Lower Extremity Pain by Region
Most Common to Least Common
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BUTTOCK AND GLUTEAL REGION
Lumbar radiculopathy or spinal stenosis: Most common cause of buttock pain radiating distally.
Sacroiliac joint dysfunction: Pain localized to the SI joint, often worse with sitting, standing from a seated position, or transitional movements.
Piriformis syndrome or deep gluteal syndrome: Sciatic nerve entrapment causing buttock pain with possible radiation down the leg. Accounts for a minority of sciatica cases.
Cluneal nerve entrapment: Can cause pseudo sciatica, often with pain near the iliac crest or posterior pelvis.
Ischiofemoral impingement: Deep buttock pain, often worse with long stride activities or hip extension.
HIP AND THIGH REGION
Hip osteoarthritis: Groin, anterior hip, or lateral hip aching, typically worse with weight bearing and activity.
Greater trochanteric pain syndrome: Lateral hip or lateral thigh pain, often associated with tenderness over the greater trochanter and iliotibial band tightness.
Meralgia paresthetica: Lateral femoral cutaneous nerve irritation causing burning, numbness, or tingling over the anterolateral thigh. May be associated with obesity, diabetes, pregnancy, or tight garments.
Obturator or femoral neuropathy: Medial thigh or anterior thigh pain, sometimes related to surgery, pelvic pathology, trauma, or mass effect.
Myofascial referred pain: Trigger points, especially in the gluteus medius or gluteus minimus, may refer pain into the hip, thigh, or lower extremity.
KNEE AND LEG REGION
Common peroneal neuropathy: A common lower extremity entrapment neuropathy, often compressed at the fibular head. May cause lateral leg pain, numbness, weakness, or foot drop.
Baker cyst: Posterior knee swelling, fullness, or tenderness, sometimes with calf discomfort if enlarged or ruptured.
Chronic exertional compartment syndrome: Exercise induced calf or leg tightness, cramping, or pain, commonly seen in athletes.
Venous claudication or deep vein thrombosis: Leg pain or swelling, often worse in the calf. Consider especially with a history of DVT, recent surgery, immobility, or vascular risk factors.
Peripheral artery disease or arterial claudication: Calf, thigh, or buttock cramping with walking, typically relieved by rest.
ANKLE AND FOOT REGION
Plantar fasciitis: Common cause of plantar heel pain, often worse with first steps in the morning or after prolonged rest.
Achilles tendinopathy: Posterior ankle or heel pain, commonly located two to six centimeters proximal to the Achilles insertion.
Morton neuroma: Compressive neuropathy causing burning, numbness, or pain, classically in the third or fourth webspace.
Tarsal tunnel syndrome: Tibial nerve compression causing medial ankle pain with plantar foot paresthesias.
Sural neuropathy: Lateral ankle or lateral foot numbness or pain, often post traumatic or post surgical.
Peripheral neuropathy: Distal symmetric numbness, burning, tingling, or pain, commonly associated with diabetes and other systemic causes.
HX - EXAM - TREATMENT
HX - EXAM - TREATMENT
BUTTOCK/GLUTEAL
Lumbar Radiculopathy
History: Leg pain worse with sitting; numbness in dermatomal pattern
Exam: Positive straight leg raise; dermatomal weakness/reflex changes
Tests: MRI lumbar spine; EMG/NCS if diagnosis uncertain
Treatment: NSAIDs, PT, epidural steroid injections, surgery if refractory
Sacroiliac Joint Dysfunction
History: Buttock pain worse sitting/rising; history of trauma/pregnancy
Exam: Tenderness at PSIS; positive SI provocation tests
Tests: MRI for inflammation; diagnostic SI joint injection
Treatment: PT, NSAIDs, SI joint injection, radiofrequency ablation
Piriformis/Deep Gluteal Syndrome
History: Deep buttock pain worse with prolonged sitting
Exam: Positive FAIR test; active piriformis test reproduces symptoms
Tests: MRI neurography; EMG to localize entrapment
Treatment: Stretching, NSAIDs, piriformis injection, surgical release if refractory
Cluneal Nerve Entrapment
History: Deep aching low back/buttock pain; "pseudo-sciatica" pattern
Exam: Tender points at iliac crest; no motor/sensory deficits
Tests: Diagnostic nerve block with ≥50% pain relief confirms
Treatment: Nerve blocks, neuroablation, surgical decompression if persistent
Ischiofemoral Impingement
History: Deep buttock pain worsened by long-stride activities like running
Exam: Positive long-stride walking test reproduces symptoms
Tests: MRI shows narrowed ischiofemoral space, quadratus femoris edema
Treatment: Activity modification, PT, image-guided injection, rarely surgery
HIP/THIGH
Hip Osteoarthritis
History: Groin/hip aching; worse with prolonged sitting or walking
Exam: Limited internal rotation; pain with flexion and rotation
Tests: Weight-bearing hip radiographs; clinical diagnosis if age >45
Treatment: PT, NSAIDs, intra-articular injection, total hip arthroplasty
Greater Trochanteric Pain Syndrome
History: Lateral hip pain; worse lying on affected side
Exam: Tenderness at greater trochanter; positive Trendelenburg sign
Tests: Clinical diagnosis; ultrasound/MRI if refractory or uncertain
Treatment: PT, NSAIDs, corticosteroid injection, surgical repair if torn
Meralgia Paresthetica
History: Burning/numbness anterolateral thigh; obesity, tight clothing, diabetes
Exam: Sensory loss anterolateral thigh; no motor weakness
Tests: Clinical diagnosis; nerve conduction studies if atypical
Treatment: Weight loss, loose clothing, nerve block, neurectomy if refractory
Obturator/Femoral Neuropathy
History: Medial thigh pain/weakness; post-surgical or pelvic mass
Exam: Weak hip adduction (obturator) or knee extension (femoral)
Tests: EMG/NCS; pelvic MRI to exclude compressive lesion
Treatment: Treat underlying cause; PT, nerve block, surgical decompression
Myofascial Pain
History: Regional aching pain; history of overuse or postural strain
Exam: Palpable trigger points reproducing referred pain pattern
Tests: Clinical diagnosis; no specific confirmatory test needed
Treatment: Trigger point injection, stretching, PT, dry needling
KNEE/LEG
Common Peroneal Neuropathy
History: Foot drop, lateral leg numbness; habitual leg crossing/compression
Exam: Weak ankle dorsiflexion/eversion; sensory loss dorsal foot
Tests: EMG/NCS localizes lesion at fibular head; MRI if mass
Treatment: AFO brace, activity modification, surgical decompression if refractory
Baker Cyst
History: Posterior knee swelling/tightness; not intermittent, worse with activity
Exam: Palpable fullness in popliteal fossa; tenderness present
Tests: Ultrasound confirms cyst; MRI if internal derangement suspected
Treatment: Treat underlying knee pathology; aspiration, injection, excision
Chronic Compartment Syndrome
History: Tight bursting calf pain with strenuous exercise; heavy-muscled athletes
Exam: Firm compartments post-exercise; normal exam at rest
Tests: Intracompartmental pressure measurement pre/post exercise
Treatment: Activity modification; fasciotomy if conservative measures fail
Venous Claudication/DVT
History: Entire leg tightness worse in calf; history of prior DVT
Exam: Leg edema, venous stasis changes; relief with elevation
Tests: Duplex ultrasound; D-dimer if acute DVT suspected
Treatment: Anticoagulation (DVT), compression stockings, leg elevation
PAD/Arterial Claudication
History: Calf cramping with walking; relieved quickly by rest
Exam: Diminished pulses, pallor on elevation, dependent rubor
Tests: Ankle-brachial index; CT/MR angiography if intervention planned
Treatment: Risk factor modification, supervised exercise, revascularization if severe
ANKLE/FOOT
Plantar Fasciitis
History: Plantar heel pain with first steps after rest
Exam: Tenderness at medial calcaneal tuberosity and plantar fascia
Tests: Clinical diagnosis; imaging only to exclude stress fracture
Treatment: Stretching, orthotics, shockwave therapy, corticosteroid injection
Achilles Tendinopathy
History: Pain 2–6 cm above heel insertion; worse with activity
Exam: Tenderness/thickening along midportion Achilles tendon
Tests: Clinical diagnosis; ultrasound/MRI if tear suspected
Treatment: Eccentric strengthening exercises, shockwave therapy, PT
Morton Neuroma
History: Burning forefoot pain radiating to 3rd/4th toes; tight shoes
Exam: Positive Mulder click and Tinel sign at webspace
Tests: Clinical diagnosis; ultrasound/MRI to confirm or exclude other pathology
Treatment: Wide shoes, orthotics, corticosteroid injection, excision if refractory
Tarsal Tunnel Syndrome
History: Burning/tingling medial ankle radiating to sole; worse standing
Exam: Positive Tinel sign posterior to medial malleolus
Tests: EMG/NCS; MRI to identify compressive lesion
Treatment: Orthotics, NSAIDs, neuromodulators, injection, surgical release
Sural Neuropathy
History: Lateral ankle/foot numbness; often post-traumatic or post-surgical
Exam: Sensory loss lateral foot/ankle; no motor deficit
Tests: Nerve conduction studies confirm; ultrasound if mass suspected
Treatment: Activity modification, desensitization, surgical exploration if needed
Peripheral Neuropathy
History: Distal symmetric numbness/burning in stocking distribution; diabetes common
Exam: Reduced vibration/pinprick distally; absent ankle reflexes
Tests: Glucose, B12, TSH, SPEP; EMG/NCS if atypical
Treatment: Treat underlying cause; gabapentinoids, duloxetine for pain
SI JOINT - REFERRED PAIN
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