BIOSOFT HELP FILES

1)      Shin splints – medial tibial stress syndrome – mid tibial or distal 1/3^rd tibial pain, pain is present even before the start of the activity like running, diffuser tenderness over a wider area over tibia and tibialis muscle, risk factors are poor flexibility, over-pronation (pes planus), internal tibial rotation (look for tibial rotation in a seated patient with both legs dangling over the edge of the bed, both eyes focusing along the longitudinal axis of both tibia from above), worn shoes, running on hard surfaces,

2)      Shin contusion – direct blow over the shin, ecchymosis, swelling,

3)      Tibial Stress Fracture – commonest stress fracture, runners, dancers, and jumpers, very localized area of pain in the tibia, usually at the junction of middle and distal 1/3^rd of the tibia, night pain, patient hopping on the affected leg severe pain  at the site (this test is also positive with femoral shaft/pelvic stress fractures), Ix – Xray with cone down view, MRI tibia,

4)       Chronic exertional compartment syndrome – leg pain, slow onset, usually bilateral, swelling of the affected limbs, predictable response for exercise – pain onset after the exercise, offset with 20 minutes of rest, pain recurs with exercise, risk factors are uneven exercise surface, worn out shoes, unacceptable training intensity, hindfoot pronation, Mx- Treat or modify the risk factors

5)      Varicose veins – leg pain worse with prolonged standing and relieved by leg elevation, heaviness of legs, mild nakle edema, skin ulceration, hyperpigmentation, recurrent episodes of superficial venous thrombosis, dilated tortuous leg veins, Mx – periodic elevation of legs, avoid prolonged standing,  elastic support hose, external compression stockings, sclerotherapy, surgical referral for intractable symptoms, recurrent superficial vein thrombosis, skin ulceration, cosmetic reasons.

6)      Superficial vein thrombosis – leg pain along the course of a superficial vein, the red, warm, tender, palpable cord of a vein, surrounding redness and swelling, Mx – NSAIDs and antibiotics.

7)      Recurrent bacterial lymphangitis – a patchy area of redness, warmth, swelling and tenderness, migrating proximally, with associated proximal site lymphadenopathy, distal leg swelling, and pain, maybe a precursor of lymphedema, Tx – NSAIDS, anti-streptococcal antibiotics

8)      Chronic venous insufficiency – leg pain worsens on standing and relieved by leg elevation, increased leg girth, edemas, superficial varicose veins, erythema, dermatitis, skin ulcers (can occur near both medial and lateral malleoli), hyperpigmentation of skin, recurrent cellulitis,  Mx – avoid prolonged standing, frequent leg elevations, graduated compression stockings, management of ulcers with wet/dry dressings with topical antibiotic solutions, and cellulitis with antibiotics.

9)      Deep venous thrombosis – iliac, femoral, popliteal veins – unilateral painful leg swelling, warmth, redness, tenderness along the vein, palpable vein like a cord, increased tissue turgor, distended superficial veins, prominent venous collaterals, dark blue discoloration of the leg, Ix and Mx see below.

10)    Deep venous thrombosis – calf veins – calf pain, swelling, posterior calf tenderness, warmth, increased tissue turgor, Homan’s sign positive (increased resistance or pain on ankle dorsiflexion), Ix – duplex venous ultrasonography, Doppler ultrasound, MRI, Mx – high risk for pulmonary embolism, chronic venous insufficiency, medical referral for further management.

1)      Growing pain

2)      Patellofemoral arthalgia

1)      Severe extremity pain disproportionate to the injury, paresthesiae or anesthesia to light touch, passive stretching of involved muscles very painful,  later pallor, pulseless limb, and muscle weakness appear (Acute exertional compartment syndrome) 

2)      Recent onset unilateral leg swelling in the presence of DVT risk factors

3)      Migrating superficial vein thrombosis (marker of carcinoma, vasculitis)

4)      Acute onset severe leg pain in a patient with Diabetes or peripheral vascular disease, paresthesiae, pallor, pulselessness (acute limb ischemia – within 6 hrs irreversible damage to muscles and nerves)

1)      Pain at a point just above the ankle after a minimal trauma, lower leg Xray AP may be almost normal but the lateral view may show the spiral fracture of the lower tibia (Toddler’s fracture or minimally displaced spiral fracture of lower tibia) 

(Leet and Skaggs 2000)

(Martinez 2008)

1)      Cellulitis – painful, red, warm, tender,  swollen area of a limb, no clear demarcation, portal of entry – wound, ulcer, skin lesion, regional lymphadenopathy,

2)      Erysipelas – the painful, red, warm, tender swollen area of a limb with a clear demarcation of the area, entry site has commonly seen (venous insufficiency, stasis ulceration, dermatophytes infection, eczemas, insect bites, intertrigo), predisposing factors common (diabetes, alcohol, HIV, nephrotic syndrome), red streaks centripetally distributed, regional proximal lymphadenopathy, fever, chills, sometimes precede 24-48 hrs, Mx – wet saline dressings, elevate the limb, Penicillin (250-500 mg qid PO) or Roxithromycin for 10-20 days, Erythromycin (250-500 mg PO qid, Pd 30-50 mg/kg/day in 3-4 divided doses)or Azithromycin of penicillin allergy,

3)      Chronic venous diseases – leg pain and swelling, foot swelling and pain, discoloration of the skin of the ankles, complications include stasis ulcers, dermatitis,

4)      Referred spinal pain – cervical radiculopathy, lumbar radiculopathy, thoracic outlet syndrome

5)      Complex Regional Pain Syndrome – CRPS 1 (Reflex Sympathetic Dystrophy Syndrome) – severe burning pain in arms or legs after a minor or major injury, after a stroke or heart attack, pain worsens with the slightest touch or breeze, swelling of the painful area warm or cold, skin over the painful area dry, thin, change of color, increased nail and hair growth, the pain moves up or down the limb, after 1-3 months stage 2 CRPS 1 sets in: swelling spreads to the whole limb, skin changes become prominent, hair growth slows down, muscles and joints become stiff, X-ray changes of bones seen, after another 3-6 months stage 3 of CRPS 1 set in : entire limb hurting, tissue changes become permanent, muscle wasting, limited mobility of the limb, muscle contractions, depression and other mood changes, Tx – steroids, analgesics, bone loss medications, physical and occupational therapy, TENS, biofeedback,

6)      Somatic anxiety syndrome

7)      Somatic depression syndrome

8)      Intermittent claudication – Peripheral Arterial Disease – intermittent claudication, calf or buttock pain while walking and stops at rest, usually comes earlier with an uphill walk, pain is located at muscles, usually unilateral, ischemic rest pain occurs at night, in toes and foot, hanging the leg out of the bed relieves the pain, raised leg turn pale and dangling leg blue and cyanotic, absent or weak pulses, gangrene, ulceration,  Duplex scanning of lower limb vessels confirm the diagnosis, Mx – blood glucose control, stopping smoking, controlling hypertension, controlling dyslipidemia, controlling the other risk factors and comorbidities like carotid stenosis, abdominal aortic  aneurysms (Noncoronary atherosclerosis markers, CHD risk equivalents), ACEI (ramipril in the HOPE study) to reduce the cardiovascular mortality,

9)      Restless legs syndrome – (see under sleep problems), abnormal sensations of the limbs may be presented as pain which is vague in the limbs nocte,

1)      Growing pains – common in 3-5yrs and 8-12 yrs, recurrent pain in the muscles, bilateral, commonly calf and thigh muscles, normal joints and bones, usually evenings, occasionally night, no point tenderness anywhere in the limbs, no limp during the day. Mx – gentle massage, paracetamol, stretching, heat pads.

2)      Traumatic pain – sprains and strains

3)      Paellofemoral pain –

4)      Stress fractures

5)      Osteochondrosis

6)      Hypermobility Syndrome – age of onset 3-10 yrs, aching after physical exertion, fatigue, easy bruising, tense or stiff joints, worsening pain during the day and less after rest, comorbid with hernias, varicose veins, flat feet, foot ache, backache, recurrent joint dislocation, common signs are – can put hand flat on the floor while knees kept straight, can hyperextend elbow, can hyperextend knees, can hyperextend thumbs onto the forearm, can hyperextend the little finger 90* to the hand, Mx – muscle strengthening exercises, muscle relaxation exercises, NSAIDs and analgesics, splints and bandages,

7)      Rickets – around 1 yr, growing pain, bow legs, bone pain, wrist swellings, chest swellings, bow legs, rachitic rosary, hot-cross bun sign, frontal bossing, delayed motor milestones, hypotonia, bone deformities – wrist waisting, lateral ot anterior bowing of tibia, femur, rickety rosary – costochondral junction swellings, Harrison’s sulcus, delayed closure of fontanelles or large fontanelles, craniotabes – softening of skull bones, usually in parietal or occipital bones, ping-pong ball sensation on firm pressure, an early sign, frontal and parietal bossing – due to longstanding deficiency,  recurrent respiratory infections due to impaired immunity, convulsions, apneic attacks, irritability, carpopedal spasms from hypocalcemia in very young infants,

8)      Normal skeletal growth variants – Osgood-Schlatter syndrome, Sever’s disease

9)      Somatization

1)      Pain, swelling, tenderness, warmth, and redness in 1 leg particularly in the presence of the following risk factors – prolonged sitting, bed rest, immobilization, recent surgery on hip, knee, or gyne surgery, trauma particularly fractures, childbirth within the last 6/12, used if OC’s (Deep vein thrombosis, See Well’s (N) Clinical prediction rule for DVT)

2)      Compartment syndrome – pain out of proportion to the injury, severe limb pain following an injury particularly high energy and high-velocity trauma, long bone fractures, penetrating injuries, vascular injuries, crush injuries, on anticoagulation, severe pain out of proportion to the injury, burning sensation and tightness, limb paresthesias, pain with passive stretching of muscle earliest indicators,  direct pressure over the compartment tender, sensory loss, and motor paralysis.  Early diagnosis and timely referral are the mainstay of good management.  Traditional 5P’s of pain, paresthesia, poikilothermia, pulselessness, and pallor are unreliable, and late developments as in compartment syndrome diagnosis should be established within 6 hrs.

3)      Erysipelas in infants, elderly, and in the immunocompromised – severe infections requiring IV antibiotics

1)      Severe limb pain – nonuse of limb, non-weight bearing

2)      Acute onset

3)      Rash, fever, conjunctivitis, dysuria, weakness

4)      Past skin infection, sore throat, diarrhea

5)      Swollen, red, painful, immobile joints

6)      Persistent pain

7)      Pain in the night or morning

8)      Hypermobility with EhlerDanlos (easy brusing, lens dislocation, skin changes)

9)      Hypermobility with Marfan

10)  Hypermobility with osteogenesis imperfecta

(Paula 2006)

(NHS Direct 2007)