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Extremity pain can have many causes. This chapter provides a comprehensive differential diagnosis of such pain. The reader should consult the individual chapters dealing with particular pain syndromes to find specific treatment options.

Acute Arterial Insufficiency

(See Chap. 50)

The pain of acute arterial insufficiency is characterized by its sudden onset. Emboli lodge at artery branch points, which are also more likely to be affected by atherosclerosis. Emboli may occlude more than one vessel at a branch point and thereby limit collateral flow. Muscle necrosis and irreversible changes may occur if blood flow is not reestablished within 4 to 6 hours.1

The five cardinal features of arterial insufficiency (the five “Ps”) consist of pain, pallor, paresthesias, paralysis, and pulselessness. The pain is well localized to an extremity and severe. It may be attenuated by good collateral circulation; that is, occlusion of a brachial artery may not produce as dramatic a clinical picture as occlusion of a common femoral artery or popliteal artery. Nerve endings and muscle tissue are extremely sensitive to hypoxia, and acute obstruction soon leads to anesthesia and paralysis in an affected extremity.2

Pulses usually, but not always, are absent distal to the site of obstruction. Therefore, pain and associated signs and symptoms of ischemia in the presence of detectable pulses warrant further investigation.2 Conversely, pulses may be unusually strong proximal to the site of the occlusion.

Acute ischemia in an extremity also is accompanied by a change in the skin temperature distal to the site of occlusion. The extremity appears pale, and the veins may seem to be empty. Palpation along the course of the artery may reveal tenderness over the site of occlusion. The muscles begin to feel hard and inelastic as the ischemia progresses.2 Muscular fatigue and weakness are apparent.

Chronic Arterial Insufficiency

Chronic arterial insufficiency can produce a wide variety of painful symptoms. Affected patients can have numbness, coldness, tingling, or total paresis. The degree of insufficiency determines the type of pain in the lower extremity (intermittent claudication or rest pain). Atherosclerosis is the most common cause of chronic lower limb ischemia. Hypertension, diabetes mellitus, hypercholesterolemia, and cigarette smoking increase the incidence and severity of atheroma formation.3 Thromboangiitis obliterans (Buerger’s disease), popliteal artery entrapment, and cystic adventitial disease can also cause lower limb ischemia.

Claudication refers to cramping pain that occurs when blood flow cannot be increased to a muscle mass in response to the increased metabolic demands of exercise. Blood flow is adequate in the extremity at rest. Claudication has several diagnostic features: (1) it is always relieved by rest after exercise, (2) it is produced by a consistent amount of exercise, and (3) it is always experienced in a functional muscle group.4

Ischemic rest pain occurs when blood ...

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