, blood vessels and bone.
Note the temperature of the feet and legs
Perform a vascular exam including the peripheral pulses and veins
Neurological exam to test nerve root lesions or entrapment neuropathies
Exam joints, esp hip and sacroiliac joints
Key investigations
FBE and ESR
plain X-ray; knee, hip, lumbosacral spine
CT or MRI, bone scan
Electromyography
Vascular studies: arterial tree or venous system.
Diagnostic tips
Pain that does not fluctuate in intensity with movement, activity or posture has an inflammatory or neoplastic cause.
Varicose veins can cause aching pain in the leg.
Older people may present with claudication in the leg from spinal canal stenosis or arterial obstruction or both.
Think of the hip pocket wallet as a cause of sciatica from the buttocks down.
