Left Leg Pain

Brian Lewis M.D.Assistant Professor of SurgeryMedical College of Wisconsin

Ms. Doe

Ms. Doe is a 55-year-old woman, c/o progressive left leg pain. She is referred by her PMD to clinic today for evaluation of left leg pain. The right leg gives her no trouble.

History

What other points of the history do you want to know?

History, Ms. Doe Consider the following:

• Characterization of Symptoms:

• Temporal sequence• Alleviating /

Exacerbating factors:

• Associated signs/symptoms • Pertinent PMH• ROS• MEDS• Relevant Family Hx.• Relevant Social Hx.

History, Ms. Doe

Characterization of symptoms• Pain occurs in left calf with walking, worsening over time.

Feels like a “cramp”. Limits her ability to play with her grandkids.

Temporal sequence• Only occurs with walking• Reproducible at the same distance

Alleviating / Exacerbating factors• Worse with walking especially up hill or stairs• Goes away when she stops

History, Ms. Doe Associated signs/symptoms:

• No pain in foot when in bed, though both feet tend to be “numb”

• No wounds on feet

Pertinent PMH:• ROS: HTN, IDDM, Hyperlipidemia, no hx of DVT/clotting disorders

• MEDS: Insulin, Amitryptiline, Atorvostatin, Lisinopril, Neurontin

Relevant Family Hx.• Positive for CAD, Diabetes

Relevant Social Hx.• Smokes cigarettes ½ ppd for 40 years

What is your Differential Diagnosis?

Differential DiagnosisBased on History and Presentation

Muscle strain Dehydration Drug reaction – statins Tendonitis Deep venous thrombosis Claudication Arthritis Varicose veins Malignancy Sciatic nerve pain

Physical Examination

What specifically would you look for?

Physical Examination, Ms. Doe Vital Signs: T 98.6° F, P 82, BP 173/81, RR 16 Appearance: Healthy, pleasant, non distressed Relevant Exam findings for a problem focused assessment

HEENT: normal, no bruits Pulses: normal radial, femoral, carotid bilaterally; absent popliteal, DP and PT pulses bilaterally

Chest: clear bilaterally Neuromuscular: neuropathy in both feet

CV: RRR, no murmurs Skin/Soft Tissue: skin shiny on bilateral legs, no wounds, legs non-tender to palpation

Abd: Soft, nontender, no masses Remaining Examination findings Remaining Examination findings non-contributorynon-contributory

Differential DiagnosisWould you like to update your differential?

Studies (Labs, X-rays etc.)

What would you obtain?

Studies, Ms. Doe

Ankle-brachial indices• Right:0.98• Left: Incompressible

Toe Pressures• Right: 60• Left: <20

ABI

Can anyone describe how ankle brachial indices are performed?

What represents normal range? Abnormal? What conditions might falsely elevate the

number?

Lab Studies ordered, Ms. Doe

CBC: Within normal limits

LFT’s Within normal limits

PT/PTT Within normal limits

Electrolytes Within normal limits

Urinalysis Within normal limits

Lipid Panel Within normal limits

Hb A1C 7.8

These were obtained by PMD 6 weeks ago

Lab Results, Discussion

Interventions at this point?

How would you manage this patient?

Risk factor control− BP control− Lower lipids/cholesterol− Blood sugar control− Smoking cessation− β-blockers− ASA

Exercise program Medications

− Pentoxifylline− Cilostazol

What next?

Next Steps

How would you schedule follow-up? Any studies at time of follow-up?

Ms. Doe calls the office 15 months later complaining of worsening symptoms in left leg.

Now pain when she walks only a few steps Now has an open wound on the left first toe

• States the wound has been present for weeks and is only getting worse

Physical Examination

PE is unchanged with exception that there is a swollen left first toe with an open 1cm x 1cm necrotic based wound on the medial aspect

The toe is extremely tender There is no drainage from the wound

What studies would you obtain?

Ankle-brachial indices• Right:0.98• Left: Incompressible

Toe Pressures• Right: 60• Left: <20

Anything else ?

Angiogram

Angiogram

Angiogram

Angiogram

Angiogram

Angiogram

Angiogram

Angiogram

How would you describe the findings?

What would you do now?

Management Options

Observe Surgery

• Options?• What workup would be required?

Endovascular management• Options?

What are some strengths and limitations of the various options?

Post op Management

Discuss routine post op

Discuss most common complications

Mention any rare findings

Discussion Additional teaching points

• Disease process− Claudication

• 1% - 2% of population <50 yo• Up to 5% of population 50 – 70 yo• Up to 10% greater then 70 yo• At 10 years only 25% have symptomatic disease

progression− Limb-threatening ischemia

• Develops in approximately 1 of every 100 claudicators• Obtaining consultants

− High incidence of CAD associated with PVD• Approximate percent with no or mild/mod CAD

40%• Approximate percent with advanced or severe CAD

60%

QUESTIONS ??????

Summary

Intervention for infra-inguinal vascular disease is most often reserved for ?• Rest pain• Tissue loss

Fix in-flow first Below the inguinal level vein is typically the preferred

conduit The role for endovascular management is evolving Vascular disease in a single territory is often a marker

for generalized vascular disease

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