The first step in managing leg pain is to identify whether the cause of the pain is localised to the leg ror if it is referred from other areas, the most common site being the lower back and pelvis.

• Most commonly injury of lower limb muscles, ligaments, and tendons – sprains, strains, tears – cause acute onset pain following a injury. These usually settle down soon , but could lead on to myofascial pain syndrome which causes muscle spasms and tenderness affecting walking and running. The common muscle groups affected are the vastii, adductors and hamstrings in the thigh, soleus, gastrocnemius muscles and plantaris in the calf and the gluteal muscles in the buttock area. Soft tissue damage of the tendons and ligaments could occur due to repetitive stress injury due to intensive workouts or jogging/ running due to the impact forces.  These can result in muscle spasm and cause exquisitely tender points in the muscle and soft-tissue known as myofascial trigger points.
• Joints in the Spine: Some of the most common causes for referred pain in the leg arises from the facet joints in the spine, narrowing of the neural foramen due to disc prolapse or age-related changes (sciatica) as well as irritation of the lumbosacral spinal nerves of plexus due to various factors that affects the different joints in the spine. Spondylolisthesis (misalignment of one vertebral body over the adjacent one) and un-natural curvature of the spine to the side (scoliosis) are examples of spinal problems that could cause leg pain due to its effect on spinal nerve roots.
• Lower limb joints: Pains in the hip, knee, ankle and small joints of the foot are common sites of arthritis and degenerative changes. Some of these problems are difficult to diagnose due to varying presentations, but pain and stiffness are common manifestations.  The Sacroiliac joint is the large joint that connects our hips to the spine and is a common source of radiating pain down the buttock and legs.
• Cramping of the leg or calf are very painful episodes lasting from a few minutes to hours. It is worse at night especially in the elderly and could be due to various underlying causes.  Cramps and pain that gets worse on walking could be due to narrowing of the spinal canal or due to poor blood supply to the legs.
• Neuropathic pain in the leg: The lower limb is a common site for nerve pain; this could be on one sided or on both feet and legs.
•      Examples of one-sided pain – shingles, post-herpetic neuralgia, mononeuritis, meralgia paraesthetica, multiple sclerosis.  However, most common causes could be due to problems within the lower lumbar spine as part of degenerative changes.
  • Conditions that could affect both feet and legs are peripheral neuropathies due to diabetes mellitus, HIV, vitamin deficiencies and alcohol misuse. Early signs of a central disc prolapse can also cause similar symptoms.
  • Post-surgical pain could be neuropathic pain in the legs after any surgery, but are common after knee joint replacements, varicose vein surgery and in infected wounds after surgery.
  • Post-amputation pain could be due to phantom limb pain or pain from a neuroma in the amputation stump.
• Peripheral vascular disease causes poor blood circulation due to narrowing or blockade of arteries and could result in pain, discolouration and if untreated might result in gangrene and amputation. Claudication pain that is described as cramp-like affects when walkig and improves on taking rest.
• Varicose veins causes pooling of blood in tortuous veins and could give rise to chronic pain
• Deep vein thrombosis (DVT) is a blood clot developing in the deep veins of the leg and some are at a higher risk. It can block the blood supply to the lungs (pulmonary embolism) and hence is a life threatening condition if not treated.

• Compartment syndrome occurs following an injury or surgery to the leg resulting in swelling of the tissues and build-up of high tissue pressures, which unless managed urgently could compromise the viability of the limb.

Pain in the foot could be due to local causes or it could be referred from other areas of the limb or from the spine.

• • Rupture of Achilles tendon happens usually as a sports injury, but could take several weeks to get better.
  • The foot has several joints and tendons which could give rise to pain due to a variety of causes.  These need proper assessment.
  • Fractures of the bones in the foot are not uncommon due to stress fractures as well due to osteoporosis or osteopenia.
  • The small joints of the foot are affected in rheumatoid arthritis, psoriatic arthritis and the big toe is often the site of very painful gouty arthritis.
  • Bunions, Bursitis, Morton’s neuroma, plantar fasciitis, calcaneal spur are other reasons to have localised foot pain.
• Referred pain: This is mainly arising from the spine particularly due to a L5-S1 pathology due to disc prolapse or spondylolisthesis.
• Complex regional pain syndrome (CRPS) is a severe pain condition afftecting the foot and leg following a trauma or prolonged immobilisation of the foot. CRPS can affect other areas like hand, face etc. CRPS is thought to be caused by malfunction of certain aspects of nerves and nervous systems. This is a serious condition and needs to be identified early and managed by a multidisciplinary team.