Leg Pain: Most Common Causes and Management
Assessment of leg pain includes a broad differential diagnosis. Complaints can fall under several systemic categories. Etiologies include but not limited to pathologies of the musculoskeletal system, the peripheral vascular system, the peripheral nervous system and the integumentary system. A few of these pain complaints are discussed below.
Radicular pain commonly described as “sharp, stabbing, electrical sensations” that travel down the leg is a common form of leg pain. The origin of this pain is usually from the axial spine as a result of compressed nerve roots from lumbosacral disc herniations or degenerative changes. This can ultimately result in lower leg pain, muscle weakness and gait deviations. Management is typically multimodal with a combination of physical therapy, anti-inflammatory medication trial, non-opioid analgesic medication therapy, and neuraxial injections. Opioid therapy is not indicated as first line management of radicular pain. Surgical decompression may be required if there is evidence of neurological compromise of lower extremity function. New advances in neuromodulation therapy have also provided an avenue for relief.
Leg pain of musculoskeletal causes can be seen in the setting of traumatic and overuse injuries. Traumatic injuries often come with a supportive history describing the mechanism of injury. One example of this is anterior cruciate ligament rupture from a high impact forced applied to the lateral knee (seen often in sports related activities). Other causes are seen in settings of overuse. One example of overuse injury is due to persistent high impact running called medial tibial stress syndrome or “shin splints.” This is often seen in long distance runners with complaints of anterior leg pain. Recommended management would be to maintain activity with reduced running mileage, however, tibial stress fracture must be on the differential diagnosis list and be screened for. Plain radiographs may not reveal stress fractures immediately and MRI is the preferred imaging modality if suspicion of a stress fracture is high .
A deep venous thrombosis (DVT) often results in significant calf pain, redness at the site and increase in swelling of the legs. This is often a result of prolonged immobility which occurs in post-surgical states or after a long flight. Other causes include hypercoagulable states such as pregnancy or cancer and direct trauma. Diagnosis of a DVT is performed with a venous Doppler Ultrasound which allows for visualization of appropriate blood flow through the veins of the legs. A dangerous complication of a DVT is a pulmonary embolism. Treatment with blood thinners such as heparin or enoxaparin is the usual course of management. More aggressive management options include placement of an inferior vena cava filter for embolism prevention and surgical thrombectomy.
Another common cause of leg pain is peripheral arterial disease (PAD). This is usually seen in those over the age of 40 years old as a result of long-standing coronary atherosclerosis in combination with other risk factors including high blood pressure, diabetes and smoking. Patients may present with non-healing wounds, hair loss, skin texture changes and intermittent claudication. Severe PAD will result in lower extremity ischemia and, in rare cases, lower limb amputations.
Lastly, skin infections in the leg after trauma tic injury, bite or open incision can also result in leg pain. Commonly known as cellulitis, this cause of leg pain presents with a quick progressive spread of a hot, painful, red inflamed area of the skin. Treatment for cellulitis includes oral or intravenous antibiotics and local wound care.
There are many causes of leg pain. The key to management of leg pain is to establish a clear diagnosis by determining the system being affected by a thorough history and physical examination as noted in the examples discussed above.
References
1. Tarulli AW, Raynor EM. Lumbosacral radiculopathy. Neurol Clin. 2007;25(2):387-405.
2. Groen GJ, Baljet B, Drukker J. Nerves and nerve plexuses of the human vertebral column. Am J Anat. 1990;188(3):282-96.
3. Vroomen PC, De krom MC, Knottnerus JA. Diagnostic value of history and physical examination in patients suspected of sciatica due to disc herniation: a systematic review. J Neurol. 1999;246(10):899-906.
4. Hamstra-wright KL, Bliven KC, Bay C. Risk factors for medial tibial stress syndrome in physically active individuals such as runners and military personnel: a systematic review and meta-analysis. Br J Sports Med. 2015;49(6):362-9.
5. Craig DI. Medial tibial stress syndrome: evidence-based prevention. J Athl Train. 2008;43(3):316-8.
6. Hirsh J, Hull RD, Raskob GE. Clinical features and diagnosis of venous thrombosis. J Am Coll Cardiol. 1986;8(6 Suppl B):114B-127B.
7. Kearon C, Akl EA, Comerota AJ, et al. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e419S-e496S.
8. White RH, Brunson A, Romano PS, Li Z, Wun T. Outcomes After Vena Cava Filter Use in Noncancer Patients With Acute Venous Thromboembolism: A Population-Based Study. Circulation. 2016;133(21):2018-29.
9. Layden J, Michaels J, Bermingham S, Higgins B. Diagnosis and management of lower limb peripheral arterial disease: summary of NICE guidance. BMJ. 2012;345:e4947.
10. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America. Clin Infect Dis. 2014;59(2):147-59.