Pain in the lower limbs and extremities

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Introduction :

We will try in this chapter to progress very pragmatically to diagnosis rather than establishing a long list etiological.

It is important to determine first of all if walking is painful, whether or not a limp.

They can be classified into five major etiological frames cause a painful march.

Careful examination can often towards an arterial origin, venous, musculoskeletal, musculotendinous or nervous.

The painful intermittent claudication is not characteristic of peripheral arterial disease.

A venous or spinal stenosis may be traps leading to sometimes unnecessary revascularization gestures.

Lower limb pain of arterial origin :

The arterial origin of pain in the lower limbs is not always easy to prove.

If the painful cramp with intermittent claudication of the calf is the most classic symptom, as we have seen there are many pitfalls and possible entanglements.Pain in the lower limbs and extremities

If we discover an arterial stenosis with Doppler ultrasound, the alleged pain by the patient is not necessarily always related to the observed ultrasound image.

Must still be described as stenosis hemodynamically significant.

Where there is a doubt, transcutaneous oximetry dynamics demonstrated ischemia effort like the sub-ST segment that can occur in the coronary artery to the effort.

The topography of the pain blood in the lower limbs varies the level of the stenosis.

We can establish some clinicopathological correlation, however, many exceptions :

- in case of arterial occlusion of the intersection aortoiliac, pain is united- or bilateral and localized to the buttock ;

- in case of cancellation iliac or femoral, pain is localized to the thigh ;

- in case of femoral obliteration or femoropopliteal, pain is localized to the calf ;

- in case of cancellation or femoropopliteal leg, pain is localized to the foot.

At the stage of the pain of decubitus (stage III Leriche and Fontaine), pain occurs most often in the second half of the night, and is relieved by the inclined position legs out of bed.

This is tissue ischemia rest.

We must distinguish the pain of primodécubitus that occur a few minutes after sunset and reflect a significant deficit circulatory, the patient getting to sleep legs dangling.

Besides atherosclerosis most often involved, describes many different mechanisms occlusive arterial disease.

Pain in the lower limbs venous :

In addition to deep venous insufficiency can cause a genuine painful intermittent claudication, DVT can be isolated by leg pain, a cramp or a mere annoyance calf.

The superficial venous insufficiency causes pain and leg heaviness upon standing, As at the day, Sometimes in the morning.

These pains are increased by trampling, increase in summer or during PMS or pregnancy.

They regress when walking or decubitus but may give way to a cramp or restless legs syndrome.

The completed clinical examination of the venous Doppler ultrasound diagnosis usually leads easily.

Lower limb pain of neurogenic origin :

A – SCIATICA :

The pain is spontaneous, seat in the posterior face of the thigh and descends into the popliteal, the leg and the foot with a variable intensity, simple twinge in excruciating pain.

It is exaggerated by coughing or sneezing (discogenic), when the patient rises or turns in bed.

The analgesic door support on the healthy side, the other side being semi-flexed.

There is often a spinal stiffness, pain caused by the pressure of sciatica itself, by elongation of the nerve during the operation Lasègue or pressure latérovertébrale.

Hypoesthesia in the area of ​​skin corresponding, but especially the reduction of ankle reflexes are all objective signs.

The two main types of sciatica interested L5 and S1 roots with their respective topography : buttock, thigh, leg outer face, dorsum of the foot and big toe L5 ; posterior aspect of the thigh and leg, heel and sole of the foot for S1.

The diagnosis of sciatica disc is first of all clinical.

In typical forms and quickly favorable, no further review is necessary.

In atypical or if the symptoms are shuffling, while the imaging allows a morphological diagnosis :

- lumbar spine face + profile and L5-S1 centered face plate ;

- electromyogram (EMG) ;

- scanner spinal.

B – NARROW CHANNEL LUMBAR :

Pain is linked to impairment mono- or more often pluriradiculaire.

rarely constitutional, Lumbar spinal stenosis is primarily the result of a conflict between a disc protrusion or development of a posterior interarticularis osteoarthritis and holster dural.

This conflict is dynamic and the size of the channel varies with the position of the lumbar spine, the diagnosis of lumbar spinal stenosis can be difficult. EMG habitually shows pluriradiculaire suffering.

Plain radiographs of the lumbar spine can view a large posterior joint osteoarthritis, a disorder of static or kyphosis.

Magnetic Resonance Imaging (IRM) and the scanner are very useful in assessing the size of the channel, but these examinations are performed lying down and sometimes only standing myelography performed can reveal the exact site of lumbar stenosis.

C – OTHER radiculalgia :

The leg pain is fescue and down, there may be paresthesia, twinges, of sensory disturbances.

The distribution of the terra métamérique reflected the atteinte radicular or tronculaire. L’EMG guide le diagnostic.

The spine radiographs, scintigraphy, spinal scanner, or the scanner or pelvic ultrasound, allow mostly rapid etiologic diagnosis : neurinome, bone metastases, pelvic tumor, etc.

D – PERIPHERAL NEUROPATHY :

The clinical characteristics of pain are specific enough.

There paresthesia end type tingling, day or night burns.

Symptoms usually occur at rest and are relieved by walking.

It can include cramps, numbness of simple, vise printing sometimes giving a similar picture to restless legs syndrome.

On the first and distal symmetric, these symptoms may progress to upper body (upper limbs and chest).

EMG is the diagnostic tool of choice.

Sometimes only the study of small fibers can confirm a chronic peripheral neuropathic damage.

E – PARKINSON DISEASE :

About 50 % Parkinson experience pain at some stage or another of their disease.

In about one in 10, phenomena are inaugural.

The symptoms can be diverse.

It can include joint pain, cramps and painful paresthesia.

Symptoms are mechanical schedule and are insensitive to pain killers or anti-inflammatory, on the other hand, they respond quickly to levodopa therapy.

F – DEEP SENSE SYNDROME :

Where there is a lesion on the anatomical pain pathways (parietal, thalamique, bulbaire, medullary)

– whether of vascular or tumor-derived

– can be seen blazing limb pain related to an infringement different sensitivities (muscular, joint or bone).

The pains are very sharp, pass through the limbs and trunk with lightning, by crises occur within minutes to hours.

Quelquefois the terra a printer to fixe type of morsure en highlight pénétrant, in other cases it is a feeling of tightness, of crushing or paresthesia type current of hot or cold water.

In these situations, is the magnetic resonance imaging (IRM) brain or spinal cord that helps the etiologic diagnosis.

G – Neuralgia paresthetic OF BERNHARDT AND ROTH :

This tunnel syndrome is related to the irritation of the nerve fémorocutané.

It is a pure sensory impairment giving paresthesia or numbness in the anterolateral area of ​​the thigh with hypoesthesia racket.

The pressure of the nerve at its passage just below the inguinal ligament, immediately below the anterior superior iliac spine, can trigger paresthesias.

Local infiltration is a diagnostic test.

Lower limb pain of muscular origin :

The muscle origin of lower limb pain is usually well reported by the patient himself.

Myalgia may be spontaneous or occur only effort.

The complex is to link the clinical picture to his cause.

EMG can guide to a myositis or myopathy syndrome but is quite regularly in default.

Elevated muscle enzymes (creatine phosphokinase [CPK] et aldolase) can confirm the muscular origin of an atypical pain but this rise is inconstant whatever the origin of muscle pain.

All situations considered below are not necessarily localized electively the lower limbs but can be dominant.

Besides muscle pain related to sports training excessive or maladaptive.

The drug causes and hypothyroidism are the two most common situations.

In other cases, it may be an inflammatory myositis.

Muscle weakness is more common here than pain.

Myalgia may have a systemic origin.

In other cases myalgia have an infectious origin :

- all viral infections may be involved giving febrile myalgia : influenza, coxsackie infections, parvovirus B19, cytomegalovirus, virus d’Epstein-Barr, etc ;

- toxoplasmosis may be the cause of sometimes diffuse myalgias and accompanied by cervical lymphadenopathy superficial persist weeks or sometimes months ;

- trichinosis sometimes causes persistent diffuse myalgias months, is accompanied by periorbital edema with conjunctivitis, a fever 40 °C, all occurs 8 at 15 days after ingestion of undercooked pork and accompanied by digestive disorders with headache.

Serology often allows diagnosis.

The appearance of myalgia in the effort evokes some rare diagnoses associated with an enzyme deficiency glycogenolysis or mitochondrial.

Lower limb pain of musculoskeletal origin :

The achievement of the musculoskeletal system is a common cause of lower limb pain.

Walking is often abnormal and accompanied by lameness, character that does not exist in the artériopathe outside trophic disorders associated.

The most common cause is osteoarthritis.

A – PATHOLOGY OF HIP AND KNEE :

The variable topography hip pain or knee fact that it is not always easy to bring a leg of his joint pain origin.

The hip may give variable topography of pain : substance, buttock and posterior thigh, anterior thigh, outer thigh or inner surface in its upper portion.

The knee can also provide variable topography of pain : anterior or posterior of the knee, lateral aspect of the knee, or anterior thigh.

Plain radiographs, or scintigraphy or MRI, are key examinations diagnosis.

B – ANKLE PATHOLOGY :

Osteoarthritis of the ankle is rare and often traumatic.

Arthritis of the ankle can be isolated and reveal sarcoidosis or chronic inflammatory rheumatism.

The CRPS is a trap because it can be secondary to minimal trauma sometimes forgotten.

Early phase pseudoinflammatoire, edema, skin redness, pain and articular limitation are conventional.

later, redness way to a pale skin with cyanosis, pain remains present with edema and limited joint mobility.

Later still, pain may be gone but the edema may persist.

The joint custody often limited mobility.

It is at this stage that the differential diagnosis with venous or lymphatic edema can be difficult. Plain radiographs and scintigraphy grind diagnosis.

C – PATHOLOGY JOINT FOOT :

Traumatic foot pain are common.

More difficult to diagnosis is the stress fracture that occurs readily on the metatarsal after a walking sustained effort that in the elderly a little effort may be sufficient.

There is initially a painful edema of the dorsum of the foot.

Radiography is, at this stage, normal but the scan to confirm the diagnosis by viewing an uptake home.

Later is visible is a callus on the radiographs.

The hollow foot is a frequent source of pain plantar.

Decompensation of a hollow foot indicates an excessive shortening of the ankle-Achilleo-calcaneus-plantar system.

At the march, the walk starts varus and will encourage ankle sprains or discomfort to wear some flat shoes (walking on tiptoe often relieves symptoms).

It can occur cramps in the calves or soles.

Particular aspects of the ends of pain :

Pain of the ends may have a very diverse origin.

The achievement can be musculoskeletal, vascular, tendon, synovial or neurogenic.

Pathomimesis is not necessarily a diagnosis of exclusion.

The glomus tumor is defined as hyperplasia glomus neuromyoartériel.

The location subungual is more common, the pain is often very intense, insomniantes and irradiating.

The pressure can trigger the painful crisis and the changes in temperature.

We sometimes observe a purplish swelling subungual.

The diagnosis is confirmed by arteriography.

The ischemic origin of pain is evoked ends when there is a cooling of one or more fingers or toes accompanying pallor. Sometimes it is a bluish Livedoid.

Heat often relieves symptoms. Whatever the cause, Raynaud's phenomenon is inconstant. Its presence argues vascular origin.

The Doppler ultrasound allows the study of proximal arteries members.

When there is an isolated obstruction digital arteries, Doppler ultrasound is normal, only the operation of Allen and measuring finger systolic, or arteriography can confirm obstruction of collateral fingers.

The erythermalgia is a peripheral vascular disease paroxysmal occurring heat, characterized by vasomotor crises sometimes giving excruciating throbbing burns with skin redness Fingers infiltrated and hot.

One can observe an arterial beat. Aspirin is a real diagnostic test.

Osteoarticular origins can be identified by the standard radiographs, or scintigraphy.

In the hands, digital osteoarthritis and rhizarthrosis are easy diagnoses.

The arthritis is characterized by swelling of the joints, an increase in the local heat, a stiffening joint mobility and especially a nocturnal awakening more readily in the second half of night, morning stiffness which exceeds 30 minutes and can last several hours.

Spondyloarthropathies may give pain to foot heel pain type crown.

A toe arthritis accompanied by a toe aspect sausage evokes be particularly reactive arthritis or psoriatic arthritis.

Peripheral neuropathies can result in distal pain that starts at the feet or hands, source paresthesia, tingling, day or night burns.

Ductal syndromes are the consequence of a localized compression on a nerve pathway.

The carpal tunnel syndrome is characterized by its frequency.

Sometimes it is entangled with Thoracic outlet syndrome.

The diagnosis is often difficult pathomimie.

It may be induced strain of the ends, edema related to a Trendelenburg position extended by one member, or related to the use of a tourniquet.

The result can be a genuine dystrophy reinforcing the typical person in pathology.

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