Thou cold sciatica Cripple 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 (SIJs).
Key facts and checkpoints
Always consider the lumbosacral spine, the SIJs 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 summary of the diagnostic strategy model is presented in TABLE 66.1.
Table 66.1Pain in the leg: diagnostic strategy model ||Download (.pdf) Table 66.1 Pain in the leg: diagnostic strategy model
Nerve root ‘sciatica’
Osteoarthritis (hip, knee)
Exercise-related pain (e.g. Achilles tendonitis), muscular injury (e.g. hamstring)
Serious disorders not to be missed
peripheral vascular disease
arterial occlusion (embolism)
thrombosis popliteal aneurysm
deep venous thrombosis
Pitfalls (often missed)
Spinal canal stenosis → neurogenic claudication
Herpes zoster (early)
Greater trochanteric pain syndrome
Nerve entrapment, e.g. meralgia paraesthetica
‘Hip pocket nerve’: from wallet pressure
Iatrogenic: injection into nerve
Sympathetic dystrophy (causalgia)
Seven masquerades checklist
Is the patient trying to tell me something?
Quite possible. Common with work-related injuries.
Many of the causes, such as foot problems, ankle injuries and muscle tears (e.g. hamstrings and quadriceps), are ...