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Probability diagnosis

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Muscle cramps

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Nerve root ‘sciatica’

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Varicose veins

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Osteoarthritis (hip, knee)

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

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Serious disorders not to be missed

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Vascular:

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  • peripheral vascular disease

  • arterial occlusion (embolism)

  • thrombosis popliteal aneurysm

  • deep venous thrombosis

  • iliofemoral thrombophlebitis

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Neoplasia/cancer:

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  • primary (e.g. myeloma)

  • metastases (e.g. breast to femur)

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Infection:

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  • osteomyelitis

  • septic arthritis

  • erysipelas/cellulitis

  • lymphangitis

  • gas gangrene

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Pitfalls (often missed)

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Osteoarthritis hip

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Osgood–Schlatter disorder

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Spinal canal stenosis → neurogenic claudication

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Herpes zoster (early)

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Greater trochanteric pain syndrome

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Nerve entrapment (e.g. meralgia paraesthetica)

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‘Hip pocket nerve’

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Iatrogenic: injection into nerve

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Sacroiliac disorders

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Complex regional pain syndrome I

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Peripheral neuropathy

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Rarities:

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  • osteoid osteoma

  • polymyalgia rheumatica (isolated)

  • Paget disease

  • popliteal artery entrapment

  • tabes dorsalis

  • ruptured Baker cyst

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Masquerades checklist

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Depression

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Diabetes

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Drugs (indirect)

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Anaemia (indirect)

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Spinal dysfunction

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Is the patient trying to tell me something?

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Quite possible. Common with work-related injuries.

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Key history

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Ask:

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  • 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?

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

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Key examination

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  • 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

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Key investigations

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Consider:

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  • FBE and ESR

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

  • electromyography

  • vascular studies: arterial tree or venous system.

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Diagnostic tips

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  • 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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