Pain in the Lower Extremity in Adults

24 Pain in the Lower Extremity in Adults


To diagnose pain in the lower extremity accurately, the physician must determine whether the pain is articular (hip, knee, or ankle) or nonarticular (muscular, vascular, or neurologic). In addition, the examiner should note whether the pain is present at rest or is primarily associated with exercise. The most likely causes of pain in a child’s leg are different from those in an adult. Therefore, lower extremity pain in adults and lower extremity pain and a limp in children are reviewed in separate chapters.


In adults the most common causes of leg pain are muscular and ligamentous strains; degenerative joint disease (DJD), particularly of the hip and knee; intermittent claudication due to arterial insufficiency; spinal stenosis; sciatica; night cramps; varicose veins; thrombophlebitis; gout; and trauma. The major clues to diagnoses are as follows:






Nature of Patient


Knee pain in children and adolescents is usually due to patellar subluxation, patellar tendinitis, tibial apophysitis, or musculoligamentous strain.


The most common cause of leg pain in adults is muscular or ligamentous strain, seen more frequently in “weekend athletes.” Questioning usually reveals a history of unusual or strenuous exercise. The usual causes of leg pain in joggers and runners are shin splints, stress fractures, and compartment syndromes. The most common is shin splints, a musculotendinous inflammation of the anterior tibia that occasionally involves the periosteum. The pain is usually on the anterior aspect of the tibia, particularly the distal third along the medial crest, but it can occur on the lateral aspect of the tibia as well. Shin splints are most common in less well-conditioned athletes and are most frequently reported early in the running season. Skiers often experience anterior knee pain due to patellofemoral problems.


Anterior knee pain due to abnormal patellar tracking is more common in women and adolescents. Patellar problems are more common in young women, often beginning in adolescence. During pregnancy the common causes of painful legs include venous insufficiency, postphlebitic syndrome, thrombophlebitis, muscle cramps, and trauma. Patients who kneel frequently (carpet installers and floor washers) often have prepatellar bursitis.


DJD is uncommon in patients younger than 40 years unless it has been facilitated by unequal leg length (causing DJD of the hip) or prior trauma, such as athletic injuries of the knee. After age 40, pain in the hip or knee is typically caused by DJD. Sports injuries, including trauma, ligamentous sprains and tears, meniscal tears, and overuse syndromes, are also more common in adults older than 40 years. Inflammatory arthritis includes rheumatoid arthritis, septic arthritis, and gout. Osteoarthritis and Baker’s cyst occur more frequently in older adults.


In patients age 50 or older, calf pain precipitated by walking or exercise that abates with rest is most likely from peripheral arterial insufficiency (peripheral artery disease). Pain in the hip from intermittent claudication is seen in patients with aortoiliac disease. When exercise-induced calf pain occurs in younger adults, frequently with a history of phlebitis, venous claudication is probable. Gout is most common in older men but can occur in women, particularly those who have had early menopause (natural or surgically induced). Patients with gout may or may not have a family history of the condition. Often a history of a prior attack can be elicited. Classic gouty pain occurs in the big toe, but it may occur in other toes or the ankles or knees; it is rare in the hip.



Nature of Symptoms


Anterior knee pain is most often caused by patellar tendinitis, patellofemoral malalignment, or chondromalacia patellae (also known as anterior knee pain syndrome). Pain due to patellofemoral malalignment is usually aching in quality, has a gradual onset, and is located in the peripatellar region. It is often bilateral and is worse with activity such as stair climbing, hill climbing, skiing, and squatting and after prolonged sitting. Sharp pain in the knee, particularly the medial aspect, suggests synovial impingement or structural difficulties such as loose bodies. Aching joint pain is usually seen in inflammatory conditions with diffuse involvement of the synovium, such as those found in rheumatoid arthritis.





Effects of Exercise and Rest on Pain


Leg pain that develops during walking occurs in patients with arterial insufficiency, venous insufficiency, spinal stenosis, and thrombophlebitis.






Spinal Stenosis


Spinal stenosis is another cause of leg pain that is exacerbated by exercise. The pain (pseudoclaudication) is similar to that associated with arterial insufficiency; it also occurs more frequently in older men. The first clue that the pain in the leg is not caused by arterial insufficiency is the presence of normal pedal pulses. Although both begin with exercise, the pain of spinal stenosis is less often relieved by rest than the pain of arterial insufficiency (Table 24-1). The pain of intermittent claudication is relieved within a few minutes, whereas the pain of spinal stenosis requires 10 to 30 minutes to subside. Some patients with calf pain from spinal stenosis state that they must sit or lie down with the thighs flexed to relieve the discomfort.


Table 24-1 Comparison of Symptoms and Signs in Vascular and Spinal (Neurogenic) Claudication























































  VASCULAR CLAUDICATION NEUROGENIC CLAUDICATION
Backache Uncommon; occurs in aortoiliac occlusion Common but need not be present
Leg symptoms Quantitatively related to effort May be brought on by effort; directly related to posture of extension of spine
Quality Cramplike, tight feeling; intense fatigue; discomfort; pain may be absent Numbness, cramplike, burning, paresthetic; sensation of cold or swelling; pain may be absent
Relief Rest of affected muscle group Rest not enough; postural alteration of spine to allow flexion is necessary in most
Onset Simultaneous onset in all parts affected Characteristic march up or down legs
Urinary incontinence Does not occur Very rare
Impotence Common in aortoiliac disease (failure to sustain erection) Very rare (failure to achieve erection)
Wasting of legs Global in aortoiliac disease Cauda equina distribution in severe cases
Trophic changes May be present; absent in aortoiliac disease Absent but may be present in combined disease
Sensory loss Absent Not uncommon; common after exercise
Ankle jerks Often absent in patients > 60 yr old Common, particularly after exercise
Straight-leg raising Full Often full

From DeVilliers JC: Combined neurogenic and vascular claudication. SA Med J 57:650-654, 1980.


The pain of spinal stenosis is caused by localized narrowing of the spinal canal due to a structural abnormality that results in cauda equina compression. Patients occasionally complain of backache or buttock pain as well as numbness and tingling in the feet with walking. Walking uphill is easier than walking downhill for these patients. They have no problem riding a bicycle, probably because the stooped position assumed during this activity reduces the amount of cauda equina compression. The examiner must remember that vascular claudication and spinal stenosis can coexist.


Mar 21, 2018 | Posted by in BIOCHEMISTRY | Comments Off on Pain in the Lower Extremity in Adults
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