Clinical practice 55
Leg discomfort
Leg discomfort is a common presentation among the elderly and can be a manifestation of
many different disease processes. One key issue is how to differentiate between the benign and
the more serious causes. Tis article will explore the main differential diagnoses including the
most common causes and management of these, and the recognition of potentially life or limb
threatening causes with an overview of red flag signs and symptoms.
Dr Louise Powter, Specialty Registrar, Acute Medicine, Gloucestershire Royal Hospital, Great Western Road,
Gloucester
Dr Pippa Medcalf, Consultant Geriatric Medicine, Gloucestershire Royal Hospital, Great Western Road, Gloucester
Email louisepowter@nhs.net
Leg discomfort can be caused by
problems in the skin, muscles,
vasculature or nerves of the leg
itself, be due to more distant
disease for instance in the spine,
or be the presentation of systemic
disease. A useful way to think
of the differential diagnosis is to
differentiate between unilateral and
bilateral causes (see box 1).
History and examination
The information gained from
the history of patients with leg
discomfort will guide subsequent
examination and investigations.
Are the symptoms unilateral or
bilateral? Is there a history of
trauma? Determine the type and
site of any pain, the presence of any
neurological or vascular symptoms;
including symptoms outside the
affected leg for instance back pain,
urinary incontinence or retention.
Are there any systemic symptoms
to indicate an infective or
inflammatory cause? A thorough
review of the past medical
history will elicit risk factors
for venous thromboembolism,
peripheral vascular disease, and
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infections (such as diabetes or
immunosuppression).
The appearance of the
affected leg will give clues as to
the diagnosis. Erythema may
indicate cellulitis or DVT, chronic
discolouration is seen in venous
insufficiency and venous eczema,
pallor or levido reticularis is seen
in ischaemia, and in chronic
ischaemia the skin may be shiny
and atrophic with loss of hair.
Muscle wasting and fasiculations
indicate a lower motor neurone
neurological condition. Look for
generalised leg oedema, unilateral
or bilateral, or more specific
swelling for instance a joint
effusion or a baker’s cyst. Assess
the power and sensation of both
legs and perform a full nervous
system examination including
anal tone and perianal sensation
if a neurological condition is
suspected. If a vascular cause is
likely check the pulse rate and
rhythm and perform an ECG,
examine the heart, palpate the
abdomen for an aortic aneurysm,
listen for carotid and femoral
bruits and check for the presence
of peripheral pulses. In suspected
trauma assess all joints for range
of movement and check ability to
weight bear.
Vascular causes
Deep vein thrombosis
DVT has an incidence of around 1
in 1000. It can present with pain,
swelling and erythema, although
can be clinically silent. Clinical
assessment combined with a
validated pre-test probability
score such as the Wells score1
can be used for risk stratification.
British committee for standards
in haematology guidelines suggest
that a D-dimer assay should
be sent in low risk patients. A
negative D-dimer can safely
exclude DVT in these patients.
Low risk patients with a positive
D-dimer and all moderate or
high risk patients should have a
compression ultrasound scan of
the affected leg, and if negative this
should be repeated in one week.2
If a DVT is found the patient
should be anticoagulated for a
period of six weeks to six months
depending on the clinical context
and local guidelines. Most trusts
offer an ambulatory service for the
March 2012 | Midlife and Beyond | GM
56 Clinical practice
Box 1: Differential diagnosis
Vascular
DVT
Superficial thrombophlebitis
Chronic venous insufficiency
Chronic peripheral vascular disease
Acute ischaemia
Neurological
Spinal cord/cauda equina
Radiculopathy
Mononeuritis multiplex
Peripheral polyneuropathy
Restless legs
Musculoskeletal
Trauma
Cramp
Bone tumours
Inflammatory
Myositis
Arthropathies
Infection
Cellulitis
Necrotising fasciitis
Osteomyelitis
assessment and management of
patients with suspected DVT. Te
cause for the DVT is ofen obvious,
for example recent immobility
or surgery, but DVT may be the
presenting feature of underlying
diseases such as malignancy. DVT
should be identified and treated to
prevent fatal pulmonary embolism.
Superficial
thrombophlebitis
Superficial thrombophlebitis
presents with localised pain and
erythema along a superficial vein. It
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Usually unilateral
Usually unilateral
Usually bilateral
Usually bilateral
Unilateral
Usually bilateral
Usually unilateral
Unilateral
Bilateral
Bilateral
Unilateral
Bilateral
Unilateral
Bilateral
Unilateral or bilateral
Usually unilateral
Usually unilateral
Usually unilateral
can be spontaneous or result from
trauma or intra-venous cannulae.
Risk factors include varicose veins,
immobility and hypercoagulable
states such as pregnancy and
hormone therapy. If it is migratory,
ofen travelling from one leg to the
other, there is a strong association
with adenocarcinoma of the
pancreas or lung (Trousseau’s sign)
and a search for an underlying
malignancy should be undertaken.
Patients with superficial
thrombophlebitis may have an
associated deep vein thrombosis, in
one case series rates of DVT were
21.6% and PE 28.3%.3 Tis study
did not identify any risk factors that
were associated with underlying
thromboembolic disease however
other studies suggest risk factors
include male sex, unprovoked
thrombophlebitis and factor V
leiden.4 Management of superficial
thrombophlebitis includes nonsteroidal anti-inflammatory
drugs, topical treatment and
compression stockings. Te role of
anticoagulants is controversial.
Chronic venous
insufficiency
Chronic venous insufficiency
is common in the elderly and
presents with aching, pressure,
burning, itching or heaviness
in the legs, associated with leg
oedema and reddish brown
haemosiderin deposits in the skin
and venous eczema. It results from
venous hypertension and valve
incompetence and is common
afer DVTs (the post thrombotic
syndrome). Management consists
of leg elevation at rest and
compression stockings. Surgery is
reserved for severe cases.
Peripheral vascular
disease
Peripheral vascular disease is
very common and increases
with age, affecting 20% of over
75s5. Presentation is often with
intermittent claudication, where
patients complain of leg pain
or weakness on walking, which
is relieved with rest. Symptoms
may reduce as a collateral
circulation develops. Rest pain
that is relieved by hanging
the leg down indicates critical
limb ischaemia. Management
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58 Clinical practice
Box 2: Red flag signs and symptoms
Signs and symptoms
Pain, pallor, pulselessness,
parasthaesia, paralysis,
perishingly cold
Back pain, numbness,
weakness, bladder or bowel
symptoms, saddle anaesthesia
Very painful, pale, tense
leg following trauma
Hot swollen joint
Septic patient with
rapidly spreading rash or
pain out of proportion to
skin signs
of peripheral vascular disease
includes lifestyle measures
such as stopping smoking and
control of cardiovascular risk
factors. Antiplatelet therapy
is recommended for patients
with symptomatic peripheral
artery disease6. Drugs licensed
for treatment include cilostazol
(Pletal), a phosphodiesterase III
inhibitor, which has antiplatelet
and vasodilator effects, and
naftidrofuryl, which has
vasodilator effects. Vascular
intervention includes angioplasty,
stenting, and bypass surgery.
Referral to a vascular specialist
should be made if the diagnosis is
in doubt, if risk factors are unable
to be managed to appropriate
targets, or if the patient has
symptoms, which limit their
lifestyle. Young and otherwise
healthy adults should also be
referred to rule out entrapment
syndromes. 6 Beta-blockers are
ofen indicated for coronary artery
GM | Midlife and Beyond | March 2012
Diagnosis
Acute ischaemia
Spinal cord compression or
cauda equina compression
Compartment syndrome
Septic arthritis until proven
otherwise
Necrotising fasciitis
disease in patients with peripheral
vascular disease and this has
previously caused concern,
however a recent Cochrane
review found no evidence that
beta blockers adversely affect
walking distance in people with
intermittent claudication.7
Acute ischaemia may
develop due to thrombus
formation or emboli. This
presents classically with the six
Ps; pallor, pulselessness, pain,
perishingly cold, parasthesia and
paralysis. An acutely ischaemic
limb needs urgent assessment for
revascularisation.
Neurological causes
Spinal cord syndromes
Spinal cord compression usually
presents with back pain but can
be associated with radicular pain
and leg discomfort. Weakness
and sensory loss are usually later
features. Cauda equina syndrome
ofen presents with non-specific
symptoms, low back pain is
usually a feature and leg pain,
usually bilateral, and/or weakness
can be the presenting complaint.
Other symptoms include
bladder and bowel dysfunction,
sexual dysfunction and saddle
anaesthesia. The most common
cause of cord compression
is malignancy and should be
considered in any patient with
known malignancy that presents
with back pain or neurological
symptoms. Central disc prolapse
is a common cause of cauda
equina syndrome; other causes
include spinal stenosis secondary
to osteoarthritis, trauma, or
inflammatory conditions such
as ankylosing spondylitis. In
suspected metastatic cord
compression an MRI of the
whole spine should be performed
within 24 hours. Te care of these
patients should be determined by
oncologists and spinal surgeons
and will include high dose
steroids, radiotherapy or surgery.8
Radiculopathy
Radiculopathy can be caused by
spinal cord compression or cauda
equina syndrome, or can result
from compression of the dorsal
nerve root alone. Sciatica is the
most common radiculopathy
and presents as pain in the back
or buttock radiating down the
leg, and can be associated with
numbness, tingling and weakness.
The usual causes are disc
herniation or degenerative disease.
Peripheral neuropathy
Peripheral neuropathy can be a
mononeuropathy, mononeuritis
multiplex or a polyneuropathy.
All of these may present as leg
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Clinical practice 59
discomfort. The most common
cause of a mononeuropathy
is compression neuropathy.
Mononeuritis multiplex is
normally caused by a systemic
disease such as diabetes or
vasculitidies. Symmetrical
polyneuropathy is the most
common form of peripheral
neuropathy. It presents in a
stocking distribution and can
present with a whole array of
sensory symptoms including
burning, stinging, itching,
tingling or numbness. If motor
nerves are involved there may be
weakness, cramps and spasms.
The most common cause is
diabetes mellitus. Other causes
include alcohol, B12 deficiency,
drugs such as isoniazid, chronic
renal failure, hypothyroidism,
malignancy and hereditary
motor and sensory neuropathies
(Charcot-Marie-Tooth). Patients
with painful diabetic neuropathy
should be offered duloxetine,
and those with other neuropathic
pain conditions should be offered
amitriptyline or pregabalin.9
Restless legs
Restless leg syndrome is very
common. The pathophysiology
is not fully understood but it is
likely that there is involvement
of the dopaminergic system
and a possible depletion of iron
stores. Te International Restless
Leg Syndrome Study Group has
developed standardised criteria
for the diagnosis. 10 These are:
an overwhelming urge to move
the legs, onset of symptoms
occurring or worsening with rest
or inactivity, symptoms relieved
by movement, and symptoms
worse in the evening or at night.
Te severity of symptoms can be
assessed using a rating scale.10.
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Box 3: Possible investigations
or inflammatory cause is suspected
underlying disease
necessary
crystals
neuropathy or myopathy suspected
Serum ferritin levels should be
checked to rule out iron deficiency.
Treatment for mild disease
includes advice on good sleep
hygiene, stretching and relaxation
exercises. Patients with frequent
symptoms can be prescribed a
dopamine agonist.11
Musculoskeletal causes
Trauma
Trauma can cause fractures or
damage to other tissues and
is usually obvious, however
sometimes elderly patients who
are confused or have dementia
will present with leg pain and
decreased mobility and will
not give a history of trauma.
These patients may have hip
or pelvis fractures that can be
missed. Tibial fractures or other
lower limb trauma can lead to
compartment syndrome which
should be suspected if there is pain
out of proportion to the injury,
or other signs such as pallor
and parasthesia. Compartment
syndrome is an emergency and the
patient may require a fasciotomy
to prevent tissue necrosis.
Cramp
Leg cramps are common
especially in the elderly and at
night. Tey are ofen idiopathic
but may be secondary to
uraemia, liver disease, thyroid
disorders, volume loss such
as diarrhoea or extreme heat,
medication especially diuretics,
radiculopathies or neuropathies.
Idiopathic leg cramps can be
diagnosed once underlying causes
have been ruled out. Stretching
exercises may help although there
is limited evidence. 12 There is
conflicting evidence for the use
of quinine but it can be used if
cramps are causing a significant
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60 Clinical practice
Arthropathies.
Arthropathies of the knees, hips,
ankles or foot joints typically
presents as joint pain but may
present as leg discomfort. Joint
aspiration is mandatory if septic
arthritis is suspected and will help
in the diagnosis of a non-septic
joint for example differentiating
between gout, pseudogout and
reactive arthritis.
Infective causes
disruption to sleep. 13 Quinine
should be stopped after a four
week trial if there is no benefit.14
Bone tumours
Bone tumours are rare and
usually present with gradually
increasing pain, sometimes a
mass or a pathological fracture.
In the elderly bony metastases are
more common than primary bone
tumours and should prompt a
search for a primary malignancy,
ofen breast, lung or prostate.
Inflammatory causes
Myositis
Leg discomfort and weakness
may indicate an inflammatory
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myopathy. This group of
disorders are characterised
by muscle cell infiltrations
causing inflammation. The
main variants are polymyositis,
dermatomyositis and inclusion
body myositis. Polymyositis
typically presents insidiously
with a proximal myopathy, in
dermatomyositis cutaneous
features such as a heliotrope rash
and gottron’s papules can precede
the muscle symptoms by several
years. Inclusion body myositis
typically affects more distal
muscles and onset is usually afer
the age of 50. If an inflammatory
myopathy is suspected specialist
referral should be made.
Some patients may respond to
immunosuppression.15
Cellulitis
Cellulitis is common in the elderly
population. Te patient normally
presents with a hot, erythematous,
tender leg. Portals of entry can
include any broken skin from
trauma, scratching and fungal
foot infections. Many patients will
have underlying diabetes mellitus
which may be a known diagnosis
or the cellulitis may be the first
presentation of diabetes, so blood
sugar should be checked in these
patients. Grading systems such as
the Eron/Dall classification system
can be used to assess whether a
patient needs oral or intravenous
antibiotics, and if they can be
managed in the community or if
they need hospital admission. 16
Intravenous antibiotics can be
safely and effectively administered
at home or in an ambulatory
setting17 and many trusts offer an
ambulatory service for once daily
outpatient intravenous antibiotics.
Necrotising fasciitis
Necrotising fasciitis is a severe,
rapidly progressing soft tissue
infection that often presents on
the lower limbs. It carries a high
mortality. It can be differentiated
from simple cellulitis as patients
ofen complain of pain, which seems
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Clinical practice 61
excessive compared to the physical
appearance, as the infection spreads
along deep tissue layers leaving the
overlying skin intact. Te patient will
appear toxic and deteriorate rapidly.
There may be rapidly advancing
erythema and a purpuric blistering
rash with subsequent necrosis. If
necrotising fasciitis is suspected the
patient needs urgent surgical review
and debridement.
2008; 4. Art. No. CD005508.
cord compression, acute ischaemia
8.
NICE
Clinical
Guideline
and necrotising fasciitis. Look for
75. ‘Metastatic spinal cord
“red flag” signs and symptoms and
compression. Diagnosis and
refer patients for urgent opinion and
management of adults at risk of
investigations if any of these serious
and with metastatic spinal cord
compression. November 2008
conditions are suspected.
Conflict of interest: Dr Powter
has none. Dr Medcalf has
been sponsored to attend
educational courses by
pharmaceutical companies.
Osteomyelitis
Osteomyelitis may co-exist with References
cellulitis and should be suspected
if there is bone pain or a deep ulcer 1. Wells P, Owen C, Doucette S et al.
Does this patient have deep vein
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radiographs may show lucent areas
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Investigations
3.
Possible investigations depend on
the likely diagnosis as listed in box 3.
Red flags
Any red flag symptoms as
described in box 2 should prompt 4.
urgent further investigation.
Conclusion
5.
There are many causes of leg
discomfort in the elderly. A thorough
history and focused examination
will guide the differential diagnosis 6.
and subsequent investigation.
Many cases are benign for instance
leg cramps and restless legs; some
are more serious but common, for 7.
example deep vein thrombosis, and
some are less common but life or
limb threatening, for example spinal
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March 2012 | Midlife and Beyond | GM