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Limb Pain

by Lyall A. J. Higginson, MD

Pain may affect all or part of a leg or arm. Most disorders that cause limb pain affect the legs more commonly. Pain in the joints is discussed elsewhere (see Joint Pain: Many Joints).

Limb pain may be constant or occur irregularly. Pain may be precipitated by motion or have no relation to movement. Other symptoms, such as warmth, redness, numbness, or tingling, may also be present depending on the cause of the limb pain.

Causes

Injuries and overuse are the most common causes of pain in a limb, but people usually know the cause of these injuries. This discussion covers limb pain unrelated to injury or strain. There are many causes.

The most common causes are the following:

Uncommon but serious causes that require immediate evaluation and treatment include

  • Sudden blockage of an artery in the limb (acute arterial occlusion)

  • Deep soft-tissue infection

  • Heart attack (arm pain only)

Other less common causes include bone tumors, bone infections (osteomyelitis), and nerve problems such as pressure on nerves or degeneration of nerves (such as caused by diabetes or long-term alcohol abuse).

Evaluation

It is particularly important to make sure the person does not have a sudden blockage of an artery because the limb can develop gangrene if there is no blood flow for more than a few hours. The following information can help people decide when a doctor's evaluation is needed and help them know what to expect during the evaluation.

Warning signs

In people with limb pain, certain symptoms and characteristics are cause for concern. They include

  • Sudden, severe pain

  • Limb that is cold to the touch or pale

  • Chest pain, sweating, shortness of breath, or palpitations

  • Signs of severe illness (for example, confusion, fever, or collapse)

  • Limb that is suddenly swollen, blistered, or has black spots

  • Risk factors for deep vein thrombosis, such as recent surgery, bed rest, or a cast on a leg

  • New nerve deficits, such as weakness or numbness of the affected limb


When to see a doctor

People who have warning signs should see a doctor right away. People without warning signs should call a doctor. The doctor will decide how quickly the person needs to be seen based on the symptoms, age, and presence of other medical disorders. Typically, a delay of several days is not harmful.


What the doctor does

Doctors first ask questions about the person's symptoms and medical history. Doctors then do a physical examination. What they find during the history and physical examination often suggests a cause of the limb pain and the tests that may need to be done.

Doctors ask

  • How long limb pain has been present

  • Whether pain occurs at certain times or during specific activities

  • How intense the pain is

  • Whether the pain is sharp or throbbing

  • Where the pain is located

  • What activities trigger or worsen pain

  • What the person does to relieve pain

  • What other symptoms (such as numbness or tingling) occur along with the pain

Doctors look for symptoms that may indicate a cause of the pain. Some obvious findings may be very helpful in diagnosing the cause of limb pain. For example, back or neck pain suggests that a nerve root may be affected and fever suggests that the person has an infection. Shortness of breath and a rapid heart rate suggest blockage of an artery by a blood clot that has traveled from a leg to the lungs (pulmonary embolism—see Pulmonary Embolism (PE)). An irregular pulse suggests that the person may have a certain abnormal heart rhythm (atrial fibrillation—see Atrial Fibrillation and Atrial Flutter) that has caused a blood clot to travel from the heart to block an artery in the leg.

The painful limb is inspected for color, swelling, and any skin or hair changes. The doctor also checks for pulses, temperature, tenderness, and crepitation (a subtle crackling sensation indicating gas in the soft tissue caused by a serious infection). Strength, sensation, and reflexes are compared between affected and unaffected sides. Blood pressure is sometimes measured in the ankle or wrist of the affected limb and compared with the blood pressure in an unaffected arm or leg. If blood pressure is much lower in the painful limb, it is likely that the arteries in the limb are blocked.

Some Causes and Features of Limb Pain

Cause*

Common Features

Tests

Sudden, severe pain that develops within a few minutes

Blockage of an artery in a limb, usually a leg, by a blood clot

Sudden, severe pain

Coolness and paleness of the limb

After several hours, signs of nerve malfunction, such as weakness, numbness, tingling, or cramping

Weak or no pulse felt in the limb

Arteriography done immediately

Sudden herniation of a disk in the spine

Pain and sometimes numbness that occurs in a line down the limb

Pain that is often worsened by movement

Often neck or back pain

Sometimes weakness in part of the affected limb

Usually MRI

Heart attack (myocardial infarction)

Pain in an arm, not a leg

Sometimes pain or pressure in the chest or jaw

Sometimes nausea, sweating, and shortness of breath

Sometimes in people known to have heart disease

ECG

Blood tests for substances that indicate heart damage (cardiac markers)

Sometimes angiography of the arteries of the heart

Fatty deposits in artery walls (atherosclerosis), which reduce blood flow, almost always in a leg

Intermittent episodes of leg pain that occur only when walking and are relieved by a few minutes of rest (intermittent claudication)

Ultrasonography

Sometimes arteriography

Pain that develops gradually (over hours to days)

Bacterial infection of the skin (cellulitis)

An irregular area of redness, warmth, and tenderness

Sometimes fever

A doctor's examination

Sometimes blood cultures

Deep vein thrombosis (a blood clot in a deep-lying vein in a leg [typically] or an arm)

Swelling of an entire part of a limb (for example, whole calf or calf and upper leg)

Usually pain, redness, warmth, and/or tenderness in the affected area

Sometimes in people with risk factors for blood clots, such as recent surgery, an injury, bed rest, a cast on a leg, use of hormone therapy, or cancer

Ultrasonography

Sometimes a blood test to detect blood clots ( d -dimer)

Bacterial infection deep under the skin and/or in the muscle (myonecrosis—see Gas Gangrene)

Deep, constant pain

Redness, warmth, tenderness, and swelling that feels tight

Signs of severe illness (such as fever, confusion, and a rapid heart rate)

Sometimes a foul discharge, blisters, or areas of blackened, dead skin

Blood and tissue cultures

X-rays

Sometimes MRI

Bone infection (osteomyelitis)

Deep, constant pain that often occurs at night

Bone tenderness and fever

Often in people with risk factors (such as a weakened immune system, use of injection drugs, or a known source for the infection)

X-rays and MRI and/or CT

Sometimes bone culture

Chronic pain (present for a week or more)

A bone tumor (originating in the bone or spread to the bone from cancer elsewhere in the body)

Deep, constant pain that is often worse at night

Bone tenderness

Often in people known to have cancer

X-rays and MRI and/or CT

Pressure on certain nerves, as occurs in

  • A disorder of the brachial plexus (a network of nerves in the shoulder and back)

  • Thoracic outlet syndrome (which involves nerves that pass between the neck and chest)

Usually weakness and sometimes numbness or tingling along part of the limb

Usually electromyography and nerve conduction studies

Sometimes MRI

Pressure on a spinal nerve root (the part of a spinal nerve next to the spinal cord), which may be caused by a herniated disk or bone spurs

Pain and sometimes numbness that occurs in a line down the limb

Pain that is often worsened by movement

Often neck or back pain

Usually weakness in part of the affected limb

Usually MRI

Degeneration or inflammation of many nerves throughout the body (polyneuropathy)

Chronic numbness and burning pain, typically in both hands and/or both feet

Often in people with a disorder that causes nerve damage, such as diabetes, alcohol abuse, or vasculitis

Only a doctor's examination

Complex regional pain syndrome

Severe burning or aching pain

Sometimes increased sensation and pain caused by a stimulus that would not ordinarily be considered painful

Often skin that appears red, mottled, or ashen and increased or decreased sweating in the affected limb

Typically in people who have had an injury (sometimes many years before)

Only a doctor's examination

Chronic venous insufficiency (causing blood to pool in the legs)

Swelling of the ankles or legs

Chronic mild discomfort, aching, or cramps in the legs but no pain

Sometimes reddish brown, leathery areas on the skin and shallow sores on the lower legs

Often varicose veins

Only a doctor's examination

*Arm or leg pain that is caused by injury is not included.

Features include symptoms and the results of the doctor's examination. Features mentioned are typical but not always present.

CT = computed tomography; ECG = electrocardiography; MRI = magnetic resonance imaging.


Testing

Testing is not needed for all people with limb pain. Doctors can often diagnose some causes of limb pain, including cellulitis and painful polyneuropathy, based on the people's symptoms and the physical examination findings. Testing is usually needed for other possible causes of pain.


Treatment

The best way to treat limb pain is to treat the underlying disorder. Analgesics such as acetaminophen and nonsteroidal anti-inflammatory drugs can help relieve pain. Sometimes opioids are needed.

Key Points

  • In people with sudden, severe pain, blood flow to the limb has often been stopped or reduced and testing must be done quickly.

  • Symptoms and characteristics found during the doctor's examination usually provide clues to the cause of limb pain.

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