Pain in the leg
Dr Wrishi Raphael
Pain in the leg has many causes, varying from a simple cramp to an arterial occlusion. Overuse of the legs in the athlete can lead to a multiplicity of painful leg syndromes, ranging from simple sprains of soft tissue to compartment syndromes. A major cause of leg pain lies in the source of the nervous network to the lower limb, namely the lumbar and sacral nerves of the spine. It is important to recognize radicular pain, especially from L5 and S1 nerve roots, and also the patterns of referred pain, such as from facet joints and sacroiliac joints.
Probability diagnosis
Many of the causes, such as foot problems, ankle injuries and muscle tears (e.g. hamstrings and quadriceps), are obvious and common. There is a wide range of disorders related to overuse syndromes in athletes. A very common cause of acute severe leg pain is cramp in the calf musculature.
One of the commonest causes is nerve root pain, invariably single, especially affecting the L5 and S1 nerve roots. Tests of their function and of the lumbosacral spine for evidence of disc disruption or other spinal dysfunction will be necessary. Should multiple nerve roots be involved, other causes, such as compression from a tumor, should be considered.
Growing pains
So-called growing pains, or idiopathic leg pain, is thought to be responsible for up to 20% of leg pain in children. Such a
diagnosis is vague and often made when a specific cause is excluded. It is usually not due to growth but related to excessive exercise or trauma from sport and
recreation, and probably emotional factors.
The pains are typically intermittent and symmetrical and deep in the legs, usually in the anterior thighs or calves. Although they may occur at any time of the day or night, typically they occur at night, usually when the child has settled in bed. The pains usually last for 30 to 6o minutes and tend to respond to attention such as massage with an analgesic balm or simple analgesics.
Leg pain in the elderly
The older the patient, the more likely it is that arterial disease with intermittent claudication and neurogenic claudication due to spinal canal stenosis will develop.
Other important problems of the elderly include degenerative joint disease, such as osteoarthritis of the hips and knees, muscle cramps, herpes zoster, Pagets disease, polymyalgia rheumatica (affecting the upper thighs) and sciatica.
Vascular causes of leg pain, only a few are considered here:
1] Occlusive arterial disease
Risk factors for peripheral vascular disease (for development and deterioration):
Smoking
Diabetes Mellitus
Hypertension
Hypercholesterolaemia
Family History
Signs and symptoms-the 6 Ps
Pain
Pallor
Paraesthesia or numbness
Pulse less
Paralysis
Perishing cold
2] Venous disorders
The role of uncomplicated varicose veins as a cause of leg pain is controversial. Nevertheless,
varicose veins can certainly cause a dull aching heaviness and cramping, and can lead to painful ulceration. Superficial thrombophlebitis is usually obvious,
but it is vital not to overlook deep venous thrombosis. These more serious conditions of the veins can cause pain in the thigh or calf.
Management of occlusive vascular disease
Prevention (for those at risk)
Smoking is the risk factor and must be stopped.
Other risk factors, especially hyperlipidaemia, must be attended to and weight reduction to ideal weight is important.
Exercise is excellent, especially walking.
Diagnostic plan
Check if patient is taking beta-blockers.
General tests: blood examination, random blood sugar, urine examination, ECG. Measurement of blood flow by duplex ultrasound examination or ankle brachial index is important.
Arteriography should be performed only if surgery is contemplated.
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