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++

Probability diagnosis

++

Muscle cramps

++

Nerve root ‘sciatica’

++

Varicose veins

++

Osteoarthritis (hip, knee)

++

Exercise-related pain (e.g. Achilles tendonitis), muscular injury (e.g. hamstring)

++

Serious disorders not to be missed

++

Vascular:

++

  • peripheral vascular disease

  • arterial occlusion (embolism)

  • thrombosis popliteal aneurysm

  • deep venous thrombosis

  • iliofemoral thrombophlebitis

++

Neoplasia/cancer:

++

  • primary (e.g. myeloma)

  • metastases (e.g. breast to femur)

++

Infection:

++

  • osteomyelitis

  • septic arthritis

  • erysipelas/cellulitis

  • lymphangitis

  • gas gangrene

++

Pitfalls (often missed)

++

Osteoarthritis hip

++

Osgood–Schlatter disorder

++

Spinal canal stenosis → neurogenic claudication

++

Herpes zoster (early)

++

Greater trochanteric pain syndrome

++

Nerve entrapment (e.g. meralgia paraesthetica)

++

‘Hip pocket nerve’

++

Iatrogenic: injection into nerve

++

Sacroiliac disorders

++

Complex regional pain syndrome I

++

Peripheral neuropathy

++

Rarities:

++

  • osteoid osteoma

  • polymyalgia rheumatica (isolated)

  • Paget disease

  • popliteal artery entrapment

  • tabes dorsalis

  • ruptured Baker cyst

++

Masquerades checklist

++

Depression

++

Diabetes

++

Drugs (indirect)

++

Anaemia (indirect)

++

Spinal dysfunction

++

Is the patient trying to tell me something?

++

Quite possible. Common with work-related injuries.

++

Key history

++

Ask:

++

  • Is the pain acute or chronic onset?

  • Did it follow trauma or activity?

  • Is it ‘mechanical’ (related to movement)?

  • Is it postural?

  • Is it related to walking?

  • Is the pain arising from bone or from a joint?

++

Past history, especially cardiovascular, back pain, trauma history.

++

Key examination

++

  • 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 inspection

  • Palpate for local causes of pain and if no cause is evident examine the spine, blood vessels and bone. Note the temperature of the feet and legs

  • Perform a vascular examination including the peripheral pulses and veins

  • Consider a neurological examination to test nerve root lesions or entrapment neuropathies

  • Examine the joints, especially the hip and sacroiliac joints

++

Key investigations

++

Consider:

++

  • FBE and ESR

  • radiology: plain X-ray, knee, hip, lumbosacral spine; CT or MRI, bone scan

  • electromyography

  • vascular studies: arterial tree or venous system.

++

Diagnostic tips

++

  • Pain that does not fluctuate in intensity with movement, activity or posture has an inflammatory or neoplastic cause.

  • Varicose veins can cause aching pain in the leg.

  • Older people may present with claudication in the leg from spinal canal stenosis or arterial obstruction or both.

  • Think of the ...

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