Leg pain has many causes and can present in different ways. Leg pain may be related to musculoskeletal, neurological and vascular causes. Musculoskeletal causes include muscle sprain or strain from trauma or even a brisk workout. Osteoarthritis can cause leg pain and is related to a joint, i.e. knee, hip or ankle joint and range of motion around that particular joint. Other musculoskeletal etiologies include numerous tendinous injuries or inflammatory causes. For a detailed list of musculoskeletal causes visit the mayo clinic site for leg pain causes. Neurological causes for leg pain include a shooting sharp pain related to a pinched nerve from a herniated disc or arthritis of the spine. Diabetes can cause nerve pain or numbness in the feet. This is called diabetic neuropathy. These patients often have a long history of uncontrolled diabetes.
Vascular causes can be separated generally into vein and artery problems. Distinguishing between these two vascular causes is critical to management of the patient's pain and overall wellness of the patient. The leg pain is very different between these two causes. An artery problem is caused by blockages in the arteries supplying blood to the legs. Someone with an artery problem will notice pain in their legs as they walk and the pain may get severe enough that the person can no longer walk and must take a break. This happens because the muscles of the legs are not getting enough oxygen because of the blockages in the arteries. This type of pain is called claudication. This may start as a cramp in the calves or thighs after walking a fair distance. If it becomes severe the patient may not even be able to walk a block before having to stop and rest to resolve the leg pain. The blockages in the arteries may worsen from smoking, diabetes, high blood pressure, age, elevated cholesterol, obesity, or overall poor health and lack of regular exercise. This problem can be diagnosed on physical exam by a diminished or lack of pulses in the leg. Confirmation can be obtained by obtaining an ankle-brachial index. This is a test that is preformed by placing blood pressure cuffs on the leg and comparing the blood pressures in the ankle and the arm. Normally they should be close to the same. If the blood pressure is lower in the ankle compare to the arm, that confirms the presence of a blockage in the artery supplying the leg. Treatment may begin with starting an exercise program, losing weight, stop smoking and managing diabetes, cholesterol and high blood pressure. If symptoms are severe, patient may require the blockages to be corrected. This may require additional tests and interventions including angiogram, angioplasty and arterial stent placement. Once the blockages are corrected, the patient's leg pain resolves almost immediately.
A common and overlooked vascular cause of leg pain is varicose vein disease and venous insufficiency. The leg pain related to vein problems is very different than the pain from an artery problem. Leg pain from varicose veins is more of a dull aching pain that worsens as the day progresses. The pain is worsened by lack of motion and standing or sitting for long periods of time. Unlike the pain from an artery problem, the leg pain from a vein problem usually improves with walking and physical activity. Usually there is a history of visible varicose veins on the symptomatic leg or legs, that may have been worsening over years. The pain can improve with leg elevation and wearing compression stockings. The leg pain from varicose veins is related to a pooling of blood within the dilated tortuous veins. Elevating the legs and walking improves the symptoms of leg pain by removing the blood from the abnormal bulbous veins. Compression stockings also improve symptoms by squeezing the blood out of the abnormal veins and forcing them into the normal deeper veins. Our veins have one way valves that keep the blood flowing in one direction from the feet up to the heart. These valves may become damaged over time because of age, pregnancy, genetics, family history, obesity and prolonged standing jobs, i.e. chefs, teachers, cashiers, and waiters. This valve problem over time can lead to swelling in the legs. This is call venous insufficiency. Varicose veins and venous insufficiency is initially diagnosed by history and physical exam.
Treatment will start with conservative management including exercise, leg elevation, weight loss and use of graduated compression stockings. If the patient continues to have limitations of normal activity by significant symptoms, the patient will require a diagnostic ultrasound of the symptomatic leg. Ultrasound of the legs can evaluate the flow in the veins and arteries of the legs. Ultrasound can confirm abnormal valves and backwards flow in the veins. It can also show any clotting in the veins known as deep venous thrombosis (DVT). Deep venous thrombosis will be discussed in detail in a separate blog. Once the abnormal varicose veins are diagnosed by ultrasound, a detailed personalized treatment plan is reviewed with the patient. There are now multiple minimally invasive treatments of varicose veins including radiofrequency ablation, endovenous thermal ablation, venaseal and sclerotherapy. All these treatments are now done as an outpatient procedure, take 30 minutes or less with minimal to no pain and no need for downtime. Most patients can resume work the same or next day after the procedures. If you have problems with varicose veins and leg vein, make an appointment with Dr. Vinay Madan at the Center for Varicose Veins.