Differential Diagnosis for Leg Pain Exacerbated by Walking

The patient's symptoms of pain in the upper legs that worsen with walking and improve with sitting suggest a condition that affects the lower extremities or the spine. Here's a categorized differential diagnosis:

• Single Most Likely Diagnosis

  • A. Spinal Stenosis: This condition is characterized by narrowing of the spinal canal, which can compress the spinal cord or the nerves that travel through the spine. Symptoms often include pain, numbness, or weakness in the legs, calves, or buttocks that worsen with walking or standing and improve with sitting or leaning forward. The patient's age and symptom profile make spinal stenosis a highly plausible diagnosis.

• Other Likely Diagnoses

  • B. Vascular Claudication: This condition is caused by inadequate blood flow to the muscles of the lower extremities, typically due to peripheral arterial disease (PAD). While it presents with similar symptoms of leg pain that worsens with walking, the pain is usually more localized to the calf and is relieved by rest. The presence of intact peripheral pulses in this patient makes vascular claudication less likely but does not rule it out entirely.

• Do Not Miss Diagnoses

  • C. Aortic Dissection: Although less common and not directly suggested by the symptoms of leg pain exacerbated by walking, aortic dissection is a medical emergency that can present with a variety of symptoms, including severe back or abdominal pain that can radiate to the legs. It's crucial to consider this diagnosis due to its high mortality rate if missed.
  • Other conditions that could be considered under "Do Not Miss" include severe infections (e.g., osteomyelitis, septic arthritis), cauda equina syndrome, or acute spinal cord compression, though these might present with additional symptoms such as fever, neurological deficits, or significant trauma history.

• Rare Diagnoses

  • Certain rare conditions could mimic the symptoms described, such as Chronic Compartment Syndrome, which involves increased pressure within a muscle compartment, leading to pain with exercise. Neurogenic Claudication due to other spinal pathologies (e.g., spondylolisthesis, degenerative scoliosis) could also be considered, though spinal stenosis is the most common cause of neurogenic claudication.
  • Other rare vascular causes, such as Popliteal Artery Entrapment Syndrome or Cystic Adventitial Disease, could also lead to claudication symptoms but are less common and might have distinctive features on physical examination or imaging.

Each of these diagnoses has a different set of implications for treatment and prognosis, highlighting the importance of a thorough diagnostic evaluation.