SCIENTIFIC SECTION
J.L. PROVAN,* B SC, MS, FRCS, FRCS[C], FACS; PAUL MOREAU,t MD, FRCS[C]; IAN MAcNAB4 FRCS, FRCS[C] Problems may confront the practitioner in the diagnosis of leg pain related to exercise. The diagnostic features of the history and the physical examination that will help to elucidate the various causes of leg pain are outlined in this article, and the necessity for re-examination of the patient after a period of exercise is stressed. In most patients the diagnosis can most easily be made by means of clinical methods, without recourse to special investigations. Lors du diagnostic de douleurs dans les jambes au cours d'exercices le medecin peut Atre confronte avec divers problemes. Les elements de diagnostic retrouves A l'anamnese et l'examen physique qui permettent d'elucider les differentes causes des maux de jambes sont esquisses dans cet article, et Ia necessite de re-examiner le patient apres une periode d'exercice est soulignee. Chez Ia plupart des patients le diagnostic peut Atre obtenu le plus facilement au moyen de methodes cliniques sans recourir a des etudes speciales.
Pain in the leg is a common presenting symptom and should usually pose no problem in diagnosis if history-taking and physical examination are careful. In some cases, however, the cause of the pain will be difficult to elucidate, and under these circumstances further tests may be necessary, especially to distinguish between peripheral vascular disease and spinal stenosis. Occasionally the unsuspecting may label a case of arthritis as one of vascular disease, From the Wellesley Hospital and the University of Toronto *Chief, division of vascular surgery, the Wellesley Hospital tWorkmen's Compensation Board research fellow, division of orthopedic surgery, the Wellesley Hospital Whief, division of orthopedic surgery, the Wellesley Hospital Reprint requests to: Dr. J.L. Provan, E.K. Jones Building, Ste. 308, 160 Wellesley St. E, Toronto, Ont. M4Y 1J3
or vice versa; this is particularly true with pain in the hip. This article stresses, in the context of the four main causes of leg pain, the points to be noted in the clinical assessment of patients who present with leg pain related to exercise.
Peripheral arterial disease
of the peripheral nervous system. When the pain is felt in the buttock as a result of common iliac artery
obstruction, it is commonly misdiagnosed as being due to osteoarthritis of the hip. This error is more likely if the buttock pain is not associated with pain in the calf. The pain of gluteal claudication may be distinguished from pain arising in the hip by the fact that claudication does not often occur when the patient walks around the house or goes up or down stairs at home, is not worse in the morning,
does not get better as the day wears on and is usually felt only when the patient walks outside. That
there is difficulty in making this diagnosis is shown by the number of patients with vascular disease who present to the offices of orthopedic surgeons as well as by the number of patients with osteoarthritis of the hip who are sent to vascular surgeons. Rest pain: Probably no symp-
Symptoms Intermittent claudication: Intermittent claudication is easily recognizable as a pain that is usually tom of severe vascular disease is felt in the calf of the leg, is brought less well appreciated than rest pain on by walking and is relieved by even though the history of the pain rest. Less commonly patients may is always characteristic.1 It is an complain of discomfort in the foot extremely important symptom in or in the thigh, groin, buttock or that it indicates that the arterial lower back. Some patients do not supply of the limb is insufficient describe their symptoms as a pain for the metabolic requirements of but rather as a tightening, heavi- the skin at rest and that restoration ness or cramping. Its presence is of the blood flow is essential to sometimes associated with the on- avoid the development of skin neset of numbness in the foot, which crosis and gangrene. The ischemic may cause confusion with disease pain of severe arterial insufficiency CMA JOURNAL/JULY 21, 1979/VOL. 121 167
.-For prescribing information see page 208
is a burning pain that is felt in the distal part of the limb, usually in the toes, but sometimes on the dorsum of the foot and occasionally in the heel. It is not made worse by exercise, may be intermittent or may be present continuously at rest. The pain is characteristically noticed at night when the limb is elevated and when the cardiac output and the blood pressure fall. It is relieved by movement and by letting the leg hang down. The fact that the pain improves when the patient gets up and walks is sometimes taken as evidence that it is not due to arterial insufficiency. However, the improvement occurs when limb dependency enhances the distal blood supply by increasing the hydrostatic pressure and hence improving the perfusion pressure. In addition, exercise may increase perfusion by raising the cardiac output and decreasing the hydrostatic pressure on the venous side; this increases the arteriovenous pressure gradient for blood flow into the foot. Coldness of the foot: This is significant only when a change in foot temperature has been noted by the patient or when one foot is noted to be colder than the other. Numbness: This results from ischemia of the peripheral nerves, which may occur when the patient walks. Physical examination The patient should be completely undressed. The blood pressure is taken in both arms, the carotid, subclavian, brachial and radial pulses on each side are checked, and bruits are listened for over the carotid and subclavian arteries on each side. The presence or absence of vascular disease in these areas may have a bearing on subsequent decisions with regard to surgical treatment. The abdomen is palpated for the presence of aortic pulsation, and an assessment is made as to whether the palpable aortic pulse is aneurysmal. The iliac pulses may be felt in thinner individuals, and the femoral pulses should be palpated and timed with the radial pulses. Auscultation is then done over the aorta and over each iliac artery in a search for bruits and
particularly for the site of their onset. The legs are then fully exposed and examined, note being made of their colour and of any obvious muscle wasting. Hair loss has been overemphasized as a diagnostic sign of peripheral arterial insufficiency. The temperature gradient is then assessed by running the palm of the hand down each limb. The presence of cold feet but warm knees is diagnostic of popliteal arterial obstruction, the skin temperature around the knee having been raised because of the collateral vessels in the subcutaneous tissues of this area. A temperature difference between the feet can easily be assessed. The peripheral pulses are then palpated. Palpation of the popliteal artery is the most difficult and is usually performed incorrectly by feeling for the artery too high in the popliteal fossa. If the thumbs are placed at the level of the tibial tuberosity and the middle fingers are then placed posteriorly, where they naturally lie over the lower part of the popliteal fossa against the upper condyle of the tibia, the artery will be felt more easily. When the foot pulses are being palpated the peroneal pulse on the anterior aspect of the lateral malleolus should not be forgotten, as it is sometimes present when the dorsalis pedis pulse is absent. The presence of palpable pulses does not exclude peripheral arterial disease. Because of subjective error it is unwise to use too many gradations when recording the pulses; that the pulse is present, absent, reduced or aneurysmal is sufficient in our view. The limbs are then elevated for a minute or so and colour changes in the soles of the feet and the toes are observed. Minor blanching will occur if the vascular system is healthy, but an ischemic limb will become paler than its fellow. This is particularly visible in the pulps of the toes and in the sole of the foot and is accompanied by loss of venous filling, with guttering of the skin overlying the veins. The patient is then sat up and the legs allowed to hang over the side of the examination table. The length of time taken for the veins to refill
168 CMA JOURNAL/JULY 21, 1979/VOL. 121
above the level of the skin surface is noted. This is the venous filling time, and at normal room temperature it should be within 10 to 15 seconds. At the same time the colour of the limbs is noted. The ischemic limb will tend to be redder, and if it is extremely ischemic very marked redness, dependent rubor, will appear. The proximal extent of the rubor is directly proportional to the severity of the arterial insufficiency. Rubor is seen most commonly in patients with pain at rest. It may not be present in patients with intermittent claudication and in severe cases may take a minute or more to develop. The arteries are then auscultated from the groin to the knee. In many instances stenosis of the superficial femoral artery will be missed unless this examination is performed. Although the examiner should know at this stage whether peripheral arterial insufficiency is present and should be able to localize the site of an arterial occlusion, termination of the examination at this point, a common error, is hardly appropriate when in most patients symptoms occur only after exercise. The patient is then asked to run rapidly on the spot, being encouraged to raise his knees as high as possible off the floor. Even a small amount of slowly performed exercise is better than none. It is not necessary that the exercise continue until pain develops. The patient is then asked to return to the examination table and is re-examined with the limbs recumbent. In the presence of peripheral arterial insufficiency the affected limb will be much paler after exercise, the veins will have collapsed and the pulses, if previously present, may have disappeared. The reason for this is shown in Figs. 1 and 2. Blood flow through the muscle vascular bed during exercise is controlled by chemical factors, whereas blood flow through the skin is controlled by the sympathetic nervous system. In the presence of proximal arterial narrowing but not complete occlusion, peripheral pulses may be present. With exercise an inadequate volume of blood is available to meet the requirements of the limb because of the
MUSCLE PR FALLS ARTERIAL NEEDED INFLOW ONLY 600m1 1mm AVAILABLE BECAUSE OF ARTERIAL LESION
SKIN PR MAY INCREASE
Peripheral neuropathy Pain in the feet at rest may be related to the peripheral neuropathies associated with metabolic disorders such as diabetes mellitus, alcoholism and vitamin B deficiencies. Some patients with these disorders experience severe burning pain in the foot, often accompanied by a sensation of coldness, that may be confused with the rest pain of advanced arterial insufficiency. However, a history of the predisposing factors can be obtained, and numbness, paresthesia and tenderness are often associated. Physical examination will reveal a sensory loss, often symmetric, of the "gloveand-stocking" type, and may show muscle wasting and weakness and depression of the deep tendon reflexes. Electromyography and nerve conduction studies may be helpful in making a diagnosis. Meralgia paresthetica This condition, which is due to entrapment of the lateral cutaneous nerve of the thigh as it passes through the inguinal ligament, may produce a burning pain, sometimes accompanied by numbness or aching, over the lower lateral aspect of the affected thigh. It is usually related to standing but may be worse after exercise, when the nerve is irritated as the inguinal ligament tightens during extension of the hip. The individual may be forced to rest on the unaffected leg or to sit down to relieve the discomfort. Physical examination may reveal nothing abnormal but may show a patch of hypoesthesia on the outer aspect of the thigh in advanced cases, though this may be detectable only while the pain persists. The diagnosis can be made from the typical distribution of the pain on the outer side of the thigh and its onset after standing or exercise. Musculoskeletal causes Osteoarthritis A misdiagnosis of peripheral arterial insufficiency may be made in patients with osteoarthritis because the pain in either the hip or the knee bears a definite relation
to exercise. If the peripheral pulses are impalpable further confusion may result. Most persons with osteoarthritis notice that their joints are "stiff". The stiffness may be worked off with exercise, but the pain will usually occur at home and may be worse while the person is going down stairs; neither feature is usual with intermittent claudication. The individual with arthritis may complain of having to "work the joints loose" and of pain in the area at night when the muscles are relaxed sufficiently to permit unguarded movements of the joint to produce pain. It is most important to commence the physical examination by watching the patient walk. Patients with intermittent claudication due to vascular disease do not limp when they start to walk, although a limp may develop as walking proceeds. Unless the two conditions are present simultaneously, patients who commence walking with a limp do not have intermittent claudication. Further examination of the joints will reveal limitation of movement, fixed flexion contractures or joint effusions, and reproduction of the presenting symptom at extremes of movement. If doubt is still present, examination of the vascular system after exercise will reveal no evidence of vascular insufficiency following this form of stress. Degenerative disease of the spine Sciatica: Pain in the distribution of the sciatic nerve may be the result of referred pain derived from segmental instability due to degenerative disc disease or it may be due to nerve root compression. Any extradural lesion can cause nerve root compression, but the most common causes are (a) disc rupture and (b) entrapment of the nerve root in the bony canal of the vertebra. This pain, accompanied at times by loss of muscle power or sensation, can be confused with the ischemic pain of vascular insufficiency of the leg. A history of unusual strain on the back can be elicited in only about one half of patients with sciatica and, indeed, many have no complaints of backache. The pain usually radiates down the lateral
170 CMA JOURNAL/JULY 21, 1979/VOL. 121
or posterior aspect of the leg and into the dorsum of the foot or into the knee, depending on the root involved. The pain may be accompanied by motor weakness, sensory aberrations or numbness. Radicular pain due to disc rupture, though aggravated by walking, is also aggravated by specific activities, such as stooping, lifting, straining, coughing and sneezing. Physical examination will reveal signs of nerve root tension, such as limitation of straight leg raising, nerve root irritation, such as spasm in the sacrospinalis muscles, and specific motor point or muscle tenderness. On occasion, impairment of nerve root conduction will be reflected by changes in reflex activity and sensory or motor loss. Spinal stenosis: This condition produces a clinical syndrome caused by localized narrowing of the spinal canal due to a structural abnormality that may give rise to cauda equina compression.2A By a poorly understood mechanism this may cause symptoms initially indistinguishable from those of intermittent claudication due to vascular disease. The patient's history is extremely important in diagnosing this disease. The condition affects the same age group as vascular disease and is usually seen in men. The symptoms vary, but the patient often presents with a history of calf pain, which starts insidiously and is made worse by walking a certain distance. The pain is often of the "cramping" or "knotting" type seen with intermittent claudication, but its relief with the cessation of exercise is less clear. Typically the pain of vascular insufficiency is relieved when the patient stands for a minute or so, while that of spinal stenosis usually takes 10 to 30 minutes to settle down. Patients often say that they must sit or lie down with the knees bent to relieve the discomfort. The pain is not made worse by coughing or sneezing. There is sometimes a significant amount of backache with buttock pain; unfortunately, this frequently resembles the buttock pain associated with common or internal iliac artery insufficiency. The pain is occasionally bilateral, but usually one leg is worse than the other. The discomfort is often in the dis-
tribution of the sciatic nerve, but made without the need for arteriothis may vary. There is usually a graphy. history of increasing numbness and tingling in the feet with walking, Discussion which can lead to an unsteady gait. The intent of this paper is to Walking uphill is often much easier than walking downhill, and there is draw attention to the fact that most no problem in riding a bicycle for types of leg pain can be diagnosed great distances, probably because by careful history-taking and phyof the maintenance of a stooped sical examination. In most instances there is no need to rely on complex position. As with the patient with peri- investigations to make the diagnopheral vascular disease, the patient sis, although special procedures with suspected spinal stenosis may be required to plan treatment should be examined both at rest once the diagnosis has been made. and after exercise. Examination of The practitioner approaching* the the back may yield completely nor- diagnostic problem of leg pain remal results, or it may show pain lated to exercise should have in with hyperextension. Occasionally mind a list of the diagnostic possipercussion of an asymptomatic bilities. The history-taking and physical examination are then back stimulates the leg pain. Signs of root pain, such as limit- designed to test each hypothesis ation of straight leg raising, are until, by exclusion, only one or rare, and the bowstring sign is usu- two remain. In most instances the ally negative. Motor, sensory and greatest difficulty arises in the disreflex changes are often absent, but tinction between vascular and neuthey can occasionally be brought rogenic claudication. The history on by exercise. Signs of nerve root may be so typical that only when irritation, such as muscle tender- the patient exercises does the true distinction appear. The importance ness, can often be elicited. If confusion still exists, nonin- of examining the patient after exervasive studies of the vascular sys- cise cannot be too strongly stressed tem will exclude arterial disease, and, indeed, it seems illogical to but electromyography, myelography examine the patient only at rest, and selective nerve root blocks may when in many instances the sympbe needed for a definite diagnosis. toms occur only after exercise. It is hoped that the diagnostic Electromyography and nerve conduction studies will occasionally techniques outlined in this paper localize the nerve root involved, will aid the practitioner in sorting especially in those with a long- out these difficult cases. Unforstanding history, but not necessarily tunately, when peripheral arterial in those with minor or no neuro- insufficiency and spinal stenosis logic deficits. The findings with coexist, as in patients over 60 years myelography vary, but there are of age, the relative importance of usually posterior or posterolateral the two diseases may be extremely defects that correspond to the areas difficult to define. It is in this group of root compression. Myelography that the use of noninvasive testing is often difficult to perform because of the arterial circulation has its of the narrowed canal and hyper- greatest value. trophied laminae. Occasionally cisReferences ternal puncture is necessary. It must never be forgotten that 1. CRANLEY JJ: Ischemic rest pain. vascular claudication and spinal Arc/i Surg 98: 187, 1969 stenosis may coexist and, indeed, 2. VALUEST H: A radicular syndrome from developmental narrowing of the there have been several cases in lumbar vertebral canal. J Bone Joini which both vascular reconstruction Surg (Br) 36: 230, 1954 and decompression laminectomy 3. SHATZGER J, PENNAL G: Spinal stenohave been necessary to relieve the sis, a cause of cauda equina compression. J Bone Joint Surg (Br) 50: 606, patient's symptoms. Noninvasive 1968 arterial blood flow studies, perP, PHEASANT HC, DOYLE JB, formed both at rest and after exer- 4. etDYCK al: Intermittent cauda equina comcise, enable a more accurate assesspression syndrome, its recognition and treatment. Spine 2: 75, 1977 ment of arterial insufficiency to be
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CMA JOURNAL/JULY 21, 1979/VOL. 121
171
J.L. PROVAN,* B SC, MS, FRCS, FRCS[C], FACS; PAUL MOREAU,t MD, FRCS[C]; IAN MAcNAB4 FRCS, FRCS[C] Problems may confront the practitioner in the diagnosis of leg pain related to exercise. The diagnostic features of the history and the physical examination that will help to elucidate the various causes of leg pain are outlined in this article, and the necessity for re-examination of the patient after a period of exercise is stressed. In most patients the diagnosis can most easily be made by means of clinical methods, without recourse to special investigations. Lors du diagnostic de douleurs dans les jambes au cours d'exercices le medecin peut Atre confronte avec divers problemes. Les elements de diagnostic retrouves A l'anamnese et l'examen physique qui permettent d'elucider les differentes causes des maux de jambes sont esquisses dans cet article, et Ia necessite de re-examiner le patient apres une periode d'exercice est soulignee. Chez Ia plupart des patients le diagnostic peut Atre obtenu le plus facilement au moyen de methodes cliniques sans recourir a des etudes speciales.
Pain in the leg is a common presenting symptom and should usually pose no problem in diagnosis if history-taking and physical examination are careful. In some cases, however, the cause of the pain will be difficult to elucidate, and under these circumstances further tests may be necessary, especially to distinguish between peripheral vascular disease and spinal stenosis. Occasionally the unsuspecting may label a case of arthritis as one of vascular disease, From the Wellesley Hospital and the University of Toronto *Chief, division of vascular surgery, the Wellesley Hospital tWorkmen's Compensation Board research fellow, division of orthopedic surgery, the Wellesley Hospital Whief, division of orthopedic surgery, the Wellesley Hospital Reprint requests to: Dr. J.L. Provan, E.K. Jones Building, Ste. 308, 160 Wellesley St. E, Toronto, Ont. M4Y 1J3
or vice versa; this is particularly true with pain in the hip. This article stresses, in the context of the four main causes of leg pain, the points to be noted in the clinical assessment of patients who present with leg pain related to exercise.
Peripheral arterial disease
of the peripheral nervous system. When the pain is felt in the buttock as a result of common iliac artery
obstruction, it is commonly misdiagnosed as being due to osteoarthritis of the hip. This error is more likely if the buttock pain is not associated with pain in the calf. The pain of gluteal claudication may be distinguished from pain arising in the hip by the fact that claudication does not often occur when the patient walks around the house or goes up or down stairs at home, is not worse in the morning,
does not get better as the day wears on and is usually felt only when the patient walks outside. That
there is difficulty in making this diagnosis is shown by the number of patients with vascular disease who present to the offices of orthopedic surgeons as well as by the number of patients with osteoarthritis of the hip who are sent to vascular surgeons. Rest pain: Probably no symp-
Symptoms Intermittent claudication: Intermittent claudication is easily recognizable as a pain that is usually tom of severe vascular disease is felt in the calf of the leg, is brought less well appreciated than rest pain on by walking and is relieved by even though the history of the pain rest. Less commonly patients may is always characteristic.1 It is an complain of discomfort in the foot extremely important symptom in or in the thigh, groin, buttock or that it indicates that the arterial lower back. Some patients do not supply of the limb is insufficient describe their symptoms as a pain for the metabolic requirements of but rather as a tightening, heavi- the skin at rest and that restoration ness or cramping. Its presence is of the blood flow is essential to sometimes associated with the on- avoid the development of skin neset of numbness in the foot, which crosis and gangrene. The ischemic may cause confusion with disease pain of severe arterial insufficiency CMA JOURNAL/JULY 21, 1979/VOL. 121 167
.-For prescribing information see page 208
is a burning pain that is felt in the distal part of the limb, usually in the toes, but sometimes on the dorsum of the foot and occasionally in the heel. It is not made worse by exercise, may be intermittent or may be present continuously at rest. The pain is characteristically noticed at night when the limb is elevated and when the cardiac output and the blood pressure fall. It is relieved by movement and by letting the leg hang down. The fact that the pain improves when the patient gets up and walks is sometimes taken as evidence that it is not due to arterial insufficiency. However, the improvement occurs when limb dependency enhances the distal blood supply by increasing the hydrostatic pressure and hence improving the perfusion pressure. In addition, exercise may increase perfusion by raising the cardiac output and decreasing the hydrostatic pressure on the venous side; this increases the arteriovenous pressure gradient for blood flow into the foot. Coldness of the foot: This is significant only when a change in foot temperature has been noted by the patient or when one foot is noted to be colder than the other. Numbness: This results from ischemia of the peripheral nerves, which may occur when the patient walks. Physical examination The patient should be completely undressed. The blood pressure is taken in both arms, the carotid, subclavian, brachial and radial pulses on each side are checked, and bruits are listened for over the carotid and subclavian arteries on each side. The presence or absence of vascular disease in these areas may have a bearing on subsequent decisions with regard to surgical treatment. The abdomen is palpated for the presence of aortic pulsation, and an assessment is made as to whether the palpable aortic pulse is aneurysmal. The iliac pulses may be felt in thinner individuals, and the femoral pulses should be palpated and timed with the radial pulses. Auscultation is then done over the aorta and over each iliac artery in a search for bruits and
particularly for the site of their onset. The legs are then fully exposed and examined, note being made of their colour and of any obvious muscle wasting. Hair loss has been overemphasized as a diagnostic sign of peripheral arterial insufficiency. The temperature gradient is then assessed by running the palm of the hand down each limb. The presence of cold feet but warm knees is diagnostic of popliteal arterial obstruction, the skin temperature around the knee having been raised because of the collateral vessels in the subcutaneous tissues of this area. A temperature difference between the feet can easily be assessed. The peripheral pulses are then palpated. Palpation of the popliteal artery is the most difficult and is usually performed incorrectly by feeling for the artery too high in the popliteal fossa. If the thumbs are placed at the level of the tibial tuberosity and the middle fingers are then placed posteriorly, where they naturally lie over the lower part of the popliteal fossa against the upper condyle of the tibia, the artery will be felt more easily. When the foot pulses are being palpated the peroneal pulse on the anterior aspect of the lateral malleolus should not be forgotten, as it is sometimes present when the dorsalis pedis pulse is absent. The presence of palpable pulses does not exclude peripheral arterial disease. Because of subjective error it is unwise to use too many gradations when recording the pulses; that the pulse is present, absent, reduced or aneurysmal is sufficient in our view. The limbs are then elevated for a minute or so and colour changes in the soles of the feet and the toes are observed. Minor blanching will occur if the vascular system is healthy, but an ischemic limb will become paler than its fellow. This is particularly visible in the pulps of the toes and in the sole of the foot and is accompanied by loss of venous filling, with guttering of the skin overlying the veins. The patient is then sat up and the legs allowed to hang over the side of the examination table. The length of time taken for the veins to refill
168 CMA JOURNAL/JULY 21, 1979/VOL. 121
above the level of the skin surface is noted. This is the venous filling time, and at normal room temperature it should be within 10 to 15 seconds. At the same time the colour of the limbs is noted. The ischemic limb will tend to be redder, and if it is extremely ischemic very marked redness, dependent rubor, will appear. The proximal extent of the rubor is directly proportional to the severity of the arterial insufficiency. Rubor is seen most commonly in patients with pain at rest. It may not be present in patients with intermittent claudication and in severe cases may take a minute or more to develop. The arteries are then auscultated from the groin to the knee. In many instances stenosis of the superficial femoral artery will be missed unless this examination is performed. Although the examiner should know at this stage whether peripheral arterial insufficiency is present and should be able to localize the site of an arterial occlusion, termination of the examination at this point, a common error, is hardly appropriate when in most patients symptoms occur only after exercise. The patient is then asked to run rapidly on the spot, being encouraged to raise his knees as high as possible off the floor. Even a small amount of slowly performed exercise is better than none. It is not necessary that the exercise continue until pain develops. The patient is then asked to return to the examination table and is re-examined with the limbs recumbent. In the presence of peripheral arterial insufficiency the affected limb will be much paler after exercise, the veins will have collapsed and the pulses, if previously present, may have disappeared. The reason for this is shown in Figs. 1 and 2. Blood flow through the muscle vascular bed during exercise is controlled by chemical factors, whereas blood flow through the skin is controlled by the sympathetic nervous system. In the presence of proximal arterial narrowing but not complete occlusion, peripheral pulses may be present. With exercise an inadequate volume of blood is available to meet the requirements of the limb because of the
MUSCLE PR FALLS ARTERIAL NEEDED INFLOW ONLY 600m1 1mm AVAILABLE BECAUSE OF ARTERIAL LESION
SKIN PR MAY INCREASE
Peripheral neuropathy Pain in the feet at rest may be related to the peripheral neuropathies associated with metabolic disorders such as diabetes mellitus, alcoholism and vitamin B deficiencies. Some patients with these disorders experience severe burning pain in the foot, often accompanied by a sensation of coldness, that may be confused with the rest pain of advanced arterial insufficiency. However, a history of the predisposing factors can be obtained, and numbness, paresthesia and tenderness are often associated. Physical examination will reveal a sensory loss, often symmetric, of the "gloveand-stocking" type, and may show muscle wasting and weakness and depression of the deep tendon reflexes. Electromyography and nerve conduction studies may be helpful in making a diagnosis. Meralgia paresthetica This condition, which is due to entrapment of the lateral cutaneous nerve of the thigh as it passes through the inguinal ligament, may produce a burning pain, sometimes accompanied by numbness or aching, over the lower lateral aspect of the affected thigh. It is usually related to standing but may be worse after exercise, when the nerve is irritated as the inguinal ligament tightens during extension of the hip. The individual may be forced to rest on the unaffected leg or to sit down to relieve the discomfort. Physical examination may reveal nothing abnormal but may show a patch of hypoesthesia on the outer aspect of the thigh in advanced cases, though this may be detectable only while the pain persists. The diagnosis can be made from the typical distribution of the pain on the outer side of the thigh and its onset after standing or exercise. Musculoskeletal causes Osteoarthritis A misdiagnosis of peripheral arterial insufficiency may be made in patients with osteoarthritis because the pain in either the hip or the knee bears a definite relation
to exercise. If the peripheral pulses are impalpable further confusion may result. Most persons with osteoarthritis notice that their joints are "stiff". The stiffness may be worked off with exercise, but the pain will usually occur at home and may be worse while the person is going down stairs; neither feature is usual with intermittent claudication. The individual with arthritis may complain of having to "work the joints loose" and of pain in the area at night when the muscles are relaxed sufficiently to permit unguarded movements of the joint to produce pain. It is most important to commence the physical examination by watching the patient walk. Patients with intermittent claudication due to vascular disease do not limp when they start to walk, although a limp may develop as walking proceeds. Unless the two conditions are present simultaneously, patients who commence walking with a limp do not have intermittent claudication. Further examination of the joints will reveal limitation of movement, fixed flexion contractures or joint effusions, and reproduction of the presenting symptom at extremes of movement. If doubt is still present, examination of the vascular system after exercise will reveal no evidence of vascular insufficiency following this form of stress. Degenerative disease of the spine Sciatica: Pain in the distribution of the sciatic nerve may be the result of referred pain derived from segmental instability due to degenerative disc disease or it may be due to nerve root compression. Any extradural lesion can cause nerve root compression, but the most common causes are (a) disc rupture and (b) entrapment of the nerve root in the bony canal of the vertebra. This pain, accompanied at times by loss of muscle power or sensation, can be confused with the ischemic pain of vascular insufficiency of the leg. A history of unusual strain on the back can be elicited in only about one half of patients with sciatica and, indeed, many have no complaints of backache. The pain usually radiates down the lateral
170 CMA JOURNAL/JULY 21, 1979/VOL. 121
or posterior aspect of the leg and into the dorsum of the foot or into the knee, depending on the root involved. The pain may be accompanied by motor weakness, sensory aberrations or numbness. Radicular pain due to disc rupture, though aggravated by walking, is also aggravated by specific activities, such as stooping, lifting, straining, coughing and sneezing. Physical examination will reveal signs of nerve root tension, such as limitation of straight leg raising, nerve root irritation, such as spasm in the sacrospinalis muscles, and specific motor point or muscle tenderness. On occasion, impairment of nerve root conduction will be reflected by changes in reflex activity and sensory or motor loss. Spinal stenosis: This condition produces a clinical syndrome caused by localized narrowing of the spinal canal due to a structural abnormality that may give rise to cauda equina compression.2A By a poorly understood mechanism this may cause symptoms initially indistinguishable from those of intermittent claudication due to vascular disease. The patient's history is extremely important in diagnosing this disease. The condition affects the same age group as vascular disease and is usually seen in men. The symptoms vary, but the patient often presents with a history of calf pain, which starts insidiously and is made worse by walking a certain distance. The pain is often of the "cramping" or "knotting" type seen with intermittent claudication, but its relief with the cessation of exercise is less clear. Typically the pain of vascular insufficiency is relieved when the patient stands for a minute or so, while that of spinal stenosis usually takes 10 to 30 minutes to settle down. Patients often say that they must sit or lie down with the knees bent to relieve the discomfort. The pain is not made worse by coughing or sneezing. There is sometimes a significant amount of backache with buttock pain; unfortunately, this frequently resembles the buttock pain associated with common or internal iliac artery insufficiency. The pain is occasionally bilateral, but usually one leg is worse than the other. The discomfort is often in the dis-
tribution of the sciatic nerve, but made without the need for arteriothis may vary. There is usually a graphy. history of increasing numbness and tingling in the feet with walking, Discussion which can lead to an unsteady gait. The intent of this paper is to Walking uphill is often much easier than walking downhill, and there is draw attention to the fact that most no problem in riding a bicycle for types of leg pain can be diagnosed great distances, probably because by careful history-taking and phyof the maintenance of a stooped sical examination. In most instances there is no need to rely on complex position. As with the patient with peri- investigations to make the diagnopheral vascular disease, the patient sis, although special procedures with suspected spinal stenosis may be required to plan treatment should be examined both at rest once the diagnosis has been made. and after exercise. Examination of The practitioner approaching* the the back may yield completely nor- diagnostic problem of leg pain remal results, or it may show pain lated to exercise should have in with hyperextension. Occasionally mind a list of the diagnostic possipercussion of an asymptomatic bilities. The history-taking and physical examination are then back stimulates the leg pain. Signs of root pain, such as limit- designed to test each hypothesis ation of straight leg raising, are until, by exclusion, only one or rare, and the bowstring sign is usu- two remain. In most instances the ally negative. Motor, sensory and greatest difficulty arises in the disreflex changes are often absent, but tinction between vascular and neuthey can occasionally be brought rogenic claudication. The history on by exercise. Signs of nerve root may be so typical that only when irritation, such as muscle tender- the patient exercises does the true distinction appear. The importance ness, can often be elicited. If confusion still exists, nonin- of examining the patient after exervasive studies of the vascular sys- cise cannot be too strongly stressed tem will exclude arterial disease, and, indeed, it seems illogical to but electromyography, myelography examine the patient only at rest, and selective nerve root blocks may when in many instances the sympbe needed for a definite diagnosis. toms occur only after exercise. It is hoped that the diagnostic Electromyography and nerve conduction studies will occasionally techniques outlined in this paper localize the nerve root involved, will aid the practitioner in sorting especially in those with a long- out these difficult cases. Unforstanding history, but not necessarily tunately, when peripheral arterial in those with minor or no neuro- insufficiency and spinal stenosis logic deficits. The findings with coexist, as in patients over 60 years myelography vary, but there are of age, the relative importance of usually posterior or posterolateral the two diseases may be extremely defects that correspond to the areas difficult to define. It is in this group of root compression. Myelography that the use of noninvasive testing is often difficult to perform because of the arterial circulation has its of the narrowed canal and hyper- greatest value. trophied laminae. Occasionally cisReferences ternal puncture is necessary. It must never be forgotten that 1. CRANLEY JJ: Ischemic rest pain. vascular claudication and spinal Arc/i Surg 98: 187, 1969 stenosis may coexist and, indeed, 2. VALUEST H: A radicular syndrome from developmental narrowing of the there have been several cases in lumbar vertebral canal. J Bone Joini which both vascular reconstruction Surg (Br) 36: 230, 1954 and decompression laminectomy 3. SHATZGER J, PENNAL G: Spinal stenohave been necessary to relieve the sis, a cause of cauda equina compression. J Bone Joint Surg (Br) 50: 606, patient's symptoms. Noninvasive 1968 arterial blood flow studies, perP, PHEASANT HC, DOYLE JB, formed both at rest and after exer- 4. etDYCK al: Intermittent cauda equina comcise, enable a more accurate assesspression syndrome, its recognition and treatment. Spine 2: 75, 1977 ment of arterial insufficiency to be
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