Chapter 60 - Pain in the leg

Thou cold sciaticaCripple our senators, that their limbs may halt As lamely as their manners.

William Shakespeare (1564-1616)Timon of Athens

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 nerve roots of the spine. It is important to recognise radicular pain, especially from L5 and S1 nerve roots, and also the patterns of referred pain such as from apophyseal (facet) joints and sacroiliac joints.Illustrative case historiesMrs PJ, aged 38, housewifeThis previously well person was walking briskly when she felt intense pain in the area of the lateral aspect of her left calf. It persisted and she visited a casualty department where a diagnosis of a torn lateral head of gastrocnemius was made. The pain then spread to the outer area of the ankle and to the outer foot, which started to feel numb.On review the diagnosis was changed to a sural nerve lesion. Two days later she was found to have persistent severe pain in the leg and anaesthesia corresponding to S1. She had no back pain. Examination showed there was no ankle jerk, and loss of eversion of the left foot.Diagnosis and outcome: progressive S1 nerve palsy due to an L5-S1 disc prolapse. The disc was removed 6 days after the onset of pain.Mr LR, aged 67, farmerA middle-of-the-night home visit was made to this upset non-English-speaking man because of the sudden onset of severe pain in his right leg. A provisional diagnosis of arterial occlusion was made over the phone but the problem was in fact a simple nocturnal cramp. Smiles of relief and embarrassment all round.Mrs CM, aged 63, librarianThis obese patient complained of a dull ache in the middle of her thigh for 2 months. Examination was normal. She was reassured but an X-ray ordered if the pain persisted. A house call 2 weeks later found the patient lying on the kitchen floor with a fractured femur.Diagnosis and outcome: pathological fracture due to a single metastasis from a breast primary (removed 9 years previously). These case histories illustrate some of the difficulties experienced by patients and doctors with diagnosing leg pain.Key facts and checkpoints

Always consider the lumbosacral spine, the sacroiliac joints and hip joints as important causes of leg pain. Hip joint disorders may refer pain around the knee only (without hip pain).Nerve root lesions may cause pain in the lower leg and foot only (without back pain).Nerve entrapment is suggested by a radiating burning pain, prominent at night and worse at rest.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.Acute arterial occlusion to the lower limb requires relief within 4 hours (absolute limit of 6 hours). The commonest site of acute occlusion is the common femoral artery.Varicose veins can cause aching pain in the leg.

A diagnostic approachA summary of the safety diagnostic model is presented in Table 60.1.Table 60.1 Pain in the leg: diagnostic strategy model

Q. Probability diagnosis

A. CrampsNerve root 'sciatica'Muscular injury, e.g. hamstring Osteoarthritis (hip, knee)

General Practice, Chapter 60

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Overuse injury, e.g. Achilles tendinitis

Q. Serious disorders not to be missed

A. Vascular arterial occlusion (embolism) thrombosis popliteal aneurysm deep venous thrombosis iliofemoral thrombophlebitis Neoplasia primary, e.g. myeloma metastases, e.g. breast to femur Infection osteomyelitis septic arthritis erysipelas lymphangitis gas gangrene

Q. Pitfalls (often missed)

A. Osteoarthritis hipOsgood-Schlatter's disease Spinal canal stenosis Herpes zoster (early)Nerve entrapment 'Hip pocket nerve'Iatrogenic: injection into nerve Sacroiliac disordersGluteus medius tendinitis Sympathetic dystrophy (causalgia) Peripheral neuropathy

Rarities Osteoid osteoma Polymyalgia rheumatica (isolated) Paget's disease Popliteal artery entrapment Tabes dorsalis Ruptured Baker's cyst

Q. Seven masquerades checklist

A. Depression Diabetes Drugs AnaemiaThyroid disease Spinal dysfunction UTI

x xx (indirect) x (indirect)-xx-

Q. Is this patient trying to tell me something else?

A. Quite possible. Common with work-related injuries.

Probability diagnosisMany of the causes, such as foot problems, ankle injuries and muscle tears (e.g. hamstrings and quadriceps), are obvious andcommon. 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, the significance of which escapes some patients as judged by middle-of-the-night calls.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 tumour should be considered. Remember that a

spontaneous retroperitoneal haemorrhage in a patient on anticoagulant therapy can cause nerve root pain and present as intense acute leg pain. The nerve root sensory distribution is presented in Figure 60.1Other important causes of referred thigh pain include ischiogluteal bursitis (weaver's bottom) and gluteus medius tendinitis or trochanteric bursitis.

Fig. 60.1 Dermatomes of the lower limb, representing approximate cutaneous distribution of the nerve roots

Serious disorders not to be missedNeoplasiaMalignant disease, although uncommon, should be considered, especially if the patient has a history of one of the primary tumours such as breast, lung or kidney. Such tumours can metastasise to the femur. Consider also osteogenic sarcoma and multiple myeloma, which is usually seen in the upper half of the femur. The possibility of an osteoid osteoma should be considered with pain in a bone relieved by aspirin.InfectionsSevere infections are not so common, but septic arthritis and osteomyelitis warrant consideration. Superficial infections such as erysipelas and lymphangitis occur occasionally.Vascular problemsAcute severe ischaemia can be due to thrombosis or embolism of the arteries of the lower limb. Such occlusions cause severe pain in the limb and associated signs of severe ischaemia, especially of the lower leg and foot.Chronic ischaemia due to arterial occlusion can manifest as intermittent claudication or rest pain in the foot due to small vessel disease. 1Various pain syndromes are presented in Figure 60.2. It is important to differentiate vascular claudication from neurogenic claudication (Table 60.2).Table 60.2 Clinical features of neurogenic and vascular claudication

Neurogenic claudicationVascular claudication

Cause Spinal canal stenosis Aortoiliac arterial occlusive disease

Age Over 50 Long history of backache

Over 50

Pain site and radiation

Proximal location, initially lumbar, buttocks and legs Radiates distally

Distal location Buttocks, thighs and calves (especially) Radiates proximally

Type of painWeakness, burning, numbing or tingling (notcramping)

Onset Walking (uphill and downhill) Distance walked varies Prolonged standing

Relief Lying down Flexing spine, e.g. squat position May take 20-30 minutes

Cramping, aching, squeezing

Walking a set distance each time, especially uphill

Standing stillfast relief Slow walking decreases severity

Associations Bowel and bladder symptoms Impotence Rarely, paraesthesia or weakness

Physical examination

Peripheral pulses Present Present (usually) Reduced or absent in some, especially after exercise

Lumbar extension Aggravates No change

Neurological Saddle distribution Ankle jerk may be reduced after exercise

Note: abdominal bruits after exercise

Diagnosis confirmation

Radiological studies Duplex ultrasound Ankle brachial index Arteriography

Fig. 60.2 Arterial occlusion and related symptoms according to the level of obstruction

Venous disordersThe 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.PitfallsThere are many traps and pitfalls in the painful leg. Herpes zoster at the pre-eruption phase is an old trap and more so whenthe patient develops only a few vesicles in obscure parts of the limbs.In future we can expect to encounter more cases of spinal canal stenosis (secondary to the degenerative changes) in the elderly. The early diagnosis can be difficult, and buttock pain on walking has to be distinguished from vascular claudication due

to a high arterial obstruction.The many disorders of the sacroiliac joint and hip region can be traps, especially the poorly diagnosed yet common gluteus medius tendinitis. Another more recent phenomenon is the 'hip pocket nerve syndrome', where a heavy wallet crammed with credit cards can cause pressure on the sciatic nerve.One of the biggest traps, however, is when hip disorders, particularly osteoarthritis, present as leg pain, especially on the medial aspect of the knee.Nerve entrapments (Fig 60.3) are an interesting cause of leg pain, although not as common as in the upper limb. Some entrapments to consider include:

lateral cutaneous nerve of thigh, known as meralgia paraesthetica common peroneal nerveposterior tibial nerve at ankle (the 'tarsal tunnel' syndrome) obturator nerve, in obturator canalfemoral nerve (in inguinal region or pelvis)

Then there are the rare causes. One overlooked problem is sympathetic dystrophy, which may follow even minor trauma to the limb. This 'causalgia' syndrome manifests as burning or aching pain with vasomotor instability in the limbs. The essential feature is the disparity between the intensity of the pain and the severity of the inciting injury.

Fig. 60.3 Distribution of pain in the leg from entrapment of specific nerves; the sites of entrapments are indicated by an X

General pitfalls

overlooking beta-blockers and anaemia as a precipitating factor for vascular claudication overlooking hip disorders as a cause of knee painmistaking occlusive arterial disease for sciaticaconfusing nerve root syndromes with entrapment syndromes

Seven masquerades checklistThe outstanding cause of leg pain in this group is spinal dysfunction. Apart from nerve root pressure due to a disc disruption orforaminal entrapment, pain can be referred from the apophyseal (facet joints). Such pain can be referred as far as the mid-calf (Fig 60.4).The other checklist conditionsdepression, diabetes, drugs and anaemiacan be associated with pain in the leg. Depression can reinforce any painful complex.Diabetes can cause discomfort through a peripheral neuropathy that can initially cause localised pain before anaesthesia predominates. Drugs such as beta-blockers, and anaemia, can precipitate or aggravate intermittent claudication in a patient with a compromised circulation.

Fig. 60.4 Possible referred pain patterns from dysfunction of an apophyseal joint, illustrating pain radiation patterns fromstimulation by injection of the right L4-L5 apophyseal jointREPRODUCED FROM C. KENNA AND J. MURTAGH, BACK PAIN AND SPINAL MANIPULATION, BUTTERWORTHS, SYDNEY, 1989, WITH PERMISSION

Psychogenic considerationsPain in the lower leg can be a frequent complaint (maybe a magnified one) of the patient with non-organic pain, such as themalingerer, the conversion reaction patient (hysteria) and the depressed. Sometimes sympathetic dystrophy (reflex or post- traumatic) is incorrectly diagnosed as functional.The clinical approachCareful attention to basic detail in the history and examination can point the way of the clinical diagnosis.HistoryIn the history it is important to consider several distinctive aspects, outlined by the following questions.

Is the pain of acute or chronic onset?If acute, did it follow trauma or activity?If not, consider a vascular cause: vein or artery; occlusion or rupture. Is the pain 'mechanical' (related to movement)?If it is unaltered by movement of the leg or a change in posture, it must arise from a soft tissue lesion, not from bone or joints.Is the pain postural?Analyse the postural elements that make it better or worse.If worse on sitting, consider a spinal cause (discogenic) or ischial bursitis.If worse on standing, consider a spinal cause (instability) or a local problem related to weight bearing (varicose veins).If worse lying down, consider vascular origin such as small vessel peripheral vascular disease. Pain unaffected by posture is activity-related.Is the pain related to walking?No: Determine the offending activity, e.g. joint movement with arthritis.Yes: If immediate onset, consider local cause at site of pain, e.g. stress fracture. If delayed onset, consider vascular claudication or neurogenic claudication.Is the site of pain the same as the site of trauma?If not, the pain in the leg is referred. Important considerations include lesions in the spine, abdomen or hip and entrapment neuropathy.Is the pain arising from the bone?If so, the patient will point to the specific site and indicate a 'deep' bone pain (consider tumour, fracture or, rarely, infection) compared with the more superficial muscular or fascial pain.Is the pain arising from the joint?If so, the clinical examination will determine whether it arises from the joint or juxtaposed tissue.

Physical examination

The first step is to watch the patient 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 the inspection.Inspect the patient's stance and note any asymmetry and other abnormalities such as swellings, bruising, discolouration, or ulcers and rashes. Note the size and symmetry of the legs and the venous pattern. Look for evidence of ischaemic changes, especially of the foot.Palpate for local causes of pain and if no cause is evident examine the spine, blood vessels (arteries and veins) and bone. Areas to palpate specifically are the ischial tuberosity, trochanteric area, hamstrings and tendon insertions. Palpate the superficial lymph nodes. Note the temperature of the feet and legs. Perform a vascular examination including the peripheral pulses and the state of the veins if appropriate.If evidence of PVD, remember to auscultate the abdomen and adductor hiatus, and the iliac, femoral and popliteal vessels. A neurological examination may be appropriate, particularly to test nerve root lesions or entrapment neuropathies. Examination of the joints, especially the hip and sacroiliac joints, is very important.InvestigationsA checklist of investigations that may be necessary to make the diagnosis is as follows:

Full blood examination and ESR X-rays:leg, especially knee, hipplain X-ray of lumbosacral spine CT scan of lumbosacral spine MRI scan of lumbosacral spine bone scanElectromyography Vasculararteriographyduplex ultrasound scan ankle brachial indexvenous pool radionuclide scan contrast venographyair plethysmograph (varicose veins)

Leg pain in childrenAches and pains in the legs are a common complaint in children. The most common cause is soreness and muscular strainsdue to trauma or unaccustomed exercise.It is important to consider child abuse, especially if bruising is noted on the backs of the legs.Growing painsSo-called 'growing pains', or idiopathic leg pain, is thought to be responsible for up to 20% of leg pain in children. 2 Such adiagnosis 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 60 minutes and tend to respond to attention such as massage with an analgesic balm or simple analgesics.Serious problemsIt is important to exclude fractures (hence the value of X-rays if in doubt), malignancy (such as osteogenic sarcoma, Ewing'stumour or infiltration from leukaemia or lymphoma), osteoid osteoma, osteomyelitis, scurvy and berri-berri (rare disorders in developed countries) and congenital disorders such as sickle-cell disease, Gaucher's disease and Ehlers-Danlos syndrome.Leg pain in the elderlyThe older the patient the more likely it is that arterial disease with intermittent claudication and neurogenic claudication due tospinal 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, Paget's disease, polymyalgia rheumatica (affecting the upper thighs) and sciatica.Spinal causes of leg painProblems originating from the spine are an important, yet at times complex, cause of pain in the leg.Important causes are:

nerve root (radicular) pain from direct pressure referred pain from:

disc pressure on tissues in front of the spinal cord apophyseal jointssacroiliac jointsspinal canal stenosis causing claudication

Various pain patterns are presented in Figures 60.1 and 60.4.Nerve root painNerve root pain from a prolapsed disc is a common cause of leg pain. A knowledge of the dermatomes of the lower limb (Fig60.1) provides a pointer to the involved nerve root, which is usually L5 or S1 or both. The L5 root is invariably caused by an L4-L5 disc prolapse and the S1 root by an L5-S1 disc prolapse. The nerve root syndromes are summarised in Table 60.3. Table 60.3 Nerve root syndromes

NerverootPain distributionSensory loss

Motor weaknesschangesReflex

L3Front of thigh, inner aspect of thigh, knee and leg

Anterior aspect of thighExtension of kneeKnee jerk

L4Anterior thigh to front of kneeLower outer aspect of thigh andknee, inner great toe

Flexion, adduction of knee, inversion of foot

Knee jerk

L5Lateral aspect of leg, dorsum of foot and great toe

S1Buttock to back of thigh and leg, central calf, lateral aspect of ankle and sole of foot

Dorsum of foot, great toe, 2nd and 3rd toes, anterolateral aspect of lower leg

Lateral aspect of ankle, foot (4th and 5th toes)

Dorsiflexion of great toe

Plantar flexion of ankle and toes, eversion of foot

Tibialis posterior (clinically impractical)

Ankle jerk

A summary of the physical examination findings for the most commonly involved nerve roots is presented in Figure 60.5.

Fig. 60.5 Comparison of neurological findings of the neurological levels L4-L5 and S1REPRODUCED FROM S. HOPPENFELD, PHYSICAL EXAMINATION OF THE SPINE AND EXTREMITIES, APPLETON AND LANGE, NORWALK, CT, USA, WITH PERMISSION

Sciatica

Sciatica is defined as pain in the distribution of the sciatic nerve or its branches (L4, L5, S1, S2, S3) that is caused by nerve pressure or irritation. Most problems are due to entrapment neuropathy of a nerve root, either in the spinal canal (as outlined above) or the intervertebral foramen.It should be noted that back pain may be absent and peripheral symptoms only will be present.Treatment of sciaticaAcute sciatica. A protracted course can be anticipated, in the order of 12 weeks. The patient should be reassured that spontaneous recovery can be expected. A trial of conservative treatment would be recommended thus:

back care educationrelative bed rest (2 days is optimal)a firm base is ideal analgesics (avoid narcotic analgesics)NSAIDs (2 weeks is recommended)basic exercise program, including swimming traction can help, even intermittent manual

Referral to a therapist of your choice, e.g. physiotherapist, might be advisable. Conventional spinal manipulation is usually contraindicated for radicular sciatica. If the patient is not responding or the circumstances demand more active treatment, an epidural anaesthetic injection is appropriate. Surgical intervention may be necessary.Chronic sciatica. If a trial of NSAIDs, rest and physiotherapy has not brought significant relief, an epidural anaesthetic (lumbar or caudal) using half-strength local anaesthetic only (e.g. 0.25% bupivacaine HCl) is advisable.Referred painReferred pain in the leg can arise from disorders of the sacroiliac joints or from spondylogenic disorders. It is typically dull,heavy and diffuse. The patient uses the hand to describe its distribution compared with the use of fingers to point to radicular pain.Spondylogenic painNon-radicular or spondylogenic pain is that which originates from any of the components of the vertebrae (spondyles) includingjoints, the intervertebral disc, ligaments and muscle attachments. An important example is distal referred pain from disorders of the apophyseal joints, where the pain can be referred to any part of the limb as far as the calf and ankle but most commonly to the gluteal region and proximal thigh (Fig 60.4).Another source of referred pain is that caused by compression of a bulging disc against the posterior longitudinal ligament and dura. The pain is typically dull, deep and poorly localised. The dura has no specific dermatomal localisation, and so the pain is usually experienced in the low back, sacroiliac area and buttocks. Less commonly it can be referred to the coccyx, groin and both legs to the calves. It is not referred to the ankle or the foot.Sacroiliac dysfunctionThis causes typically a dull ache in the buttock but it can be referred to the iliac fossa, groin or posterior aspects of the thighs.It rarely radiates to or below the knee. It may be caused by inflammation (sacroiliitis) or mechanical dysfunction. The latter must be considered in a postpartum woman presenting with severe aching pain present in both buttocks and thighs.Nerve entrapment syndromesEntrapment neuropathy can result from direct axonal compression or can be secondary to vascular problems, but the maincommon factor is a nerve passing through a narrow rigid compartment where movement or stretching of that nerve occurs under pressure.Clinical features of nerve entrapment:

pain at rest (often worse at night) variable effect with activitysharp, burning painradiating and retrograde painclearly demarcated distribution of pain paraesthesia may be present tenderness over nervemay be positive Tinel's sign

Meralgia paraestheticaThis is the commonest lower limb entrapment and is due to the lateral femoral cutaneous nerve of the thigh being trappedunder the lateral end of the inguinal ligament, 1 cm medial to the anterior superior iliac spine. 3The nerve is a sensory nerve from L2 and L3. It occurs mostly in middle-aged people, due mainly to thickening of the fibrous tunnel beneath the inguinal ligament, and is associated with obesity, pregnancy, ascites or local trauma such as belts, trusses and corsets. Its entrapment causes a burning pain with associated numbness and tingling (Fig 60.3).The distribution of pain is confined to a localised area of the lateral thigh and does not cross the midline of the thigh.

Differential diagnosis

L2 or L3 nerve root pain (L2 causes buttock pain also) femoral neuropathy (extends medial to mid-line)

Treatment options

injection of corticosteroid medial to the ASIS, under the inguinal ligament surgical release (neurolysis) if refractory

Note: Meralgia paraesthetica often resolves spontaneously.Peroneal nerve entrapmentThe common peroneal (lateral popliteal) nerve can be entrapped where it winds around the neck of the fibula or as it dividesand passes through the origin of the peroneus longus muscle 2.5 cm below the neck of the fibula. It is usually injured, however, by trauma or pressure at the neck of the fibula.Symptoms and signs:

pain in the lateral shin area and dorsum of the foot sensory symptoms in the same areaweakness of eversion and dorsiflexion of the foot (described by patients as 'a weak ankle')

Differential diagnosisL5 nerve root (similar symptoms)Treatment

shoe wedging or other orthotics to maintain eversion neurolysis is the most effective treatment

Tarsal tunnel syndromeThis is an entrapment neuropathy of the posterior tibial nerve in the tarsal tunnel beneath the flexor retinaculum on the medialside of the ankle (Fig 60.6 a). The condition is due to dislocation or fracture around the ankle or tenosynovitis of tendons in the tunnel from injury, rheumatoid arthritis, and other inflammations.

Fig. 60.6 (a) Anatomy of the tarsal tunnel syndrome; (b) showing injection sites

Symptoms and signs

a burning or tingling pain in the toes and sole of the foot, occasionally the heel retrograde radiation to calf, perhaps as high as the buttocknumbness is a late symptomdiscomfort often in bed at night and worse after standing removal of shoe may give reliefsensory nerve loss variable, may be no lossTinel test (finger or reflex hammer tap over nerve below and behind medial malleolus) may be positive tourniquet applied above ankle may reproduce symptoms

The diagnosis is confirmed by electrodiagnosis.Treatment

relief of abnormal foot posture with orthotics

corticosteroid injectiondecompression surgery if other measures fail

Injection for tarsal tunnel syndromeUsing a 23-gauge 32 mm needle, a mixture of triamcinolone 10 mg/mL or 40 mg methylprednisolone in 1% xylocaine or procaine is injected into the tunnel either from above or below the flexor retinaculum. The sites of injection are shown in Figure 60.6b ; care is required not to inject the nerve.Vascular causes of leg painOcclusive arterial diseaseRisk factors for peripheral vascular disease (for development and deterioration):

smoking diabetes mellitus hypertensionhypercholesterolaemia family historyatrial fibrillation (embolism) Aggravating factors:beta-blocking drugs anaemia

Acute lower limb ischaemiaSudden occlusion is a dramatic event that requires immediate diagnosis and management to save the limb.Causes:

embolismperipheral arteries thrombosismajor artery popliteal aneurysmtraumatic contusion, e.g. postarterial puncture

The symptoms and signs of acute embolism and thrombosis are similar, although thrombosis of an area of atherosclerosis is often preceded by symptoms of chronic disease, e.g. claudication. The commonest site of acute occlusion is the common femoral artery (Fig 60.7).

Fig. 60.7 Common sites of acute arterial occlusion

Signs and symptomsthe 6 P's

Pain PallorParaesthesia or numbness PulselessnessParalysis 'Perishing' cold

The pain is usually sudden and severe and any improvement may be misleading. Sensory changes initially affect light touch, not pinprick. Paralysis (paresis or weakness) and muscle compartment pain or tenderness is a most important and ominous sign.Other signs include mottling of the legs, collapsed superficial veins, and no capillary return.

Note: Look for evidence of atrial fibrillation.Examination of arterial circulationThis applies to chronic ischaemia and also to acute ischaemia.Skin and trophic changesNote colour changes, hair distribution and wasting. Note the temperature of the legs and feet with the backs of your fingers.Palpation of pulsesIt is important to assess four pulses carefully (Fig 60.8). Note that the popliteal and posterior tibial pulses are difficult to feel, especially in obese subjects.Femoral artery. Palpate deeply just below the inguinal ligament, midway between the anterior superior iliac spine and the symphysis pubis. If absent or diminished, palpate over abdomen for aortic aneurysm.Popliteal artery. Flex the leg to relax the hamstrings. Place fingertips of both hands to meet in the midline. Press them deeply

into the popliteal fossa to compress artery against the upper end of the tibia, i.e. just below the level of the knee crease. Check for a popliteal aneurysm (very prominent popliteal pulsation).Posterior tibial artery. Palpate, with curved fingers, just behind and below the tip of the medial malleolus of the ankle.Dorsalis pedis artery. Feel at the proximal end of the first metatarsal space just lateral to the extensor tendon of the big toe.

Fig. 60.8 Sites of palpation of peripheral pulses in the leg

OedemaLook for evidence of oedema: pitting oedema is tested by pressing firmly with your thumb for at least 5 seconds over the dorsum of each foot, behind each medial malleolus and over the shins.Postural colour changes (Buerger's test)Raise both legs to about 60 for about 1 minute, when maximal pallor of the feet will develop. Then get the patient to sit up on the couch and hang both legs down. 4 Note, comparing both feet, the time required for return of pinkness to the skin (normally less than 10 seconds) and filling of the veins of the feet and ankles (normally about 15 seconds). Look for any unusual rubor (dusky redness) that takes a minute or more in the dependent foot. A positive Buerger's test is pallor on elevation and rubor on dependency and indicates severe chronic ischaemia.Auscultation for bruits after exerciseListen over abdomen and femoral area for bruits.

Note: Neurological examination (motor, sensory, reflexes) is normal unless there is associated diabetic peripheral neuropathy.Management of acute ischaemiaGolden rules. Occlusion is usually reversible if treated within 4 hours, i.e. limb salvage. It is often irreversible if treated after 6hours, i.e. limb amputation.Treatment

Intravenous heparin (immediately) 5000 U Emergency embolectomy (ideally within 4 hours)under general or local anaesthesiathrough an arteriotomy site in the common femoral artery embolus extracted with Fogarty balloon or catheter

orArterial bypass if acute thrombosis in chronically diseased arteryIn selected cases thrombolysis with streptokinase or urokinase appropriate Amputation (early) if irreversible ischaemic changesLifetime anticoagulation with warfarin will be required

Note: An acutely ischaemic limb is rarely life threatening in the short term. Thus, even in the extremely aged, demented or infirm, a simple embolectomy not only is worthwhile but also is usually the most expedient treatment option.Chronic lower limb ischaemiaChronic ischaemia caused by gradual arterial occlusion can manifest as intermittent claudication, rest pain in the foot, or overttissue loss ulceration, gangrene.Intermittent claudication is a pain or tightness in the muscle on exercise (Latin claudicare, to limp), relieved by rest. Rest pain is a constant severe burning-type pain or discomfort in the forefoot at rest, typically occurring at night when the blood flow

slows down.The main features are compared in Table 60.4.Table 60.4 Comparison between intermittent claudication and ischaemic rest pain

Intermittent claudicationIschaemic rest pain

Quality of painTightness/crampingConstant ache Timing of pain (typical) Daytime; walking, other exercise Night-time; rest Tissue affectedMuscleSkinSiteCalf > thigh > buttockForefoot, toes, heels

AggravationWalking, exerciseRecumbent, walking

ReliefRestHanging foot out of bed; dependency

AssociationsBeta-blockers Anaemia

Night cramps Swelling of feet

Intermittent claudicationThe level of obstruction determines which muscle belly is affected (Fig 60.2 and 60.7).Proximal obstruction, e.g. aortoiliac

pain in the buttock, thigh and calf, especially when walking up hills and stairs persistent fatigue over whole lower limbimpotence is possible (Leriche syndrome)

Obstruction in the thigh

superficial femoral (the commonest) causes pain in the calf, e.g. 200-500 metres, depending on collateral circulation profunda femoris claudication about 100 metresmultiple segment involvement claudication 40-50 metres Causes:atherosclerosis (mainly men over 50, smokers) embolisation (with recovery)Buerger's disease: affects small arteries, causes rest pain and cyanosis (claudication uncommon) popliteal entrapment syndrome (< 40 years of age)

Note: The presence of rest pain implies an immediate threat to limb viability. 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. Measure blood flow by duplex ultrasound examination or ankle brachial index. Arteriography should be performed only if surgery contemplated.

Treatment

General measures (if applicable): control obesity, diabetes, hypertension, hyperlipidaemia, cardiac failure. Achieve ideal weight.

There must be absolutely no smoking.Exercise: daily graduated exercise to the level of pain. About 50% will improve with walking; so advise as much walking as possible.Try to keep legs warm and dry. Maintain optimal foot care (podiatry). Drug therapy: aspirin 150 mg daily.

Note:

Vasodilators and sympathectomy are of little value.About one-third progress, while the rest regress or don't change. 5

When to refer to a vascular surgeon

'Unstable' claudication of recent onset; deteriorating Severe claudicationunable to maintain lifestyle Rest pain'Tissue loss' in feet, e.g. heel crack, ulcers on or between toes, dry gangrenous patches, infection

Surgery. Reconstructive vascular surgery is indicated for progressive obstruction, intolerable claudication and obstruction above the inguinal ligament.

endarterectomyfor localised iliac stenosisbypass graft (iliac or femoral artery to popliteal or anterior or posterior tibial arteries)

Percutaneous transluminal dilation: This angioplasty is performed with a special intra-arterial balloon catheter for localised limited occlusions. An alternative to the balloon is laser angioplasty.Venous disordersVaricose veinsVaricose veins are dilated, tortuous and elongated superficial veins in the lower extremity.The veins are dilated because of incompetence of the valves in the superficial veins or in the communicating or perforating veins between the deep and superficial systems. The cause is a congenital weakness in the valve and the supporting vein wall but there are several predisposing factors (Table 60.5), the most important being family history, female sex (5:1), pregnancy and multiparity. Previous deep venous thrombosis (DVT) can also damage valves, especially calf perforators, and cause varicose veins.Table 60.5 Risk factors for varicose veins

Female sex Family history Pregnancy Multiparity Age OccupationDiet (low-fibre)

Dilated superficial veins, which can mimic varicose veins, may be caused by extrinsic compression of the veins by a pelvic or intra-abdominal tumour (e.g. ovarian carcinoma, retroperitoneal fibrosis). Uncommonly, but importantly, superficial veins dilate as they become collaterals following previous DVT, especially if the ilio-femoral segment is involved.

SymptomsVaricose veins may be symptomless, the main complaint being their unsightly appearance. Symptoms include swelling, fatigue, heaviness in the limb, an aching discomfort and itching.

Fig. 60.9 The common sites of varicose veins

Varicose veins and painThey may be painless even if large and tortuous. Pain is a feature where there are incompetent perforating veins running from the posterior tibial vein to the surface through the soleus muscle.Severe cases lead to the lower leg venous hypertension syndrome 6 characterised by pain that is worse after standing, cramps in the leg at night, irritation and pigmentation of the skin, swelling of the ankles and loss of skin features such as hair.A careful history will usually determine if the aching is truly due to varicose veins and not to transient or cyclical oedema, which is a common condition in women. 7The complications of varicose veins are summarised in Table 60.6.Table 60.6 Complications of varicose veins

Superficial thrombophlebitis Skin 'eczema' (10%)Skin ulceration (20%) BleedingCalcification

Marjolin's ulcer (squamous cell carcinoma)

ExaminationThe following tests will help determine the site or sites of the incompetent valves.Venous groin cough impulse. This helps determine long saphenous vein incompetence.Place the fingers over the line of the vein immediately below the fossa ovalis (4 cm below and 4 cm lateral to the pubic tubercle). 8 Ask the patient to coughan impulse or thrill will be felt expanding and travelling down the long saphenous vein. A marked dilated long saphenous vein in the fossa ovalis (saphena varix) will confirm incompetence. It disappears when the patient lies down.Trendelenburg test. In this test for long saphenous vein competence the patient lies down and the leg is elevated to 45 to empty the veins (Fig 60.10 a). Apply a tourniquet with sufficient pressure to prevent reflux over the upper thigh just below the fossa ovalis. (Alternatively, this opening can be occluded by firm finger pressure, as originally described by Trendelenburg.) The patient then stands. The long saphenous system will remain collapsed if there are no incompetent veins below the level of the fossa ovalis. When the pressure is released the vein will fill rapidly if the valve at the saphenofemoral junction is incompetent (Fig 60.10 b). This is a positive Trendelenburg test.Note: A doubly positive Trendelenburg test is when the veins fill rapidly before the pressure is released and then with a 'rush' when released. This indicates coexisting incompetent perforators and long saphenous vein.Short saphenous vein incompetence test. A similar test to the Trendelenburg test is performed with the pressure (tourniquet or

finger) being applied over the short saphenous vein just below the popliteal fossa (Fig 60.11).Incompetent perforating vein test. Accurate clinical tests to identify incompetence in the three common sites of perforating veins on the medial aspect of the leg, posterior to the medial border of the tibia, are difficult to perform. The general appearance of the leg and palpation of the sites give some indication of incompetence here.

Note: Venous duplex ultrasound studies will accurately localise sites of incompetence and determine the state of the functionally important deep venous system.

Fig. 60.10a Trendelenburg test: the leg is elevated to 45 to empty the veins and a tourniquet applied

Fig. 60.10b Trendelenburg test: test for competence of long saphenous venous system (medial aspect of knee)

Fig. 60.11 Testing for competence of the short saphenous vein

Management of varicose veins

Prevention

Maintain ideal weight. Eat a high-fibre diet.Rest and wear supportive stockings if at risk (pregnancy, a standing occupation).

Treatment

Keep off legs as much as possible. Sit with legs on a footstool.Use supportive stockings or tights (apply in morning before standing out of bed). Avoid scratching itching skin over veins.

Compression sclerotherapy

Use a small volume of sclerosant, e.g. sodium tetradecyl sulfate (Fibro-vein 3%). It is ideal for smaller isolated veins particularly below the knee joint.

Surgical ligation and stripping

This is the best treatment when a clear association exists between symptoms and obvious varicose veins, i.e. long saphenous vein incompetence.Remove obvious varicosities and ligate perforators.

Superficial thrombophlebitis

usually occurs in superficial varicose veinspresents as a tender, reddened subcutaneous cord in leg usually localised oedemano generalised swelling of the limb or anklerequires symptomatic treatment only (see below) unless there is extension above the level of the knee when there is a risk of pulmonary embolismvenous duplex scan is diagnostic and also determines:1. extent of superficial thrombosis, and2. if coexisting, unsuspected DVT is present

TreatmentThe objective is to prevent propagation of the thrombus by uniform pressure over the vein.

Cover whole tender cord with a thin foam pad.Apply a firm elastic bandage (preferable to crepe) from foot to thigh (well above cord). Leave pad and bandage on for 7-10 days.Bed rest with leg elevated is recommended. Prescribe an NSAID, e.g. indomethacin, for 10 days.

Note:

No anticoagulants are required.The traditional glycerin and ichthyol dressings are still useful.Consider association between thrombophlebitis and deep-seated carcinoma.If the problem is above the knee, ligation of the vein at the saphenofemoral junction is indicated.

Deep venous thrombosis (DVT)There is an up to 20% association with pulmonary emboli, of which 30% may be fatal. DVT may be asymptomatic but usuallycauses tenderness in the calf. One or more of the following features may be present.Clinical features

ache or tightness in calf acute diffuse leg swelling pitting oedematender 'doughy' consistency to palpation increased warmthpain on extension of foot (Homan's sign)

Differential diagnosis

Pseudophlebitis from ruptured popliteal (Baker's) cystthis must be excluded before anticoagulation.

Investigations

duplex ultrasound contrast venography

ManagementPrevention (cases at risk):

elastic stockings physiotherapy pneumatic compressionelectrical calf muscle stimulation during surgery heparin 5000 U (sc) bd or tds

Treatment

collect blood for APTT, INR and platelet count bed rest with leg elevatedone-way-stretch elastic bandages (both legs to above knees)IV heparin 5000 U statim, then continuous monitored infusion (at least 10 days); aim for partial thromboplastin time 1.5 to 2 normaloral anticoagulant (warfarin) for 3 to 6 months do not give aspirinmobilisation upon resolution of pain, tenderness and swelling

Surgery is necessary in extensive and embolising cases.Iliofemoral thrombophlebitis (phlegmasia dolens) 10This rare but life-threatening condition is when an extensive clot obstructs the iliofemoral veins so completely thatsubcutaneous oedema and blanching occurs. This initially causes a painful 'milky white leg' previously termed phlegmasia alba dolens. It may deteriorate and become cyanoticphlegmasia cerulea dolens. Massive iliofemoral occlusion is an emergency as such patients may develop 'shock', gangrene and pulmonary embolus.Management of other painful conditionsCellulitis and erysipelas

Rest in bed.Elevate limb (in and out of bed). Use aspirin for pain and fever.

Streptococcus pyogenes (the common cause) 10

severe

benzylpenicillin 1.2 g IV 4 hourly

less severeprocaine penicillin 1 g IM 12 hourly orphenoxymethyl penicillin 500 mg (o) 6 hourly if penicillin sensitivecephalothin IV or cephalexin 0.5 mg (o) 6 hourly orerythromycin 500 mg (o) 12 hourly

Staphylococcus aureus 11

severe, may be life-threatening flucloxacillin/dicloxacillin 2 g IV 6 hourlyless severeflucloxacillin/dicloxacillin 500 mg (o) 6 hourly orcephalexin 500 mg (o) 6 hourly orerythromycin 500 mg (o) 12 hourly

Nocturnal cramps

Note: Treat cause (if known) e.g. tetanus, drugs, sodium depletion, hypothyroidism.Physical measures

Muscle stretching and relaxation exercises: calf stretching for 3 minutes before retiring, 12 then rest in chair with the feet out horizontal to the floor with cushion under tendoachilles for 10 minutes.Massage and apply heat to affected muscles.Try to keep bedclothes off feet and lower part of legsa doubled-up pillow at the foot of the bed can be used.

Medication

Tonic water before retiring may help. Drug treatment:quinine sulphate 300 mg nocte orbiperiden 2-4 mg nocte

Roller injuries to legsA patient who has been injured by a wheel passing over a limb, especially a leg, can present a difficult problem. A freelyspinning wheel is not so dangerous, but serious injuries occur when a non-spinning (braked) wheel passes over a limb and these are compounded by the wheel then reversing over it. This leads to a 'degloving' injury due to shearing stress. The limb may look satisfactory initially, but skin necrosis may follow.

Admit to hospital for observation.Fasciotomy with open drainage may be an option.Surgical decompression with removal of necrotic fat is often essential.

When to refer

The sudden onset of pain, pallor, pulselessness, paralysis, paraesthesia and coldness in the leg Worsening intermittent claudicationRest pain in footPresence of popliteal aneurysm Superficial thrombophlebitis above knee Evidence of deep venous thrombosis Suspicion of gas gangrene in leg Worsening hip painEvidence of disease in bone, e.g. neoplasia, infection, Paget'sSevere sciatica with neurological deficit, e.g. floppy foot, absent reflexes

Practice tips

Always X-ray the legs (including hips) of a patient complaining of unusual deep leg pain, especially a child.Pain that does not fluctuate in intensity with movement, activity or posture has an inflammatory or neoplastic cause. Hip disorders such as osteoarthritis and slipped femoral epiphysis can present as pain in the knee (usually medial aspect).Consider retroperitoneal haemorrhage as a cause of acute severe nerve root pain, especially in people on anticoagulant therapy.Avoidance of amputation with acute lower limb ischaemia depends on early recognition (surgery within 4 hourstoo late

if over 6 hours).

References

1. House AK. The painful limb: is it intermittent claudication? Mod Med Aust, November 1990; 16-26.2. Tunnessen WW. Signs and symptoms in paediatrics (2nd edn). Philadelphia: Lippincott, 1988, 483.3. Hart FD. Practical problems in rheumatology. London: Dunitz, 1983, 120.4. Bates B. A guide to physical examination and history taking (5th edn). New York: Lippincott, 1991, 450.5. Fry J, Berry H. Surgical problems in clinical practice. London: Edward Arnold, 1987, 125-134.6. Ryan P. A very short textbook of surgery (2nd edn). Canberra: Dennis and Ryan, 1990, 61.7. Hunt P, Marshall V. Clinical problems in general surgery. Sydney: Butterworths, 1991, 172.8. Davis A, Bolin T, Ham J. Symptom analysis and physical diagnosis (2nd edn). Sydney: Pergamon, 1990, 179.9. Mashford ML (Chairman). Cardiovascular drug guidelines (2nd edn). Melbourne: Victorian Medical Postgraduate Foundation 1995-96, 158-160.10. Colucciello SA. Evaluation and management of deep venous thrombosis. Primary care reports, 1996; 2(12):105.11. Mashford ML (Chairman). Antibiotic guidelines (9th edn). Melbourne: Victorian Medical Postgraduate Foundation 1996- 97, 137-138.12. Murtagh JE. Practice tips (2nd edn). Sydney: McGraw-Hill, 1995, 244.