Nerve and Leg Pain

The useful question: What makes it better: sitting down, standing still, or resting the leg?
Numbness and tingling: Point to a nerve, usually one being compressed in the back.
Needs seeing quickly: One swollen, warm calf, or a leg that is cold, pale and suddenly painful.

Nerve, circulation, or muscle and joint?

Most leg pain sorts into one of three groups, and what relieves it is the quickest way to tell them apart.

	From a nerve	From the circulation	From muscle or joint
How it feels	Burning, shooting, electric; follows a line down the leg	Cramping or tight, usually in the calf	Aching, local, sore to press
What brings it on	Sitting, bending, coughing; or standing and walking upright	Walking a predictable distance, sooner uphill	Using or loading that part
What relieves it	Changing position; leaning forward	Standing still for a minute or two	Rest, and time
Other clues	Pins and needles, numbness, weakness	Cold foot, hairless shiny skin, slow-healing sores	Swelling or tenderness at one spot
Where to start	Sciatica, spinal stenosis, neuropathic pain	Your doctor, or a vascular specialist	Our orthopaedic surgeons

The leg skeleton with the sciatic nerve in yellow and the artery and vein in red and blue running down the same limb. — The nerve and the blood vessels take the same route down the leg, which is why their pain is so easily confused.

On the left, bone. On the right, the sciatic nerve in yellow alongside the artery and vein — all in the same leg, from the pelvis to the foot.

That shared path is the whole difficulty. Pain from either can be felt in the same calf, so the distinction comes from what provokes and relieves it rather than from where it sits.

Leaning forward is the giveaway for spinal stenosis. Pain that eases when you lean on a trolley or sit down, and returns when you stand upright, points to the spinal canal rather than the arteries, even though both are brought on by walking.

When leg pain needs attention quickly

One calf swollen, warm and tender, particularly after a long flight, surgery or a period of bed rest, should be assessed the same day. A clot in a deep vein needs treating promptly.

A leg that is suddenly cold, pale and severely painful, or numb and weak, should go to an emergency department now. So should numbness around the groin or loss of bladder control alongside leg symptoms.

Neither of those is what this page is mainly about, but both are mistaken for ordinary leg pain often enough to be worth naming first.

Pain that starts in the back

A nerve root leaving the lower spine supplies a strip of the leg, so pressure at that point is felt far from where it happens. A pinched nerve and leg pain usually arrive together for that reason, and it is why leg pain is so often a back problem in disguise.

Sciatica — pain down the back of one leg from a compressed nerve root, often with numbness or tingling
Spinal stenosis — heaviness and aching in both legs on walking, easing when you sit or lean forward
Slipped disc — the commonest cause of a squeezed nerve root under 50
Weakness rather than pain — a foot that drops, or a leg that gives way, which deserves prompt assessment

Where the symptoms fall tells us the level. Pain down the back of the calf into the sole comes from a different nerve root than pain along the outside of the calf into the big toe. That mapping, checked against a scan, is what makes treatment specific rather than general.

Pain from the nerves themselves

Nerves can also be damaged along their length rather than squeezed at the spine. That produces burning, numbness or tingling, often in both feet, and usually without back pain.

Diabetes is the commonest cause, typically starting in the toes and creeping upwards
Pressure on a nerve at the knee or ankle, which can cause a dropped foot or numbness on the top of the foot
Restless legs — an urge to move the legs at night rather than pain as such
More on this at neuropathic pain

Pain from muscle, bone and joint

Overuse and training

Muscle strain in the calf, hamstring or thigh
Tendon pain at the heel or behind the knee
Shin pain from a sudden increase in running
Stress fracture, where the pain is sharp, local and worse with every session

Joints referring pain

Hip arthritis felt in the groin and thigh, sometimes at the knee
Knee problems felt down the shin
Sacroiliac joint pain felt in the buttock and back of the thigh
Gout, which is sudden, hot and severe

How leg pain is assessed

History. Where it runs, what provokes it, what relieves it, and whether there is numbness or weakness
Examination. Strength, reflexes and sensation; nerve stretch tests; the pulses in the foot; and the joints above and below
MRI of the spine where the pattern points to a nerve root
Nerve conduction tests where damage along the nerve is suspected
X-ray or ultrasound for joints, tendons and suspected clots
Blood tests where diabetes, gout or inflammation may be involved

Leg pain treatment

Treatment follows the cause rather than the symptom, which is the reason the first appointment is spent working out which of the three systems is responsible.

Nerve compression from the spine

Staying as active as the pain allows, medication, physiotherapy, and a nerve root injection where it has not settled. Decompression surgery where weakness is progressing or the pain has not responded.

Nerve damage along the leg

Treating the underlying cause where there is one, medication aimed at nerve pain rather than ordinary painkillers, and neuromodulation in selected cases.

Muscle, tendon and joint

Load management, a graded strengthening programme, and injections where a specific structure is inflamed. Surgery only where the problem is structural.

Circulation

Not treated here. Cramping calf pain that comes on at a set walking distance belongs with your doctor or a vascular specialist, and we will say so rather than investigate the spine indefinitely.

When to see someone about it

Pain running down the leg that has lasted more than two or three weeks
Numbness, pins and needles, or weakness
Walking distance shrinking, whatever you think the cause is
Night pain, or pain at rest
A foot that catches or drops when you walk

Why see us about it

Back and leg are examined together. Leg pain from a nerve root is treated at the spine, not where it hurts.
The three systems are separated first, including the one we do not treat.
Both disciplines in one clinic. Dr Mathew Tung for nerve and spinal causes, and our orthopaedic surgeons for the joints and soft tissues.

Common questions

Why does my leg hurt when my back feels fine?

A compressed nerve root is felt along the nerve rather than at the point of compression. Leg pain worse than back pain is typical of a squeezed root, and the back can feel almost normal.

My calf cramps when I walk and settles when I stop. Is that a nerve?

It may be circulation rather than a nerve, particularly if it starts at a predictable distance and eases within a minute or two of standing still. Nerve-related leg pain more often eases when you sit or lean forward.

What does numbness in both feet mean?

Symptoms in both feet, starting at the toes, more often come from nerve damage along the nerves than from a single compressed root. Diabetes is the commonest cause and is worth testing for.

Do I need an MRI of my back for leg pain?

Only if the pattern points to a nerve root and the result would change the plan. Examination comes first, and many people improve before a scan is needed at all.

Is walking bad for leg pain?

Usually not, and staying active helps most causes. What matters is which activity provokes it, since that itself is part of the diagnosis.

Do I need a referral?

No. Bring any scan reports, and be ready to describe exactly where the pain runs and what relieves it.

Related conditions

Sciatica · Spinal stenosis · Slipped disc · Neuropathic pain · Knee pain · Lower back pain