Leg pain

Leg pain: Excerpt from Handbook of Signs & Symptoms (Third Edition)

Although leg pain commonly signifies a musculoskeletal disorder, it can also result from a more serious vascular or neurologic disorder. The pain may arise suddenly or gradually and may be localized or affect the entire leg. Constant or intermittent, it may feel dull, burning, sharp, shooting, or tingling. Leg pain may affect locomotion, limiting weight bearing. Severe leg pain that follows cast application for a fracture may signal limb-threatening compartment syndrome. The sudden onset of severe leg pain in a patient with underlying vascular insufficiency may signal acute deterioration, possibly requiring an arterial graft or amputation. (See Highlighting causes of local leg pain, page 372.)

If the patient has acute leg pain and a history of trauma, quickly take his vital signs and determine the leg’s neurovascular status. Observe the patient’s leg position and check for swelling, gross deformities, or abnormal rotation. Also, be sure to check distal pulses and note skin color and temperature. A pale, cool, and pulseless leg may indicate impaired circulation, which may require emergency surgery.

History and physical examination

If the patient’s condition permits, ask him when the pain began and have him describe its intensity, character, and pattern. Is the pain worse in the morning, at night, or with movement? If it doesn’t prevent him from walking, must he rely on a crutch or other assistive device? Also ask him about the presence of other signs and symptoms.

Find out if the patient has a history of leg injury or surgery and if he or a family member has a history of joint, vascular, or back problems. Also ask which medications he’s taking and whether they have helped to relieve his leg pain.

Begin the physical examination by watching the patient walk, if his condition permits. Observe how he holds his leg while standing and sitting. Palpate the legs, buttocks, and lower back to determine the extent of pain and tenderness. If a fracture has been ruled out, test the patient’s range of motion (ROM) in the hip and knee. Also, check reflexes with the patient’s leg straightened and raised, noting action that causes pain. Then compare both legs for symmetry, movement, and active ROM. Additionally, assess sensation and strength. If the patient wears a leg cast, splint, or restrictive dressing, carefully check distal circulation, sensation, and mobility, and stretch his toes to elicit associated pain.

Medical causes

Bone cancer

Continuous deep or boring pain, commonly worse at night, may be the first symptom of bone cancer

Later, skin breakdown and impaired circulation may occur, along with cachexia, a fever, and impaired mobility.

Compartment syndrome

Progressive, intense lower leg pain that increases with passive muscle stretching is a cardinal sign of compartment syndrome, a limb-threatening disorder

Restrictive dressings or traction may aggravate the pain, which typically worsens despite analgesic administration

Other findings include muscle weakness and paresthesia, but apparently normal distal circulation. With irreversible muscle ischemia, paralysis and an absent pulse also occur.

Fracture

Severe, acute pain accompanies swelling and ecchymosis in the affected leg

Movement produces extreme pain, and the leg may be unable to bear weight. Neurovascular status distal to the fracture may be impaired, causing paresthesia, an absent pulse, mottled cyanosis, and cool skin. Deformity, muscle spasms, and bony crepitation may also occur.

Infection

Local leg pain, erythema, swelling, streaking, and warmth characterize soft-tissue and bone infections

A fever and tachycardia may be present with other systemic signs.

Occlusive vascular disease

Continuous cramping pain in the legs and feet may worsen with walking, inducing claudication

The patient may report increased pain at night, cold feet, cold intolerance, numbness, and tingling. Examination may reveal ankle and lower leg edema, decreased or absent pulses, and increased capillary refill time. (Normal time is less than 3 seconds.)

Sciatica

Pain, described as shooting, aching, or tingling, radiates down the back of the leg along the sciatic nerve

Typically, activity exacerbates the pain and rest relieves it. The patient may limp to avoid exacerbating the pain and may have difficulty moving from a sitting to a standing position.

Strain or sprain

Acute strain causes sharp, transient pain and rapid swelling, followed by leg tenderness and ecchymosis

Chronic strain produces stiffness, soreness, and generalized leg tenderness several hours after the injury; active and passive motion may be painful or impossible. A sprain causes local pain, especially during joint movement; ecchymosis and, possibly, local swelling and loss of mobility develop.

Thrombophlebitis

Discomfort may range from calf tenderness to severe pain accompanied by swelling, warmth, and a feeling of heaviness in the affected leg

The patient may also develop a fever, chills, malaise, muscle cramps, and a positive Homans’sign. Assessment may reveal superficial veins that are visibly engorged; palpable, hard, thready, and cordlike; and sensitive to pressure.

Varicose veins

Mild to severe leg symptoms may develop, including nocturnal cramping; a feeling of heaviness; diffuse, dull aching after prolonged standing or walking; and aching during menses

Assessment may reveal palpable nodules, orthostatic edema, and stasis pigmentation of the calves and ankles.

Gender cue

Venous stasis ulcer

Localized pain and bleeding arise from infected ulcerations on the lower extremities

Mottled, bluish pigmentation is characteristic, and local edema may occur.

Special considerations

If the patient has acute leg pain,closely monitor his neurovascular status by frequently checking distal pulses and evaluating the legs for temperature, color, and sensation. Also monitor his thigh and calf circumference to evaluate bleeding into tissues from a possible fracture site. Prepare the patient for X-rays. Use sandbags to immobilize his leg; apply ice and, if needed, skeletal traction. If a fracture isn’t suspected, prepare the patient for laboratory tests to detect an infectious agent or for venography, Doppler ultrasonography, plethysmography, or angiography to determine vascular competency. Withhold food and fluids until the need for surgery has been ruled out, and withhold analgesics until a preliminary diagnosis is made. Administer an anticoagulant and antibiotic as needed.

Pediatric pointers

Common pediatric causes of leg pain include a fracture, osteomyelitis, and bone cancer. If parents fail to give an adequate explanation for a leg fracture, consider the possibility of child abuse.

Pictures

Book Source Details

• Book Title: Handbook of Signs & Symptoms (Third Edition)
• Author(s): Springhouse
• Year of Publication: 2006
• Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2006 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Handbook of Signs & Symptoms (Third Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 1-58255-402-1

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