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I
LEG PAIN
II
LIMP
LEG PAIN
Possible causes for the kind of leg pain that often is
referred to as “growing pains”
Differentiation from “growing pains” by careful
evaluation: history, physical examination (pain
location, systemic symptoms) and few laboratory
studies (X-rays, blood count, ESR)
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LEG PAIN
I
Idiopathic leg pain
(“Growing pains”)
II
Trauma
III
Leukemia & lymphoma
IV
Bone tumors
V
Infection & inflammation
VI
Miscellaneous
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LEG PAIN:
Idiopathic leg pains (1)
10-20% of children may complain
vague leg pain on a recurrent basis
sometimes in association with headaches and
abdominal pains
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LEG PAIN:
Idiopathic leg pains (2)
Pain
‫ ׳‬usually intermittent, bilateral, deep in legs
‫ ׳‬commonly: thigh or leg
‫ ׳‬joint pain: rare, points to other diagnosis!!
‫ ׳‬may occur at any time, typically only at night
(when child falling asleep or actually waking up)
‫ ׳‬last about 1 hour
‫ ׳‬may respond to rubbing, heat or analgesics
‫ ׳‬systemic signs and symptoms: absent
‫ ׳‬X-ray and ESR: normal
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LEG PAIN:
Idiopathic leg pains (3)
- still to be determined
- not due to “growth” !
Etiology
- excessive exercise, trauma
- hidden food allergy, emotional factors have been
suggested
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LEG PAIN:
Trauma (1)
most common cause
superficial clues: bruises, swelling
may be history of an episode of physical trauma
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LEG PAIN:
Trauma (2)
muscle or bone bruises
fractures
pathological fractures
muscle injections
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LEG PAIN:
Bone Tumors (1)
Malignant
- pain: persistent, increasing severity
Benign tumors - more likely to be painless unless
associated with pathological fracture or
mechanical difficulties.
Exceptions: Osteoid Osteoma
Benign Osteoblastoma
Eosinophilic Granuloma
Metastatic tumors - more common: Neuroblastoma
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LEG PAIN:
Bone Tumors (2)
ROENTGENOGRAMS SHOULD BE OBTAINED IN
ANY CHILD COMPLAINING OF LOCALIZED
BONE PAIN
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LEG PAIN:
Infection & Inflammation
Osteomyelitis: localized, tenderness, swelling not always with
systemic signs
Bone scan !!
Myositis:
A. pyogenic infection
B. myositis as a result of a systemic infection
*Calf tenderness in influenza
Tuberculosis: Limb pain without systemic symptoms !
Syphilis:
periostitis - severe pain, pseudoparalysis
(in cong. infection)
Trichinosis: severe muscle pain, fever, periorbital edema,
eosinophilia.
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LEG PAIN:
Shin splints
Scurvy
Miscellaneous Causes (1)
(ant. & post. compartment synd.):
hypertrophy, swelling of muscle cramping pain on sudden resumption of
excessive exercise
Subperiosteal hemorrhages tenderness in limbs
Hypervitaminosis A - bony pain, symptoms of increased
cranial pressure
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LEG PAIN:
Miscellaneous Causes (2)
Caffey Disease -
Infantile Cortical Hyperostosis
usually onset before 6 m.
Sickle-Cell Disease - black child, painful extremities and anemic
Gaucher Disease -
may suggest osteomyelitis !
severe pain, tenderness, swelling,
erythema, heat
Melorheostosis -
rare, longitudinal thickening of shaft of
long bone, usually one limb;
pain: severe, skin-tense, shiny, indurated
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LEG PAIN:
Miscellaneous Causes (3)
Engelmann Dis. (Diaphyseal Dysplasia)
rare, symmetric enlargement sclerosis of the shafts of
major long bone and skull;
difficult walking - limb pain
Multiple Epiphyseal Dysplasia
painful joints, enlarged in size; hips, knees or ankles:
restriction in mobility, back pain: common, waddling gait
Stickler Syn. (Hereditary Artho-ophthalmopathy)
autosomal dominant, marfanoid habitus, large joints,
hyperextensible knees, elbows and fingers, painful
joints, morning stiffness, cong. myopia, conductive
hearing loss
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LIMP
fairly straightforward in most children
a thorough history, physical examination usually reveals the origin
type of gait responsible for limp should be observed
A. - by having the child walk unencumbered
by clothing in the hallway
B. - gait may suggest a foot, knee or hip problem
1
LIMP
systemic symptoms indicate a more complex problem than
simple trauma
careful palpation of extremities: changes in temperature,
coloration, swelling
all joints put through range of motion
2
LIMP
Painful causes
Non-painful causes
3
LIMP
Painful Causes
I Trauma
IV Aseptic necrosis & Osteochondritis
II Inflammatory
V Neoplasms
III Infections
VI Hematologic
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LIMP - Painful:
Trauma (1)
local superficial lesions: skin irritation (tight shoe!!);
lacerations or F.B. in foot, plantar warts
ligamentous strains & sprains: ankle & knee injuries: common;
may mimic fractures; joint swollen and
sometimes bruised
tendon disorders
Achilles tendinitis:
sudden acute pain, pain on palpation,
but strong plantar flexion
Achilles tendon rupture : lack of forceful plantar flexion
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LIMP - Painful:
Trauma (2)
muscle bruising: history of trauma, purpura of skin;
tenderness of affected muscle
fractures must be considered in any painful limp!!
PALPATION
stress fractures:
in joggers & athletes; pain: not severe
toddler’s fracture: undisplaced, often spiral;
radiology: may be normal early, typically tibia
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LIMP - Painful:
Trauma (3)
child abuse: may be muscle bruising, sprains or fractures; history
does not fit the injury, evidence of abuse: present
infection:
typically in toddlers after DPT booster,
gluteal injections may irritate the sciatic nerve,
thigh injections
subluxation of patella: adolescent girls - commonly affected;
suddenly knee gives away, joint swelling
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LIMP - Painful:
Inflammatory Conditions (1)
toxic (transient) synovitis: hip - most common; may follow
trauma or viral infection, fever; systemic signs
- usually absent; painful abduction and internal
rotation; predisposes to Perthes disease ??
acute rheumatic fever: migratory joint pain or swelling, Jones
criteria; pain is usually out of proportion to
findings
juvenile rheumatoid arthritis: different presentations, one or
more joints, diagnosis by exclusion; pain: usually
not severe!
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LIMP - Painful:
Inflammatory Conditions (2)
systemic lupus erythematosus: arthritis, arthralgias and muscle
weakness - common, other clues !
polyartheritis nodosa: diffuse symptoms; vasculitis
dermatomyositis: proximal more than distal weakness, pain on
muscle palpation, erythematous scaling papules
over elbows, knees and knuckles
Henoch-Schonlein Purpura: petechial or purpuric rash,
abdominal pain, arthritis, nephritis, tissue swelling
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LIMP - Painful:
Inflammatory Conditions (3)
serum sickness: urticaria, arthralgias or arthritis, fever and
lymphoadenopathy; commonly associated with
drug use
ulcerative colitis, regional enteritis: arthritis, arthralgias
lupoid hepatitis: arthritis or arthralgia with jaundice;
hepatosplenomegaly - common
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LIMP - Painful:
Infections (1)
osteomyelitis:
localized pain, fever, ESR;
may mimic septic arthritis
septic arthritis: onset usually acute, generally monoarticular,
very painful; gonococcal arthritis - may be
migratory
acute myositis: follows a viral illness (usually influenza);
severe calves pain;
CPK
.
pyomyositis:
uncommon; localized muscle infection
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LIMP - Painful:
Infections (2)
disc infection:
back pain, hip referred pain;
child may refuse to walk
epidural abscess:
extreme back pain, sensory changes in
lower extremities
acute appendicitis: psoas irritation may alter gait
retroperitoneal masses: infection or inflammation, may be referred
to hip; palpate for abdominal masses
acute iliac adenitis: suppuration of lymph nodes; irritates
hip capsule - limp;
careful palpation along the ilium
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LIMP - Painful:
Aseptic necrosis & Osteochondritis (1)
Perthes dis.:
femoral epiphysis; boys - 4 to 8 y.;
may be totally asymptomatic
Osgood-Schlatter dis.: painful tibial tuberosity, limping after
heavy exercise; boys - 11 to 15 y.
Freiberg dis.:
head of 2nd metatarsus, pain on palpation;
girls - 12 to 15 y.
Kohler dis.:
tarsal navicular, mild limp; boys - 3 to 6 y.
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LIMP - Painful:
Aseptic necrosis & Osteochondritis (2)
Sever’s dis.:
calcaneal apophysitis, pain on heel palpation;
primarily boys 8 to 12 y.
Osteochondritis dissecans: knee - most common; history of
joint locking and intermittent swelling
Chondromalacia patella: pain - worse after exercise
Larsen-Johansson dis.: pain & tenderness over lower pole of
patella; swelling of adjacent soft tissue;
boys - 10 to 14 y.; limp + inability to kneel and
run - typical
Sinding-Larsen dis.: avulsion of patellar ligament, especially in
CP
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LIMP - Painful:
Neoplasms
leukemia:
leg pain and limp may be presenting signs;
may suggest arthritis
malignant bone tus.:
osteogenic sa., Ewing, metastatic
neuroblastoma, etc.
benign bone tus.:
osteoid osteoma, eosinophilic granuloma,
fibrous dysplasia, etc.
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LIMP - Painful:
Hematologic Conditions
hemophilia:
hemarthrosis - usually obvious
sickle-cell anemia: hand-foot syn. in toddlers; may be
secondary to bone infection; painful
symmetric swelling
phlebitis:
tenderness & local swelling of involved veins
scurvy:
limp secondary to periosteal hemorrhage
hypervitaminosis A: bone pain may occur with intoxication;
pseudotumor cerebri
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LIMP - Non-painful Causes
I
Neurologic disorders
II Muscle disorders
IV Bony deformities
V Functional state
III Joint disorders
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LIMP - Non-painful:
Neurologic
flaccid paralysis:
limp due to weak muscle groups
(poliomyelitis)
spastic paralysis: jerky gait is accentuated on running;
CP - most common
(increased muscle tone, hyperreflexia)
ataxia:
due to drugs, infection or heredity;
unsteady and broad based gait
spinal involvement: intraspinal masses, diastematomyelia,
cauda equina, lesions, herniated disc,
spondylolisthesis
CAREFUL NEUROLOGIC EXAMINATION IS MANDATORY !
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LIMP - Non-painful:
Muscle Disorders
muscular dystrophy: limp secondary to muscle weakness;
pseudohypertrophy
* numerous other primary muscle disorders with weakness may
produce an abnormal gait
arthrogryphosis: unclear etiology, neurogenic or muscular
lack of full extension due to contracture
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LIMP - Non-painful:
Joint Disorders
stiffness or contracture: may be seen in a number of inherited
diseases (mucopolysaccharidoses)
instability:
CDH - waddling gait, +ve Trendelenburg;
severe hyperextensibility - Ehlers - Danlos syn.;
severe pes-planus
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LIMP - Non-painful:
Bony Deformities (1)
leg length discrepancies
slipped femoral capital epiphysis: onset - insidious;
adolescent - 11 to 15 y.; obese
coxa vara: congenital, waddling gait
knock knees: severe, may cause unsteady gait
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LIMP - Non-painful:
Bony Deformities (2)
Blount dis.: unilateral or bilateral bowing of tibia; beaking of
proximal tibial epiphysis
torsional deformities of lower extremities
epiphyseal dysplasias: symptoms may mimic Perthes.
Hereditary multiple epiphyseal dysplasia, Gaucher,
hypothyroidism, sickle-cell disease - should be considered
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LIMP - Non-painful: Functional States
hysteria:
uncommon in young children
mimicry:
likely to occur intermittently or to vary in form
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