What is Leg Pain?
Patients with chronic leg pain frequently report a variety of symptoms such as a sudden, stabbing pain in the hip, groin, buttocks or thigh, a burning pain or dull ache, reduced range of motion, decreased extension, limping or inability to walk naturally, pain when bearing weight, raising straight leg or bending and flexing, stiffness, tightness, or even a locked joint. Other symptoms include activity-induced pain, specifically from walking or exercise, signs of an infection such as fever, redness, or warmth, swelling of the hip or the thigh area, pain that worsens with activity or when lying on the affected side, or a hip joint that “gives out” causing the leg to collapse. Many times a patient will experience a painful clicking, catching or snapping sensation that may include an audible cracking or popping sound.
The leg is essential in supplying the body with movement and basic functions such as sitting, running and walking. The leg attaches to the body at the hip. The leg and hip are very strong, weight-bearing support structures that play an important role in functioning and facilitating movement, but are still vulnerable to disease and injury. Damage to the leg and hip joint occurs most often from falls, sports-related injuries and motor vehicle accidents. Many times this pain originates in the hip joint and radiates down the leg into the thigh.
While leg pain is common after trauma, it can also occur with other medical conditions. Pain can result from irritation or inflammation of the bones, joints, skin, nerves, tendons, ligaments and muscles of the leg. Pain can be referred pain that starts in the hip or lower back and radiates down into the leg. Spine and back issues can result in numbness and tingling in the leg if nerves are compressed. Arthritis can strike the joints in the hips and knees resulting in leg pain. Disease or mechanical dysfunction can also occur.
Regardless of etiology of pain, leg pain is a serious condition that can decrease a variety of daily functioning and interfere with quality of life. Oregon Pain can provide relief and help facilitate normal functioning.
Anatomy of the Leg
The leg consists of seven bones. The hip joint, femur, patella, and tibia are the main structures in the leg that facilitate movement and may be subject to dysfunction. Disease and dysfunction can affect any of the anatomy in leg resulting in pain and inhibiting movement. Occasionally, several different regions and structures may be affected at once due to degeneration, injury, pain, inflammation and irritation. The physicians at Oregon Pain are trained to treat and manage such complicated conditions.
Hip & Thigh
The large thigh bone is known as the femur, and it is the largest and strongest bone in the entire body. The femur, and thus the entire leg, is attached to the torso by the hip joint. The hip joint is a ball-and-socket joint and consists of a socket made of three fused pelvic bones, known as the acetabulum. The acetabulum houses the rounded tip of the femur. Ligaments and muscles support the hip joint and allow the ball of the femur to rotate, swivel and glide within the acetabulum without mechanical dysfunctions such as overextension or malrotation. The hip joint also contains a synovial lining in which there is a small amount of fluid that acts as a lubricant and allows the femoral head to glide smoothly within the acetabulum without friction or irritation. If the hip and femur are functioning appropriately, no problems arise. If any one part begins to degenerate or dysfunction, pain results and inhibits movement.
Knee, Tibia, Ligaments & Muscles
Below the femur is the kneecap, the patella, located just above the tibia, the shin bone. The leg also contains an assortment of ligaments, that stretch across joints, joints that facilitate range of motion, and muscles and tendons that provide strength and movement.
The leg also consists of nerves that begin at the spinal cord and transmit sensory information from the leg to the brain while also relaying movement commands. Under normal conditions the nerves provide sensory information such as pain, temperature, pressure, position and movement sensations. If nerves are dysfunctioning or compressed the leg can experience numbness, pins-and-needles sensations or pain.
Leg Pain Treatment
There are many successful pain management therapies available for leg pain. Most leg pain typically responds well to conservative methods of treatment, but more aggressive methods may be necessary in some cases. In order to determine the proper treatment plan a patient needs a complete evaluation. This should include patient history, physical examination and an assessment of pain that evaluates swelling, soreness, tenderness, range of motion and extended straight leg test. Patients should be sure to report the location and duration of pain, events that trigger or reduce pain, medications used and family history of arthritis. After conducting a full history and physical exam the physician may want additional studies and diagnostic tests, including radiological films and blood work. Imaging techniques are useful in order to allow the physician to see pathology inside the affected joint. Dependent on the type of pain presented and suspicion of disease additional testing may be suggested and may including the following:
Common Diagnostic Methods for Leg Pain
During routine office visits for leg pain or arthritis pain management a physician may recommend any combination of tests to properly diagnose pain and form a treatment plan: X-Rays utilize electromagnetic energy to produce images of internal tissues and bones and can help the physician view fractures and breaks; Computerized Tomography (CT Scans) using X-rays and computers to produce detailed, cross sections of bones, muscles and joints; Magnetic Resonance Imaging (MRI Scans) utilize large powerful magnets to produce a highly detailed image of interior anatomy of a much higher quality than X-Rays and CT Scans. Additionally, the physician may wish to order a Complete Blood Count (CBC), Urinalysis, or White Blood Cell Count to ensure no infections are present.
Advanced Diagnostic Methods for Leg Pain
Occasionally a patient may present symptoms of a severe infection, disease or disorder and further testing is necessary. This can include Complement Test, Antinuclear antibody (ANA), Creatinine, Erythrocyte sedimentation rate, Rheumatoid factor, Arthrocentesis or Arthroscopy.
In cases of leg pain that has not adequately responded to conservative pain management treatments Arthrocentesis and Arthroscopy may be recommended to obtain a proper diagnosis.
Arthrocentesis involves removal of synovial fluid from the joint with a syringe. Arthrocentesis allows the fluid within the joint to be properly evaluated for consistency and infection and can help determine diagnose gout, arthritis and synovial infections.
Arthroscopy is a minimally invasive surgical procedure utilized to see inside of the joint. During arthroscopy an optic tube called an arthroscope is inserted into the joint through a small incision. Arthroscopy has shown to be an effective, “valuable diagnostic and therapeutic procedure” (McCarthy and Busconi, 1995).
McCarthy and Busconi have published research in which they used Arthroscopy on fifty-nine patients suffering from pain that did not respond appropriately to conservative methods of treatment. The patients in the study were analyzed and “56 percent of patients reported painful clicking of the hip joint, 37 percent had pain on straight leg raising, 9 percent had decreased extension and 34 percent had had episodes of locking of the joint. Five percent had pain predominantly in the thigh, 41 percent reported at least one episode of ‘giving way’ of the hip and 7 percent had snapping of the iliotibial band” (McCarthy & Busconi, 1995). All patients received Arthroscopy which helped to diagnose “69 percent of patients had synovitis in the hip joint, 59 percent had a tear of the acetabular labrum, 39 percent had loose bodies, 32 percent had degenerative arthritis and 27 percent had a chondral defect,” proving that Arthroscopy is a highly effective means of diagnosing hip pain successfully (McCarthy & Busconi, 1995).
Once a patient with leg pain has been properly evaluated, a treatment plan can begin based on presentation of pain and Pathology.
Leg Pain Pathology
Traumatic injuries to the leg or hip such as broken bones or hip dislocation, typically from falls, accidents, sports-related injuries and motor vehicle accidents, produce acute pain and are easily treated. Other common causes of acute leg pain are shin splints, muscle strain, sprains and mechanical issues. Chronic progressive pain involving the leg can be caused by degeneration, disease or dysfunction and requires pain management therapy. Many times this pain originates in the lower back, spinal column or hip joint and radiates down the leg into the thigh.
There are a variety of etiologies for chronic leg pain. Pain can result from irritation or inflammation of the bones, joints, skin, nerves, tendons, ligaments and muscles of the leg. Pain can be referred pain that starts in the hip or lower back and radiates down into the leg. Spine and back issues can result in numbness and tingling in the leg if nerves are compressed resulting in Sciatica. Arthritis can strike the joints in the hips and knees resulting in leg pain. Disease or mechanical dysfunction can also occur.
There are two different forms of Arthritis that can cause leg pain by affecting the hip joint or knee cap. According to the Centers for Disease Control (CDC), “Arthritis continues to burden the U.S. population as the leading cause of physical disability and affects women disproportionately: women with arthritis report greater prevalence of activity and work limitations, psychological distress and severe joint pain than their male counterparts” (Theiss 2007).
Osteoarthritis (OA) affects the joints as the result of wear and tear over time and with age. OA is a degenerative condition that is the most common cause of arthritis in the United States. It is more likely to strike women, obese people, those over age 55 and patients with a history of joint trauma or disease. Osteoarthritis can affect any movable joint resulting in chronic, non-inflammatory arthritis. Most often OA affects the knees and DIP joints in the fingers. Typically pain is asymmetrical, striking only one side of the joint. Normally a cracking or popping sound known as crepitus is present. Crepitus is the result of deteriorating pieces of broken cartilage within the joint rubbing against each other. Swelling or redness is not a common sign of osteoarthritis. Patients report that pain worsens with movement and they suffer from a decrease in range of motion.
Rheumatoid Arthritis (RA) is inflammatory arthritis that is chronic, systemic and destructive. Though is can affect anyone, it is most commonly seen in young women 35 to 50 years of age. Viruses, bacteria and genetic factors are suspected of triggering destructive rheumatoid inflammation. Rheumatoid Arthritis is characterized by symmetric involvement of the large and small joints. RA originates when nonspecific inflammation causes T-Cells to activate and form a pannus. The pannus is a flap of tissue that erodes into local anatomy such as cartilage, bones, and tendons.
Avascular Femoral Head Necrosis occurs when there is incomplete blood supply to the bone. In most cases the normal tissue is destroyed and the bone becomes necrotic. This can occur if the blood vessels that supply the femoral head are damaged from a fracture of the femoral head or dislocation. Once necrosis sets in the damaged bone cannot support weight and may collapse or fracture. This will cause pain and further complications. Avascular Femoral Head Necrosis can also stem from infection, radiation, local or systemic steroids, arthritis syndromes, or causes of unknown origin. While AFHN is specific to the top of the femur in the hip, pain can radiate into the thigh and entire leg. Also, necrosis can strike any bone or tissue in the leg that has been damaged and is not receiving adequate blood supply.
Neuropathy occurs when the spinal nerves that descend into the legs and feet malfunction due to irritation or inflammation resulting in pain numbness, tingling, loss of control or a pins and needles feeling. It may also result from peripheral nerve inflammation not associated with the spine, known as peripheral neuropathies. Neuropathy affects diabetics, pregnant women, and alcoholics the most and typically only strikes one section of the leg. Patients with Neuropathy usually report that the pain is similar to a burning sensation. Studies show that patients suffering from Neuropathic back and leg pain greatly benefit from Spinal Cord Stimulation (Taylor, 2005).
Peripheral Artery Disease (PAD) occurs when there is a low supply of blood to the muscles in the legs due to arteries narrowing, usually from diabetes. This results in exercise induced pain, muscle aches, cramps, and pain associated with movement and exertion, specifically walking.
Labral Tears is a mechanical dysfunction that can result from arthritis, degeneration, wear and tear or injury. Labral Tears affect both sexes and all ages equally (Narvani et al, 2003). The labrum is the cartilage that lines the hip socket (acetabulum) which causes the femur ball to glide smoothly in the hip joint. When this cartilage tears patients report a sharp, painful sensation along with a feeling of clicking, catching or locking with specific movements (Narvani et al, 2003). Labral Tears can be diagnosed with radiography, arthroscopy, MRIs, CT Scans and arthrography (Narvani et al, 2003). Treatment often involves medications, injections, physical therapy and sometimes surgery. Many patients improve with bed rest and by simply staying off of the affected joint by using crutches (Narvani et al, 2003). Arthritis patients have shown to have excellent success with Arthroscopic Debridement of the torn Labrum, which involves surgical removal of the damaged cartilage (Narvani et al, 2003).
Bursitis occurs in joints when the sac (bursa) of synovial fluid in the joint becomes inflamed due to injury, trauma, rheumatoid arthritis or complication from a fracture. There are three types of Bursitis that can result in leg pain: Trochanteric Bursitis in the hip joint and Prepatellar Bursitis and Infrapatellar Bursitis of the Knee. If the bursal sac becomes inflamed pain strikes with every movement or step as the tendon passes across the bone in the joint. Usually patients complain of tenderness and swelling as well as pain when walking. Typically Bursitis responds well to conservative, non-invasive pain management therapies.
Lumbar Radiculitis occurs when spinal nerves in the lower back become aggravated or irritated resulting in pain that emanates into the lower extremities. This is called referred pain because the pain occurs in the leg although it stems from the lower back. A physical exam and spinal imaging will typically diagnose lumbar radiculitis.
Referred pain occurs when pain in one region sends pain to another area. Referred leg pain can be caused by radiculopathy, herniated disc in the lower back and sciatica. Referred leg pain can typically be treated by conservative pain management therapies and epidural steroid injections. Radiculopathy is referred pain that occurs when a nerve root in the lower spinal column is compressed or pinched, usually by a bulging disc, and referred pain radiates into the lower extremities. Herniated Disc, or ruptured disc, occurs when a spinal disc bulges out of place causing the lower vertebrae to misalign and painfully interact with local anatomy such as nerves, tendons, and muscles. Pain from the irritated, inflamed and affected anatomy then can descend into the legs. Sciatica is the inflammation of the sciatic spinal nerve that is part of the lumbar and sacral nerve roots in the lower spine. It is the largest peripheral nerve in the entire body and extends from the lower spinal cord down the leg passing behind the hip joint and down the back of the thigh. Inflammation of this nerve can cause referred pain in the legs and hip joint. Sciatica is typically caused by compression of the nerve by herniated discs in the lower spine. Patients report that sciatica pain is a sharp and intense pain along the inflamed nerve.
Treatment Plans for Leg Pain
Physicians at Oregon Pain are highly skilled at recommending the proper procedure based on type of pain and related symptoms. There are numerous effective pain management therapies available for leg pain. Typically, conservative treatments include: over-the-counter medications such as NSAIDs and Acetaminophen (Tylenol), exercise, physical therapy, bed rest or use of crutches to keep weight off affected leg. Physical therapy has proven to successfully improve the postural stability in OA patients (Giemza 2007). Studies show that most leg pain responds successfully with conservative measures.
When leg pain does not subside with conservative means, more aggressive treatment is sometimes necessary. Innovative treatments are becoming more readily available and have proven to be quite effective at reducing and eliminating chronic leg pain. Many times patients successfully eliminate pain with therapeutic injections such as intra-articular joint injections, Epidural Steroid injections or cortisone injections and Spinal Cord Stimulation.
Intra-articular joint injections have become popular due to their minimally invasive approach and successful, long-lasting effects. A joint injection is useful when diagnosing source of pain, relieving symptoms and reducing inflammation. Joint injections provide rapid relief and allow patients to quickly resume normal physical activities. Many times these joint injections attain success that was not reached with conservative treatments and patients can happily get back to daily routines.
Epidural Steroid Injections can be recommended for referred pain that is due to sciatica, herniated vertebral disc pain, radiculopathy and Degenerative Disc Disease that begins in the lower back. Epidural Steroid Injections involve the injection of steroids, corticosteroids, or local anesthetics, or a combination thereof, into the epidural space by affected spinal root nerves. The injection supplies medication to the affected regions and inflammation and irritation are reduced. Most patients benefit from multiple injections and a series of three is normally the initial recommendation. Patients report reduction in pain with each subsequent treatment. Epidural Steroid Injections are successful, minimally invasive and effective in reducing or eliminating pain.
Spinal Cord Stimulation (SCS) utilizes small electrodes that are positioned within the epidural space near the spinal cord. Pain transmission is then blocked by a small electrical current that is sent from the electrodes to the spinal cord. Significant pain relief results when the transmission of pain is interrupted. Patients suffering from refractory neuropathic back and leg pain, Failed Back Surgery Syndrome, complex regional pain syndrome, chronic neck pain, diabetic neuropathy, post herpetic neuralgia, peripheral ischemia, and other conditions that are resistant to more conservative treatments have been shown to benefit significantly from SCS (Vallejo 2007).
After SCS therapy patients report fewer headaches and decreased lower extremity pain (Vallejo 2007). In cases of refractory neuropathic back and leg pain and Failed Back Surgery Syndrome “results showed that 62 percent of SCS patients achieved 50 percent pain relief or more and 53 percent of patients no longer required analgesics. Functional capacity and HRQL were significantly improved by SCS, and 40 percent of patients were able to return to work. Furthermore, 70 percent of SCS patients expressed satisfaction with their treatment. An SCS complication rate of 18 percent per year was observed, most of which were reversible and mainly due to electrode or lead problems. No serious adverse events and no neurological-related complications were reported. SCS not only reduces pain, improves quality of life, reduces analgesic consumption, and allows some patients to return to work, with minimal significant adverse events, but may also result in significant cost savings over time” (Taylor 2005).
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