Vertebral dysfunction especially facet joint and disc (mechanical pain)
Spondylosis (degenerative OA)
Serious disorders not to be missed
Is the patient trying to tell me something?
Quite likely. Consider lifestyle, stress, work problems, malingering, conversion reaction.
Routine analysis of pain (SOCRATES approach), especially intensity of pain and its relation to rest and activity and also diurnal variation. Ask about pain on standing, sitting and walking with types of claudication (if any).
Review family history, occupational history, drug history, psychosocial history and ask questions about red flags that are alarm symptoms of serious disease.
Follow the LOOK, FEEL, MOVE, MEASURE clinical approach with an emphasis on palpation—central and lateral.
The movements with normal ranges are:
Perform a neurological and vascular examination of the lower limb/s with pain.
This should be conservative, especially in the absence of red flags. Basic screening is:
Reserve CT scan, MRI or radionuclide scan for suspected serious disease (malignancy and infection).
Continuous pain (day and night) points to neoplasm (esp. malignancy) or infection.
Pain (and stiffness) at rest, relief with activity indicates inflammation (e.g. spondyloarthropathy).
Pain provoked by activity with relief at rest indicates mechanical (vertebral) dysfunction.
Pain in the periphery of the limb can be discogenic causing radicular pain or spinal cord stenosis causing neurogenic claudication or vascular causing intermittent claudication.