Leg pain that is poorly localized, non-traumatic, and recurrent or persistent is a common clinical complaint in rheumatology clinics. It refers to conditions that cause various uncomfortable symptoms, located in a wide area, from the hip to the lower part of the legs. It is extremely important to observe the patient’s symptoms, since much of the diagnosis can be facilitated by this measure.

Discomfort may originate from conditions related to the musculoskeletal, vascular, neurological system or even be part of chronic diffuse pain conditions.

Therefore, the first step is to recognize common characteristics of the main large groups of causes, called syndromes:

Musculoskeletal origin:

• Better localized pain
• May concentrate near joint areas
• May worsen at the beginning or during exercise
• Rest usually improves
• Pain may worsen with palpation of defined regions
• It usually improves with painkillers and anti-inflammatories

Venous or lymphatic vascular origin

• Poorly localized pain
• Weight in the calves
• Worse at the end of the day
• Worse with prolonged standing
• It usually improves with leg elevation
• Mildly painful swelling in the ankles
• Presence of varicose veins
• Brownish skin on legs and ankles

Arterial vascular origin

• Poorly localized pain
• Worse in the lower leg and calf
• Pain almost always appears when walking
• Worse with faster walking
• Improves rapidly with interruption of walking
• Pale or purple tips of toes
• Hair loss and shiny skin on legs
• Presence of heart and brain disease

Neurological origin

• Poorly localized pain
• Burning sensation, shocks, stinging, stinging, tingling
• There may be associated low back pain
• Reduced sensitivity of the feet
• Loss of slippers while walking

Diffuse pain syndrome

• Sensation of “sore flesh” throughout the body
• Sleep impairment, fatigue, memory loss
• Depressed mood or nervousness
• Worse with cold
• Sensitivity to touch in various muscle areas

After this step has been well executed, based on careful observation of the symptoms reported by the patient and a clinical medical examination, some additional tests may be necessary. These are quite varied and should be directed towards the main hypotheses. The tests may include:

• Various laboratory tests
• Musculoskeletal radiological examinations, such as X-rays, Ultrasound, Nuclear Magnetic Resonance Imaging
• Venous or arterial Doppler ultrasound
• Arteriography or Nuclear Magnetic Resonance Angiography
• Lymphoscintigraphy
• Electroneuromyography, sensory evoked potential
• Skin biopsy for quantification of fine fibers

The last step is to determine the specific cause of leg pain, the main ones being:

1. Muscle pain, contractures:

Patients may develop symptoms after prolonged or intense exercise, long periods of walking, or acute injury. It is more common in athletes, but also in sedentary individuals. Obese individuals and those with poor muscle stretching are more prone. Cramps are common.

2. Venous insufficiency:

Pain is typically an early symptom, prior to the formation of varicose veins. Females are more so affected. It is also worse at the end of the day and during menstruation.

3. Fibromyalgia:

Leg pain is part of a larger context in which there is diffuse pain throughout the body, below and above the waist and on both sides of the body, in addition to insomnia, fatigue, and poor memory. It is frequently linked to anxiety and sadness. There is often great sensitivity to pain when touched in different parts of the body.

4. Arthritis:

Various inflammatory arthritis (rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, gout, and others) or also degradative arthritis (arthrosis) when they especially affect the knees can generate local pain or radiate to the legs.

5. Sciatica:

Sciatica is located below the buttocks and down to the foot, and may or may not be accompanied by lower back pain, resulting from compression of nerve roots in the spine. It is almost always unilateral and worsens or reappears when raising the extended leg when lying down.

6. Peripheral neuropathy:

Usually more severe in the foot and leg extremities because to injury to peripheral nerves. Changes in sensitivity are common. The most common causes are diabetes, alcoholism, leprosy, HIV infection and vasculitis.

7. Peripheral arterial occlusive disease:

Decreased delivery of oxygenated blood to the tissues via the arteries, virtually always secondary to atherosclerosis (fatty plaques). Gets worse with walking, with a burning quality that rapidly resolves with cessation of walking. More frequent in older adults, hypertensive, diabetic, hyperlipidemic, obese and smokers.

8. Medial tibial stress syndrome (shin splints):

Pain along the inside of the shin, caused by edema (swelling) in the tibia bone. It occurs when excessive load is applied to healthy bone. It is common in runners. The pain is worse at the beginning and end of the activity, but it can persist even with rest. Obesity, poorly conditioned muscles and changes in gait are predisposing factors.