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 Symptoms of Musculoskeletal Disorders: Musculoskeletal Pain).

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:

• Blood clot in a deep-lying vein (deep vein thrombosis)
• Bacterial infection of the skin (cellulitis)
• Pressure on a spinal nerve root

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 an acute arterial occlusion 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 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 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). An irregular pulse suggests that the person may have a certain abnormal heart rhythm (atrial fibrillation) 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 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.

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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 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 Usually 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 Bacterial Infections: 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 or alcohol abuse 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 blood in the legs) Swelling of the ankles or legs Chronic mild discomfort, aching, or cramps inn 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. 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 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 Usually 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 Bacterial Infections: 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 or alcohol abuse 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 blood in the legs) Swelling of the ankles or legs Chronic mild discomfort, aching, or cramps inn 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, myofascial pain, 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.

Last full review/revision October 2012 by Lyall A. J. Higginson, MD