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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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