Some Causes of Nontraumatic Limb Pain
Cause | Suggestive Findings | Diagnostic Approach |
|---|---|---|
Musculoskeletal and soft tissue | ||
Focal erythema (or darker color on dark skin), warmth, tenderness, swelling Sometimes fever | Clinical evaluation Sometimes blood and tissue cultures (eg, when patients are immunocompromised) | |
Deep soft-tissue infection (eg, myonecrosis, necrotizing subcutaneous infection) | Deep, constant pain, typically out of proportion to other findings Erythema (or darker color on dark skin), warmth, tenderness, tense swelling, fever Sometimes crepitation, foul discharge, bullae or necrotic areas, signs of systemic toxicity (eg, delirium, tachycardia, pallor, shock) | Blood and tissue cultures Radiography Sometimes MRI |
Deep, constant, often nocturnal pain Bone tenderness, fever Often risk factors (eg, immunocompromise, parenteral illicit drug use, known contiguous or remote source for infection) | Radiography, MRI, and/or CT Sometimes bone culture | |
Bone tumor (primary or metastatic) | Deep, constant, often nocturnal pain Bone tenderness Often a known cancer | Radiography, MRI, and/or CT |
Vascular | ||
Swelling, often warmth and/or redness, sometimes venous distension Often risk factors (eg, hypercoagulable state, recent surgery or immobility, cancer) | Ultrasound Sometimes D-dimer testing | |
Mild discomfort with swelling, erythema, and warmth of distal lower extremity Sometimes shallow ulcerations | Clinical evaluation | |
Acute ischemia (typically due to arterial embolism, dissection, or thrombosis but sometimes due to massive iliofemoral venous thrombosis that completely obstructs blood flow in the limb) | Sudden, severe pain Signs of distal limb ischemia (eg, coolness, pallor, pulse deficits, delayed capillary refill) Sometimes chronic ischemic skin changes (eg, atrophy, hair loss, pale color, ulceration) After several hours, neurologic deficits and muscle tenderness Sometimes known peripheral vascular disease | Immediate arteriography |
Intermittent leg pain triggered predictably by exertion and relieved by rest (intermittent claudication), sometimes rest pain which may worsen with leg elevation Low ankle-brachial blood pressure index, chronic ischemic skin changes | Ultrasound Sometimes arteriography | |
Neurologic | ||
Plexopathy (brachial or lumbar) | Usually weakness, often decreased reflexes Sometimes numbness in a nerve plexus distribution | Usually electrodiagnostic testing (electromyography and nerve conduction velocity) Sometimes MRI |
Pain and paresthesias beginning in neck or shoulder and extending to medial aspect of arm and hand | Clinical evaluation Sometimes, electrodiagnostic testing and/or MRI | |
Radiculopathy (eg, caused by herniated intervertebral disk or bone spurs) | Pain and sometimes sensory deficits following a dermatomal distribution and often worsening with movement Often neck or back pain Usually weakness and diminished deep tendon reflexes in a nerve root distribution | Usually MRI Sometimes electromyography and nerve conduction velocity |
Painful polyneuropathy (eg, alcoholic neuropathy) | Chronic, burning pain, typically in both hands or both feet Sometimes sensory abnormalities such as hypoesthesia, hyperesthesia, and/or allodynia (pain with non-noxious stimuli) | Clinical evaluation Sometimes electromyography and nerve conduction velocity |
Burning pain, hyperesthesia, allodynia, vasomotor abnormalities Typically a prior injury (may be remote) | Clinical evaluation | |
Other | ||
Acute coronary ischemia (causing referred arm pain) | Absence of explanatory physical findings at the site of pain; other suggestive findings (eg, history suggesting coronary artery disease, sweating and/or dyspnea occurring simultaneously with arm pain) | ECG and serum troponin Sometimes stress testing or coronary angiography |
Myofascial pain syndrome | Chronic pain and tenderness along a taut band of muscle, worsening with movement and with pressure on a trigger point (focal area separate from site of pain) | Clinical evaluation |