Lower-back pain is a common reason for patients to consult a doctor of chiropractic. In isolation, lower-back pain is usually benign and self-limiting. But this is often not true among patients with concomitant lower-extremity symptoms. A strong determinant of disability associated with lower-back pain is the presence of a symptomatic leg.1 This article reviews the current scientific literature and presents a practical, evidence-based approach to the differential diagnosis of lower-extremity symptoms and aims to reduce patient morbidity by enhancing the clinician’s acumen for the recognition of a worrisome leg.
Lumbar radiculopathy is estimated to occur with a prevalence of 3-5 percent in the general population2 and is a complaint that is seen regularly by chiropractic physicians. In the majority of cases, the presentation is straightforward, uncomplicated, and responds favorably to conservative management. The rare “needle-in-the-haystack” occurrence is the symptomatic leg that does not represent a “simple” radiculopathy. Instead, that is the result of an imminently more serious disorder that requires prompt management. Though uncommon, it is the feared etiologies that clinicians must systematically rule out before committing to a diagnosis with a benign or self-limiting cause.
This article presents a systematic evidence-based approach for the evaluation and recognition of disorders causing lower-extremity symptoms that may require prompt management. It is not an exhaustive review. It focuses on diseases likely to be encountered in a typical chiropractic clinic. Among the most feared disorders associated with the clinical presentation of leg pain are: ruptured aneurysm, peripheral arterial disease, venous thromboembolism, cauda-equina syndrome, persistent neurological deficit, and compartment syndrome (see Figure 1).
Although cauda-equina syndrome is a serious concern, the most ominous etiology is the vascular event. For this reason, the diagnostic work-up of a patient with leg pain should first consider the potential of an evolving vascular condition (see Figures 2 and 3).
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