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Leg Pain Cheat Sheet (DRAFT) by

Leg pain causes, symptoms, management

This is a draft cheat sheet. It is a work in progress and is not finished yet.

Lumbar causes

Pitfalls: Herpes Zoster
Spinal Canal Stenosis
Disorders of SIJ and hip joint
Glut Med/Min TrP
Hip pocket wallet syndrome
Nerve Entrap­ments
NR syndromes
Refer when: Leg pain is severe and disabling
Symptoms to Lx radioc­ulo­pathy that persists without improv­ement or progre­ssion
Clinical Evidence of signif­icant motor deficit
No sigini­ficant response after 4 weeks of conser­vative care
Incapa­cit­ating low back and leg pain
Hx: When the back pain and leg pain started - twisti­ng/­weight lifting at onset? , SOCRATES, Red Flags

Red Flags

- Severe, new neurol­ogical deficits (Cauda Equina - severe lower extremity weakne­ss/­par­alysis, saddle anaest­hesia, limb sensory loss/n­umb­ness, rectal obstip­ati­on/­inc­ont­inence, erectile dysfun­ction)
- Bilate­ral­/Mu­ltiple root levels Neurol­ogical Deficits
- Recent Spinal anaest­hes­ia/­spinal tap/back procedures (surge­ry/­inj­ection)
- Ask about GI, Urinary and gynaec­olo­gical symptoms

L3 Radioc­ulo­pathy

- Sensation loss in all or part of the areas above
- No reflex testing
- Weak Quads,­Add­uctors and Iliopsoas

L4 Radioc­ulo­pathy

- Sensation loss in all or part of the areas above
- Hypore­fflexia of Patella reflex
- Weak Quads


- Sensation loss in all or part of the areas above
- Hypore­flexia of hamstring reflex
- Weakness of Tib post + anterior + hip abductors

S1 Radicu­lopathy

- Sensation loss in all or part of the areas above
- Hypore­flexia in Achilles reflex
- Muscle weakness in hip extensors + ankle planta­rfl­exion


- Observ­ation
- Passive accessory movement testing
- Nerve Tension Testing
- Special Tests
- Pathol­ogical reflex testing
- Palpation


- X-ray - fractures + disloc­ations in trauma patients, multiple root levels
- CT - acute fractures, disc herniation
- MRI - be wary of asympt­omatic abnorm­ali­ties, cauda equina, abscess, tumour, haematoma
- EMG - NR dysfun­ction

Sensit­ising Movements


- Fajers­ztajn's sign = Pain on contra­lateral side when the non-pa­inful side is flexed at the thigh with leg held in extension
- Szabo's sign = Loss of sensation on the lateral portion of the foot
- Bonnet's sign = Pain on adduction of the thigh
- Turyn sign = Pain in buttocks when great toe is hypere­xtended
- Linder sign = Pain in lower back/down the leg when the patient is supine
-Braggard's sign = An increase of pain when the straight leg is extended and foot is dorsif­lexed

Herniated Disc

- 90% of disc hernia­tions occur at L4-5 & L5-S1
- L4 NR = L3-L4 Herniation
L5 NR = L4-5 herniation
S1 root = L5-S1 herniation
- Pain = tearing of pain sensitive outer annulus (nocic­eptive fibres innervated by recurrent meningeal nerve)
Mechanical compre­ssion of discal + adjacent ligame­ntous tissue
Secondary inflam­mation due to nuclear extrusion


Buttock + leg pain in affected NR distri­bution - leg pain usually worse
Hx of flexio­n/r­otation at onset
May radiate to calf and foot in severe cases
Pain is sharp and severe
Leg numbness, pins and needles, weakness
Aggravated by - trunk flexion, coughing, sneezing, sitting
Relieving - supine with supported hip/knee flexion
Hx of chroni­c/r­epe­titive LBP


Antalgic posture - towards leg pain = poster­omedial herniation
away from leg pain = poster­ola­teral herniation
Lx Flexion decreased + painful - increases leg pain. Extension relieves but still restricted
SLR +ve
Femoral nerve tension tests provoke leg pain if herniation is at L3/L4
+ve Valsalva
+ve SMR findings (can be present without them)


- MFPS - Glut med, Pirifo­rmis, Glut Min, TFL
- Dynamic lateral entrapment
- Central stenosis
- Peripheral entrapment neuropathy
- Lx facet syndrome
- SIJ syndrome


- Omega 3 fatty acids
- Manipu­lat­ion­/mo­bil­isa­tio­n/a­cti­vator
- Flexion - distra­ction
- TrP therapy
- Interf­ere­ntial
- McKenzie procedures

Spinal Stenosis

- Can be central or lateral
Q1: Numbne­ss/pain in the thighs down to the calves and shins
Q2: Numbne­ss/pain increases in intensity after walking for a while but are relived by taking a rest
Q3: Standing for a while brings on numbness and or pain in the thighs down to the calves and shins
Q4: Numbne­ss/pain reduced by bending forward
4 mores on Q1-4 = LSS
4 points on Q1-4 and <1 on cauda equina questi­onnaire = radicular type of LSS
>1 on Q1-4 and >2 on cauda equina questions = cauda equina LSS


- Dominant symptoms below gluteal fold
- Hx of interm­ittent neurogenic claudi­cation
- Centra­lis­ation not possible
- Symptoms improved when seated and walking with spine in flexion
- Symptoms worse with standi­ng/­walking


- Slow, gradual decreasing activity tolerance especi­allly with walking and standing
- If occurs before 60 - check for diabet­es/­met­abolic problems
- Numbness /pain in the thighs down to the calves­/shins
- Numbne­ss/pain increase in intensity after walking for a while but relieved by rest
- Standing for a long time brings on numbne­ss/pain in the thighs down to the calves and shins
- Numbne­ss/pain are reduced by bending


- Usually NAD
- SLR +ve, symmet­rical weakness and atrophy + diminished reflexes
- Cycle test - cycling distance same in vascular interm­ittent claudi­cation when spine is flexed­/up­right - extended spine limits distance in neurogenic claudi­cation


- Flexion distra­ction
- Nerve mobili­sation - Pt supine while dr dorsif­lexes the ankle and flexes hip with the knee extended and raises the leg until a barrier is felt. Foot is moved into plantar flexion + dorsif­lexion for several cycles
- Exercises - cat camel + nerve flossing
- 2-3 times per week for 3 weeks then reduce the time to 1 per week if improved

Lateral Entrapment

- Bony encroa­chment from osteop­hytes/ ossified spinal ligame­nts­/soft tissue changes - facet joint hypert­rophy, PLL thicke­ning, LF thickening and scar tissue from a repair of annulus fibros­us/­ext­ruded nucleus pulposus
- Fixed Lateral entrapment = reduced mobility around IVF is reduced and entraped more - symptoms less related to movement


- Chronic LBP with radiation to buttock and leg - can radiate to foot , but distal leg pain is more common
- Pain is burning + tingli­ng/­numbess
- Distri­bution of leg symptoms are related to NR involved
- Dynamic lateral entrapment - flexio­n/e­xte­nsion increase pain, Rotation can periph­eralise pain
- SMR present but can be absent or small
- Nerve tension tests can produce minor leg pain


- Dynamic entrapment associated with better prognosis than fixed
- SMT if there is no frank neurod­eficit
- TrP therapy + myofascial therapy
- Ultras­ound, electrical stimul­ation
- Flexio­n-d­ist­raction to increase canal and IVF diameter
- Chronic phase - rehab needed

Epidural Compre­ssion Syndrome

- Should be considered if patient has neurol­ogical S&S of cauda equina/ above L2
- Caused by haematoma, infect­ion­/ma­lig­nancy


- LL sensor­imotor neurol­ogical deficits
- Saddle Distri­bution sensory loss
- Bowel incont­ine­nce­/un­exp­lained loss of rectal sphincter tone
- Urinary retent­ion­/ov­erflow urinary incont­inence
- Impotence
- Soft neurol­ogical signs involving >1 dermatome
- Look for UMNL signs (conus medullaris syndrome)

Cauda Equina

Hx: Low back pain with acute/­chronic radiating pain
Unilat­era­l/b­ila­teral lower extremity motor/­sensory abnorm­ality (saddle anaest­hesia)
Bladde­r/bowel dysfun­ction (start­ing­/st­opping stream of urine, urinary incont­inence)
Q1 Numbness present in both legs
Q2: Numbness is present in the soles of both feet
Q3: Numbness arises around the buttocks
Q4: Numbness is present but pain is absent
Q5: A burning sensation arising around buttocks
Q6: Walking nearly causes urination


- Pain localised to the low back , local tenderness to palpat­ion­/pe­rcu­ssion
- Reflex abnorm­alities - loss of reflexes; hypera­ctive linked to spinal cord involv­ement - excludes CES
- Pain in the legs
- Sensory abnorm­ality (perin­eal­/lower extrem­ities
- Muscle weakness in affected roots - Quads, foot evertors + dorsif­lexors, foot planta­rfl­exion - muscle wasting can occur
- Poor anal sphincter tone

Neurol­ogical bladder dysfun­ction Qs

- Have a sense of bladder filling
no =neuro bladder
- Feel urine passing?
no = neuro bladder
- Stop the urine passing?
no = neuro bladder
- bladder leakage or suddenly releases?
yes = neuro bladder
- associated rectal disorder?
yes = neuro bladder
- Disorders of potency? (erectile dysfun­ction)
yes = neuro bladder
- Numbness in perineum?
yes = neuro bladder
Retention of urine - large "­ato­nic­" bladder
Dimini­sed­/absent sensation of bladder fullness
Consid­erable residual urine - high risk of infection
Continual dribbing incont­inence
Due to: Loss of parasy­mpa­thetic supply to the bladder - LMNL to bladder wall + spincter
Loss of motor control to the external sphincter
- No/dim­inished afferent supply from the bladder

Non-me­cha­nical CES

- Nerve Sheath Tumours: Schwan­noma, neurof­ibroma, gangli­one­uroma, neurof­ibr­osa­rcoma
Usually affects middle aged adults, in neurof­ibr­oma­tosis multiple lesions can occur
- Imaging: Enlarged IVF, post body erosions

Synovial Cysts

- Facet Cysts
- Usually affects L4/5 & L5/S1
- Usually asympt­omatic
- Presents with worsening LBP and leg pain as it expands
- MRI used


-Common neoplasm
- Slow growing and benign
- Mainly in Tx region - can occur in the cx spine
- Radicular pain, becoming worse as lesion expands

Perineural (Tarlov's cysts)

- Most are asympt­omatic
- Involves sacral­/co­ccygeal NRs
- Causes LBP, leg pain and sacroc­occ­ygeal pain
- Symptoms worsen as lesion expand


- More common in lumbar spine
- Can cause lateral mono-r­adi­cul­opathy
- Symptoms get worse as lesion grows
- Bony destru­ction + VB collapse occur
- Look for Hx of cancer, cancer risk factors, family hx

VB Osteom­yelitis

- Infection - look for fever, hx of recent infect­ion­/wo­und­/su­rgery
- Destru­ctive lesions cause an imaging "­lag­"
- Refer for FBC, ESR, CRP

Infection (Herpes Zoster)

- Most common at Tx + CN V - Lx most common at L2-4
-Radicular pain + vesicular eruptions in the dermatome
- Post herpetic neuralgia in a small percentage of patients
- Aggressive early treatment - analgesia + retro-­virals

Diabetic Radiculo, polyra­dic­ulo­,amotr

- Usually in L2,L3 or L4 NR
- Non-in­sulin dependent diabetic (males)
- Onset of excruc­iating pain down the front of the thigh to the medial leg
- Within a few days of onset, the pain gets better and a rapid wasting and weakness of quads occurs
- Weeks prior to onset, Hx of rapid weightloss + general ill health
- Often improves within 6 months - can take up to 2 years
- Tight diabetic control with insulin needed

When to refer

- Sudden onset of Pain, pallor, pulsel­ess­ness, paralysis, paraae­sthesia and coldness
- Worsening interm­ittent claudi­cation
- Rest pain in foot
- Presence of popliteal aneurysm
- Evidence of DVT
- Worsening of hip pain
- Evidence of disease in bone
- Severe Sciatica with neurol­ogical deficit


Acute or chronic pain?
If acute - trauma related or unusual activity? If not, consider vascular causes
Pain related to movement? If no consider soft tissue lesion
Postural pain? Postures that make the pain better or worse? Worse on sitting = disoge­nic­/is­chial bursitis, if worse on standing = instablity or local problem, if worse lying down = vascular
Related to walking? No = what is the offending activity? Yes: If immediate - local cause. If delayed = vascular claudi­cat­ion­/ne­uro­genic claudi­cation
Site of pain same site of trauma? If no = lesions in the spine,­abd­omen, hip and entrapment neuropathy
Pain arising from bone? If yes, pain is very specific with deep and boring "­bon­e" pain
Pain arising from joints? AROM + PROM


- FBC, ESR, D-dimer, CRP
- X-rays of spine, knee , hip
- Bone scan
- Duplex ultras­ound, ankle brachial index

Ankle Brachial Pressure index (ABPI)

<0.4 - 0.79 = pain at rest

Leg pain in children

- Common soreness and muscular strains due to trauma or unaccu­stomed exercise
- Growing pains - usually in the evening in thighs and calves (both legs) lasts for minutes to an hour, most commonly at 9-12yo, massage of the area best treatment

Leg pain in the elderly

- Arterial disease with interm­ittent claudi­cation + neurogenic claudi­cation
- Degene­rative joint disease
- Muscle Cramps
- Herpes Zoster
- Paget's disease
- Sciatica
- Retrop­eri­toneal haemor­rhage - antico­agulant therapy

Hip Pocket Wallet Syndrome

- Wallet in back pocket compresses the sciatic nerve
- Presents with buttock and upper posterior thigh pain - without back pain


- Watch patient walk and assess the nature of any limp
- Exam Lx
- Inspect patient's stance and note any asymmetry and other abnorm­alities - swelling, bruising, discol­our­ation, ulcers, rashes, size and symmetry of legs and venous pattern, ischaemic changes in the foot/LL
- Palpate for local causes - ischial tubero­sity, trocha­nteric area, hamstrings and tendon insert­ions, superf­icial lymphn­odes, temper­ature of LL
- Palpate pulses of LL and look at the veins
- Auscultate abdomen and iliac, femoral and popliteal vessels for bruits
- Exam of Hip and SIJs

Piriformis syndrome

Caused by: Trauma
Hormonal changes (pregn­ancy, menstrual) ,therefore F:M = 6:1
Excessive manipu­lation
Prolonged external rotation of the thigh (driving)
S&S: Deep, boring, ill-de­fined pain in buttock, poster­ola­teral thigh and calf (rarely to foot)
Burning sensation over greater trochanter
Unable to lie on involved side
Leg externally rotated and reduced internal rotation
Piriformis muscle test demons­trates unilateral shortness
Trigger points in Piriformis
Deep palpation of muscle belly is tender and may reproduce leg pain
+ve Bonnet's test
SIJ Dysfun­ction often presents ipsila­terally
DDx: Lx Disc herniation
Manage­ment: TrP
Spray and stretch
Manipu­lation of SIJ
Hip mobili­sation (if both are stiff)
Ultras­ound, electrical stimul­ation
Home stretching

Arterial causes

PAD is the main cause - build up of plaque in arteries
Tight squeezing pain in the calf, foot , thigh or buttock during exercise, relieved by rest, decreased leg strength and function, poor balance when standing, cold and numb feet and toes, sores that are slow to heal

Overuse injuries

- Medial tibial stress syndrome
- Stress fractures
- Exertional compar­tment syndrome
- Tibialis anterior tenosy­novitis
- Chronic muscle strains


Myofascial therapy
Exercise program
Correction of predip­osing factors - training errors, unsuitable footwear
Analgesics (NSAIDs)