Symptoms » Limping » Book Sections

Limp

Clinically it is useful to classify limpas painful or nonpainful and to localize problem to long bones, joints,foot, lumbosacral spine, skin and soft tissues, or neuromuscularsystem.

Principal Causes of Limp

1. Painfullimp
   1. Longbones
      1. Trauma
      2. Sickle cell disease
      3. Osteomyelitis
      4. Neoplasm
   2. Various joints
      1. Trauma
      2. Infection-related arthritis
         1. Bacterialseptic arthritis
         2. Tuberculosis
         3. Lyme disease
         4. Viral arthritis
         5. Fungal arthritis
      3. Reactive arthritis
         1. Acuterheumatic fever
         2. Poststreptococcal arthritis
         3. Arthritis following other bacterialinfections
         4. Arthritis following infection withenteric bacteria
         5. Mycoplasma arthritis
      4. Seronegative spondyloarthropathies
         1. Inflammatorybowel disease
         2. Juvenile ankylosing spondylitis
         3. Psoriatic arthritis
         4. Reiter syndrome
      5. Connective tissue diseases
         1. Henoch-Schönleinpurpura
         2. Juvenile rheumatoid arthritis
         3. Systemic lupus erythematosus
      6. Hematologic disorders
         1. Sicklecell disease
         2. Hemophilia A (Factor VIII deficiency)and B (Factor IX deficiency)
         3. Homozygous beta-thalassemia
   3. Hip
      1. Transient synovitis of the hip
      2. Avascular necrosis of the femoral head(Legg-Calvé-Perthes disease)
      3. Slipped capital femoral epiphysis
   4. Knee
      1. Trauma
      2. Patellofemoral disorders
         1. Patellarfractures
         2. Patellar dislocation and subluxation
         3. Patellofemoral pain syndrome (chondromalaciapatella)
         4. Prepatellar bursitis
         5. Patellar tendonitis
         6. Sinding-Larsen-Johansen syndrome (jumper'sknee)
      3. Baker cyst
      4. Osgood-Schlatter disease
      5. Osteochondritis dissecans
      6. Referred pain from hip disease
   5. Ankle
      1. Trauma
   6. Foot
      1. Trauma
      2. Tight footwear
      3. Foreign body
      4. Ingrown toenail
      5. Osteochondroses
         1. Tarsalnavicular (Kohler disease)
         2. Metatarsal head (Freiberg disease)
         3. Sever disease
      6. Tarsal coalitions
      7. Accessory tarsal navicular bone
      8. Plantar warts
      9. Plantar keratoma
   7. Lumbosacral spine
      1. Herniateddisc
      2. Discitis
   8. Skin and soft tissue (fascia, ligaments,tendons)
      1. Trauma
         1. Contusions
         2. Ligament and tendon injuries
      2. Infection/inflammation
         1. Cellulitis
         2. Abscess
         3. Lymphadenitis
         4. Thrombophlebitis
   9. Neuromuscular system
      1. Trauma
      2. Myositis
      3. Reflex sympathetic dystrophy
      4. Benign limb pain (growing pains)
      5. Neoplasm
2. Nonpainful limp
   1. Long bones
      1. Leg lengthdiscrepancy
      2. Congenital short femur
      3. Coxa vara
   2. Joints
      1. Developmental dysplasia of the hip
      2. Avascular necrosis of the hip
      3. Contractures
   3. Lumbosacral spine
      1. Scoliosis
      2. Scheuermann disease
   4. Neuromuscular system
      1. Braindisorders
      2. Spinal cord disorders
      3. Anterior cell disorders
      4. Peripheral nerve disorders
      5. Neuromuscular junction disorders
      6. Muscle disorders

Clinical Features and Diagnosis

Painful Limp

Long Bones

Trauma

Most commoncause of painful limp involving long bones.

Deformity of extremity or localizedbone tenderness suggests fracture.

Radiograph usually confirms diagnosis.If radiographs are normal and pain persists, bone scan may identifystress fracture.

Sickle Cell Disease

Mild-to-severebone pain secondary to tissue ischemia may occur in tibia and fibula andless often in femur in sickle cell disease.

Diagnosis may be confirmed by Hgb electrophoresis.

Osteomyelitis

An infectionthat involves metaphysis of bone. Infection may occur from directinjury to bone, extension from adjacent focus of infection, or fromblood-borne pathogens.

Femur and tibia are commonly involved,but any bone of lower extremity, pelvis, and spinal column may beaffected.

Most common pathogen is S. aureus,but others include group B Streptococcus (neonates), P. aeruginosa(puncture wounds of heel and foot), Salmonella species (sickle celldisease), and C. albicans (ill newborn and immunocompromised host).

Usual clinical findings are pain andlocalized bone tenderness with or without fever.

Bone aspirate should be performed toconfirm diagnosis and identify specific pathogen. Bone scan maybe useful in suspected cases. Lytic bone lesions and periostealnew bone formation are visible on plain radiographs 10–14days after onset of illness. Blood cultures may yield organism,but bone aspirate cultures are positive in higher percentage ofcases.

Neoplasm

Benign Tumors

Osteochondroma

Usuallypresents as painful or painless hard mass in metaphyses of longbones in children >10 yrs.

Radiographs show bony outgrowth fromcortex that has same trabecular pattern and density as normal bone.

Benign Ossifying Fibroma

Macro- ormicrofractures cause pain in any long bone with this tumor.

Distinctive radiographs show roundradiolucent areas in metaphyseal cortex surrounded by rim of newbone formation.

Osteoid Osteoma

Local bonepain and tenderness of femur or tibia tend to occur at night, andresponse to aspirin is often dramatic.

Characteristic radiograph shows smallnidus of osteoid tissue surrounded by reactive sclerosis.

Bone scintigraphy and CT are usefulif radiographs are negative or equivocal.

Simple Bone Cyst (Unicameral Cyst)

Forms inmetaphysis of long bones, especially proximal femur and distal tibia.Usual presentation is localized pain from pathologic fracture. Fractureheals, but cyst remains. Radiographs show the fracture and a lucencyin the metaphysis with cortical ridges of bone.

Osteoblastoma

Rare tumorthat occurs in older children and adolescents.

Common locations are femur, tibia,and small bones of feet.

There is local pain and occasionalswelling.

Radiographs show radiolucent destructivelesion that expands bone.

Excisional biopsy is diagnostic aswell as therapeutic.

Eosinophilic Granuloma of the Bone (Langerhans Histiocytosis)

Common locationsare femur, vertebrae, and pelvis.

Painful limp and localized swellingmay be noted.

Plain radiographs show lucent lesion.

Histologic diagnosis is definitive.

Malignant Tumors

Osteogenic Sarcoma

Most commonmalignant bone tumor in pediatric population.

Onset is primarily during second decadeof life.

Generally involves metaphyses of longtubular bones, especially distal femur or proximal tibia.

Clinical findings include localizedpain, tenderness, swelling, and palpable firm mass.

Radiographs show bone destruction andproduction, irregular periosteal reaction often with spicules perpendicularto cortex of involved bone, and usually soft tissue mass.

CT and MRI also help define extentof tumor.

Bone scintigraphy is useful to detectany metastatic tumor.

Histologic diagnosis is definitive.

Ewing Sarcoma

Second mostcommon bone cancer in pediatric population, with onset usually insecond decade of life.

Involves diaphysis (shaft) of boneand usually presents with pain and soft tissue mass.

Usual radiographic appearance is lyticdestructive bone lesion with several layers of periosteal reactionand soft tissue mass overlying area of bone destruction.

Diagnosis is confirmed by characteristichistologic features. About 95% of individuals with thistumor have t(11;22) or t(21;22) translocation, which is a usefuldiagnostic marker.

Metastatic Neoplastic Lesions

Acute lymphoblasticleukemia is most common type of childhood leukemia.

Localizedbone pain and tenderness often occur because of bone infarction,expansion of marrow cavity, and infiltration of periosteum. Usualsites of bone destruction are metaphyseal ends of femur and tibia,proximal humerus, and distal radius.

Bone radiographs show osteolytic lesionsof bone cortex and marrow cavity, periosteal new bone formation,demineralization, and transverse metaphyseal radiolucent bands.

Other clinical manifestations includefever, lymphadenopathy, hepatosplenomegaly, leukopenia or leukocytosis,anemia, thrombocytopenia, and lymphoblasts on blood smear.

Bone marrow aspirate or biopsy confirmsdiagnosis.

Besides leukemia, osteogenic sarcoma,and Ewing sarcoma, most common neoplastic lesions that metastasizeto bone are lymphoma, neuroblastoma, rhabdomyosarcoma, Wilms tumor,and retinoblastoma.

Most lesions are osteolytic and often involveproximal metaphyses of long bones of extremities.

Bone scintigraphy demonstrates locationof metastases.

Histologic diagnosis is definitive.

Various Joints

Trauma

May cause joint effusion, subluxation, ordislocation of joint. History, physical exam, and joint radiographsare usually diagnostic.

Infection-Related Arthritis

Bacterial Septic Arthritis

Joint infectiondue to pyogenic infection involves single joint in most cases. Hip, knee,or ankle may be involved.

In neonates, most common pathogensare group B Streptococcus, S. aureus, and gram-negative entericbacteria. H. influenzae type b is much less common since introductionof Haemophilus vaccine.

S. aureus is most common pathogen inchildren >2 yrs through adolescence. Other pathogens inthis age group include group A Streptococcus, S. pneumoniae, N.meningitidis, and Salmonella species.

In adolescents, N. gonorrhoeae maycause migratory polyarthritis, tenosynovitis, and vesicopustularrash.

Characteristic features of septic arthritisare fever and limp or refusal to bear weight and walk. Infants areirritable and do not want leg moved. Painful joint is warm and swollenand motion is limited.

Radiographs may show only soft tissueswelling, but as disease progresses, joint capsule becomes distended.

Aspiration of pus from joint confirmsdiagnosis. Synovial fluid findings are usually as follows:

WBC countis >25,000/mm³ withpredominance of neutrophils.

Glucose is usually <50% ofserum glucose.

Protein is elevated (>2–2.5g/dL).

Mucin clot is poor.

Gram stain shows organism in 75% ofcases.

Bacterial culture is positive in about60% of cases.

Latex agglutination tests of jointfluid and urine may detect bacterial antigens of organisms responsiblefor disease process. Joint fluid and blood cultures are often negativein patients with N. gonorrhoeae septic arthritis; however, cervical,rectal, and pharyngeal cultures are often positive and confirm diagnosis.

Tuberculosis

Althougharthritis is rare with tuberculosis, large weight-bearing jointssometimes are affected.

Onset is insidious with painful limp.

Radiographs of affected joint usuallyshow bone erosion. Joint fluid usually shows WBC count of >50,000/mm³ withpredominance of mononuclear cells. Acid-fast stains of synovialfluid rarely yield organism.

Positive synovial fluid culture orsynovial biopsy is diagnostic. Results of tuberculin skin test areusually positive.

Lyme Disease

Cause isspirochete B. burgdorferi. Transmission is usually by infected tickvectors.

At site of recent tick bite, red maculeor papule forms and develops into larger erythematous lesion callederythema chronicum migrans (usually >5 cm in diameter)in about 70% of cases. Other findings can include fever,headache, and arthralgias.

The diagnosis in early disease, especiallywith the characteristic skin lesion, is clinical.

In late-onset disease, arthritis affectinglarge joints, encephalopathy, and peripheral neuropathy are characteristicfindings. Antibodies against B. burgdorferi may be detected.

Positive or equivocal results fromELISA or immunofluorescence assay can be confirmed by Western immunoblottest.

Viral Arthritis

In rubellainfection, arthritis usually appears after rash and may involveknee, wrist, and hand joints. Arthritis with same distribution alsomay occur 1–3 wks after immunization with rubella vaccine.

Hepatitis B virus may produce transientarthritis in large joints (knee, ankle, wrist) and small joints(hands and feet), which usually occurs before clinical manifestationsof hepatitis. Arthritis generally resolves with appearance of jaundice.Serum positive for hepatitis B surface antigen is diagnostic.

Infection with mumps virus, varicella-zostervirus, Epstein-Barr virus, parvovirus B19, herpesvirus 6, adenoviruses,influenza viruses, enteroviruses, and cytomegalovirus also may causemild arthritis that usually involves large joints.

Fungal Arthritis

C. albicansis most common cause of fungal joint infections, which usually occurin neonate or immunocompromised host.

Synovial WBC count may be low.

Positive synovial fluid culture isdiagnostic.

Reactive Arthritis

Acute Rheumatic Fever

Most commonlypresents with migratory polyarthritis and fever.

According to Jones criteria, presenceof 2 major criteria (arthritis, carditis, erythema marginatum, subcutaneousnodules, chorea) or 1 major and 2 minor criteria (fever, tachycardia,arthralgia, increased sedimentation rate, prolonged PR interval)with recent evidence of streptococcal infection indicates high probabilityof acute rheumatic fever.

Most commonly involved joints includeknee, ankle, elbow, and wrist.

Some children do not have any precedinghistory of pharyngitis.

Poststreptococcal Arthritis

Another poststreptococcal joint syndromethat differs from acute rheumatic fever may occur. Arthropathy tendsto be polyarticular, affecting both small and large joints, andmay persist for many months.

Arthritis following Other Bacterial Infections

Arthritisthat occurs with endocarditis is characteristically polyarticularand symmetric, affecting large and small joints.

Arthritis with invasive pathogens (e.g.,N. meningitidis or H. influenzae type b) may occur during antibiotictherapy or up to a few weeks after antibiotic treatment. In somecases, immune complexes have been found in blood and joint fluid.

Bacterial infection of ventriculoatrialshunts, especially with coagulase-negative staphylococci, may resultin formation of immune complexes and arthritis.

Arthritis following Infection with Enteric Bacteria

Shigella, Salmonella, and Campylobacter speciesor Y. enterocolitica may result in arthritis following infection.

Mycoplasma Arthritis

Pauciarticular, polyarticular, or migratoryarthritis can follow infection with M. pneumoniae.

Seronegative Spondyloarthropathies

Inflammatory Bowel Disease

Arthritismay occur in association with inflammatory bowel disease.

Clinically, joint manifestations ofCrohn disease and ulcerative colitis are indistinguishable. Mostfrequently affected joints are knee, ankle, elbow, and wrist.

Arthritis can precede, follow, or occurwith other manifestations, including abdominal pain, diarrhea, hematochezia,weight loss, fever, and growth failure (see Chap. 14, Diarrhea).

Juvenile Ankylosing Spondylitis

Disorderof unknown cause primarily affecting sacroiliac joints and lesscommonly extrapelvic spine and peripheral joints. Usually occursafter 10 yrs of age and is more common in boys. Strong associationexists with HLA-B27.

Characteristic findings include feverand sacroiliac and lumbosacral pain, with limitation of motion,iritis, and enthesitis. Common areas of inflammation are insertionof Achilles tendon into calcaneus, quadriceps tendon into patella,patellar tendon into patella and tibial tuberosity, and plantarfascia attachments to calcaneus and metatarsal heads.

Results of tests for antinuclear antibody(ANA) and rheumatoid factor (RF) are usually negative.

Unequivocal diagnosis requires radiographicevidence of sacroiliitis, but this finding may not occur until severalyears after onset of the illness.

Psoriatic Arthritis

Occurs infrequentlyin childhood, with average age of onset of about 10 yrs. Most commonlyaffected joints are distal interphalangeal joints of hands and smalljoints of feet.

Sacroiliitis and cervical spine arthritisusually follow peripheral joint disease by months to years. Skinmanifestations often follow arthritis years later. Typical rashconsists of silvery scales surrounded by erythema occurring on face,scalp, and extremities. Nail pitting and ridging also may occur.

Skin biopsy confirms diagnosis.

Reiter Syndrome

Associationof polyarthritis, urethritis, and conjunctivitis.

Usually affects young men and frequentlyoccurs in HLA-B27–positive individuals.

Although cause is unknown, many casesfollow dysentery-like illness (Shigella or Salmonella species, Y.enterocolitica) or sexually-acquired infection.

Often develops over 1–4 wkswith onset of diarrhea or urethritis followed by polyarthritis andconjunctivitis. Arthritis usually affects knees and ankles.

ANA and RF tests are usually negative.

Usually resolves over several months.

Isolates of C. trachomatis have beenrecovered from eye, urethra, and joints of some individuals.

Connective Tissue Diseases

Henoch-Schönlein Purpura

Common formof vasculitis found in pediatric population.

Striking feature is purpuric rash foundon buttocks and lower legs. Although transient arthritis involvingankle, knee, wrist, or elbow joints may occur, more common are arthralgiasinvolving knees, hips, and ankles. Other manifestations includeabdominal pain with occasional GI bleeding and hematuria. Plateletcount is normal.

Diagnosis is usually clinical.

Juvenile Rheumatoid Arthritis

Form ofchronic arthritis that begins before 16 yrs of age. Defined as arthritisin 1 or more joints, persisting for >6 wks in given joint,and absence of other specific diseases that cause or may be associatedwith arthritis.

3 types can be distinguished clinically:systemic onset, polyarticular onset, and pauciarticular onset.

Systemic-onset juvenile rheumatoidarthritis (JRA) is characterized by fever with daily or twice dailytemperature spikes to ≥39.4°C (103°F), lasting 3–4wks and sometimes 6–8 wks. Average age of onset is about6 yrs.

Mayoccur with or without rash or other organ involvement (e.g., hepatosplenomegaly,lymphadenopathy, pericarditis, myocarditis, pneumonitis, or pleuritis).The typical rash is an evanescent, erythematous, macular or papular,nonpruritic rash found on trunk and extremities.

Presence of fever and rash indicatesprobable JRA, but definite arthritis of 6 wks' duration mustoccur before specific diagnosis can be made.

Joints most commonly involved are knee,ankle, carpal, and tarsal joints, but onset of arthritis commonlylags behind other systemic features.

Usual lab findings include leukocytosis,normochromic normocytic anemia, and increased sedimentation rate.Uveitis and positive tests for ANA and RF are rare.

Polyarticular-onset JRA is cumulativearthritis in 5 or more joints that occurs most commonly in girls.

Involves knee,ankle, wrist, and small joints of hands and feet.

Low-grade fever, fatigue, leukocytosis,and mild anemia also may occur. Occurrence of typical rash, lymphadenopathy,hepatosplenomegaly, pleuritis, and pericarditis is less common inthis type compared with systemic-onset type. Chronic uveitis occursin small number of cases.

2 clinical forms of polyarticular-onsetjuvenile arthritis seem to exist based on age and presence of RF.

In seronegative group, onset is commonlyat 1–3 yrs of age. Small and large joints may be affected,and ANA is positive in about 25% of cases. These childrenare at minimal risk for uveitis.

In seropositive group, onset is usuallyin girls at average age of 12. ANA is often positive. Individualswith positive RF who have involvement of many joints often developprogressive erosive disease of these joints.

Pauciarticular-onset JRA is most commontype of JRA in children. Onset can be early (<5 yrs) orlate (>8 yrs).

Up to 4 joints, most commonly knee, ankle,elbow, proximal interphalangeal joint, and carpal joint, are involved.

Other manifestations are low-gradefever and irritability. Hepatosplenomegaly, pericarditis, myocarditis,pneumonitis, anemia, and typical rash are rare.

Girls primarily have early-onset disease,and chronic uveitis is common. Small number eventually develop polyarticularform.

Late-onset disease usually affectsboys, who may develop arthritis of hip, knee, or ankle joints. HLA-B27is usually positive, while RF and ANA are usually negative. Chronicuveitis is much less common compared with early-onset disease. Someindividuals develop juvenile ankylosing spondylitis.

Clue to this diagnosis is decreasedlumbosacral spine mobility.

Systemic Lupus Erythematosus

This chronicmultisystem autoimmune disease usually presents in adolescence andis much more common in girls than in boys. Rare in children <5yrs of age.

Arthritis and typical erythematousrash over malar eminences are common findings. Arthritis usuallyaffects hands, knees, and ankles in symmetric fashion. Other clinicalmanifestations include fever, weight loss, hepatosplenomegaly, pneumonitis,pericarditis, and seizures.

Lab findings include leukopenia, thrombocytopenia,hemolytic anemia, hematuria, proteinuria, increased sedimentationrate, and low serum C3.

ANA is frequently positive at onsetand eventually becomes positive in >95% of individuals. Antibodyto double-stranded DNA is confirmatory.

Hematologic Disorders

Sickle Cell Disease

During sicklecell pain episode, bone infarction may produce localized swellingand tenderness, especially in lower extremities. In infancy, symmetricdiffuse swelling and pain in hands or feet is called sickle celldactylitis or hand-foot syndrome. Arthritis with effusion may occurin knee or ankle.

Another complication of sickle celldisease is septic arthritis, with hip and knee joints most commonlyaffected. Most common pathogens are S. pneumoniae, S. aureus, andSalmonella species.

Avascular necrosis of femoral headmay develop during second decade of life. Presenting findings arehip pain and limp with limitation of hip joint movement. Plain radiographsof hip are diagnostic.

Hemophilia A (Factor VIII Deficiency) and B (Factor IX Deficiency)

Spontaneousbleeding into knee, ankle, and elbow joints is common with factorVIII and IX deficiencies.

There is usually pain, swelling, tenderness,and limitation of joint motion.

Decreased serum concentration of factorVIII or IX confirms diagnosis.

Homozygous Beta-Thalassemia

Episodesof joint pain, swelling, and effusion may occur.

Quantitative Hgb electrophoresis isdiagnostic.

Hip

Transient Synovitis of Hip

Most commoncause of nontraumatic painful limp in childhood. Occurs most oftenin children 3–6 yrs of age and is always unilateral. Causeis unknown, although viral infection often precedes onset of illness,which may manifest itself by hip or knee pain, limp, or difficultywalking.

Fever is variable finding. Hip is usuallyin flexed position, with decreased internal rotation and abduction.Log-roll sign is usually positive. WBC count and sedimentation rateare normal or mildly increased.

Radiographs of hip can be normal orshow minimal widening of joint space from effusion.

If any suspicion exists that pyogenicarthritis is present, arthrocentesis should be performed.

Transient synovitis is self-limitedillness, which usually resolves within 1–2 wks.

Avascular Necrosis of Femoral Head (Legg-Calvé-PerthesDisease)

This disorderof unknown cause occurs most commonly in boys 2–12 yrsof age. Usually unilateral but can be bilateral.

Onset is generally insidious with appearanceof limp.

Pain usually occurs in hip but maybe referred to knee. Exam of hip reveals limitation of motion, particularlyabduction and internal rotation.

Radiographic findings depend on extentof involvement and on stage of disease. First specific change issubchondral fissure fracture in anterolateral epiphysis. Increasedbone density of femoral epiphysis and a difference in size of the2 capital femoral epiphyses also may be seen. Dead bone resorptionand new bone formation produce fragmented appearance of epiphysis.

Early on, MRI can reveal diagnosisbefore plain radiographs demonstrate any change.

Slipped Capital Femoral Epiphysis

Epiphysealgrowth plate fracture involving proximal femur.

Cause is unknown, although in somecases history of trauma exists.

Occurs most commonly in adolescenceand can affect both hips.

Hip or knee pain and limp are usualpresenting features. Exam reveals restricted hip motion, and legis usually held in external rotation and abduction.

Radiographs of hip show slippage ofcapital femoral epiphysis off the metaphysis.

Knee

Trauma

Knee injuriesin school-aged children are different from those in adolescentsand older athletes.

In younger age group, epiphyseal fracturesare more likely to occur because of open growth plates, and radiographyof knee should be performed.

In older age group, epiphyseal plateshave closed, and significant trauma is most likely to cause tornmeniscus or ruptured collateral or cruciate ligament.

Type of injury and knee exam suggestpresence of ligament or meniscal tears. Arthroscopy is procedureof choice to diagnose ligament or meniscal damage.

Patellofemoral Disorders

Patellar Fractures

Producepain, tenderness, swelling, and decreased range of motion.

Radiograph of patella is diagnostic.

Patellar Dislocation and Subluxation

Dislocationof patella is more common in girls than boys and has peak incidencein adolescence.

There is intense pain, and a poppingsound may have been heard.

Patella appears in more lateral positionthan normal.

Radiographs of knee with tangentialviews are diagnostic.

History consistent with dislocationbut with subsequent absence of pain and normal exam suggest subluxation.

Patellofemoral Pain Syndrome (Chondromalacia Patella)

Clinicalsyndrome of uncertain cause. Produces ill-defined aching knee pain.

Commonly occurs in athletes.

Pain is usually parapatellar in locationand worsens with activities that require quadriceps use (e.g., walkingup stairs, squatting, jumping, and running). Compression of patellaagainst distal femur with knee in extension with simultaneous contractionof quadriceps muscle usually produces pain as well as crepitus.

Plain radiographs are usually normal.

Diagnosis is clinical.

Prepatellar Bursitis

Acute or chronic trauma produces inflammationof bursa that overlies patella. Sometimes bursa becomes infected(septic bursitis) and needle aspiration needs to be performed fordiagnosis.

Patellar Tendonitis

Usually occurs during growth spurt, and patellartendon is tender. Plain radiographs are usually normal.

Sinding-Larsen-Johansson Syndrome (Jumper's Knee)

Common in individuals involved with jumpingactivities. Patellar tendon is tender at its insertion into inferiorborder of patella.

Baker Cyst

Palpable on medial side of popliteal fossa,and enlargement can produce pain and swelling.

Osgood-Schlatter Disease

Most commonin preadolescent boys.

Repeated minor trauma produces tendernessand swelling of patellar tendon and enlargement of tibial tubercleof 1 or both knees.

Pain worsens with activity and improveswith rest.

Diagnosis is almost always clinical.

Osteochondritis Dissecans

Microtraumais thought to play role in this disorder in which cartilage andsegment of bone separate from surrounding bone and ligaments.

There is history of knee pain and limpor knee giving way and locking. Medial femoral condyle is usuallyinvolved and is tender.

Diagnostic radiograph shows rarefactionof articular surface of femoral condyle and detached osteochondralfragment in joint.

Referred Pain from Hip Disease

Hip disorders that often cause referred kneepain are transient synovitis, septic arthritis, slipped capitalfemoral epiphysis, and Legg-Calvé-Perthes disease (seeprevious section).

Ankle

Trauma

Ankle sprains,contusions, and epiphyseal fractures of distal tibia or fibula occursecondary to trauma.

The ankle is swollen and painful.

Radiographs usually distinguish fracturesfrom other injuries.

When in doubt, severe sprain shouldbe treated initially as fracture.

In some cases, follow-up radiographsmay reveal fracture.

Foot

Trauma

Any contusion,sprain, or fracture may cause pain and limp.

If fracture is suspected, radiographyshould be performed.

With stress fractures, plain radiographsmay initially show only soft tissue swelling; however, bone scanshows increased uptake and may be diagnostic early in the course.

Callus formation may be seen in a fewweeks.

Tight Footwear

Tight, stiff, or small shoes may producefoot pain and limp. Redness, tenderness, and blisters are commonindications that this is the problem.

Foreign Body

Foreignmaterial embedded in foot tissue, which may not be visible, maycause pain and localized swelling.

Radiograph shows only radiodense ormetallic objects.

With wood or nonradiopaque glass, onlysoft-tissue swelling may be visible.

Ingrown Toenail

Penetrationof soft tissue of toe by edge of improperly trimmed nail can causelocal infection with redness, tenderness, swelling, and pus.

Recurrent ingrown toenails may indicatepresence of subungual exostosis. Radiograph of toe is diagnostic.

Osteochondroses

Tarsal Navicular (Köhler Disease)

Avascularnecrosis of tarsal navicular bone (Köhler disease) usuallyoccurs in children 3–6 yrs of age and is more common inboys.

Pain occurs in medial arch on bearingweight, and exam reveals tenderness of tarsal navicular bone.

Radiographs show flattening, sclerosis,and sometimes fragmentation of bone.

Metatarsal Head (Freiberg Disease)

Avascularnecrosis of metatarsal head (Freiberg disease), usually involvessecond metatarsal and produces pain on weight bearing and tendernessto palpation.

Most common in adolescent girls, especiallyballet dancers.

Radiographs show increased densityand fragmentation of affected metatarsal head.

Sever Disease

Inflammationof apophysis of calcaneus at site of insertion of Achilles tendon.

Usually occurs in boys 6–12yrs of age.

Pain, tenderness, and swelling occurover back of heel.

Radiographs show increased densityand fragmentation of calcaneal apophysis.

Tarsal Coalitions

Union between2 or more tarsal bones that may cause painful, stiff flatfoot.

Calcaneonavicular and talocalcanealcoalitions are most common, whereas talonavicular and calcaneocuboidcoalitions are less common.

Pain is gradual in onset and usuallylocalized to lateral aspect of ankle. Foot is flat whether standingor sitting in contrast to flexible flatfoot.

Radiographs are usually diagnostic,but CT may be necessary, especially to demonstrate underlying talocalcanealcoalition.

Accessory Tarsal Navicular Bone

May be asymptomaticor cause pain and swelling of medial aspect of foot just above arch.

Radiographs are diagnostic after 5or 6 yrs of age when they show small ossification centers posteromedialto normal tarsal navicular bone.

Plantar Warts

Single ormultiple viral papillomas that are usually painful with weight bearing.

Pinpoint black centers indicative oflocal thrombosis provide important diagnostic clue.

Plantar Keratoma

Areas of hypertrophic skin found over weight-bearingportions of foot that can cause mild pain. Calluses are avascularwith clear center, which distinguishes them from plantar warts.

Lumbosacral Spine

Herniated disc and discitis are discussedin Chap. 5, Back Pain.

Skin and Soft Tissue (Fascia, Ligaments, Tendons)

Trauma

Contusions

Bruises are most common musculoskeletal injuriesin children. Usually occur on lower legs and may give rise to limp.

Ligament and Tendon Injuries

Seriousligament and tendon injuries are more common in adolescents whenepiphyseal plates have closed. Sprain refers to ligament injury,whereas strain refers to tendon or muscle–tendon unit injury.

In grade I sprain or strain, mild localtenderness and swelling occur, but joint is stable and muscle strengthis normal.

In grade II injury, there is near-completetear of ligament or tendon with more tenderness and swelling thangrade I, some joint laxity and muscle weakness, and difficulty inambulation.

In grade III injury, complete ruptureof ligament or tendon occurs with severe pain, tenderness, and swelling;joint instability and effusion; and inability to bear weight. Tendonrupture causes tenderness, severe spasm of involved muscle, andinability of muscle to produce its usual effect.

Infection/Inflammation

Cellulitis

Infectionof skin and subcutaneous tissues that is characterized by erythema,warmth, tenderness, and swelling.

Most common pathogens are S. aureusand group A Streptococcus.

Fever is variable finding.

Previous wounds or insect bites arecommon predisposing factors.

Culture from leading edge of cellulitismay reveal pathogen.

Abscess

Presence of fluctuance often follows cellulitisand indicates abscess. Needle aspiration reveals pus, and positivebacterial culture is diagnostic. Most common pathogen is S. aureus.

Lymphadenitis

Swollen,tender lymph nodes, especially in inguinal or femoral regions, maycause pain and limp.

Usual pathogens are S. aureus and groupA Streptococcus.

Primary source is usually break inskin from scratch, puncture, bite, or laceration.

Thrombophlebitis

Inflammationof superficial or deep veins of leg.

Aching and swelling localized to knotor bump on leg occurs with superficial thrombosis, but thrombi insuperficial veins rarely if ever cause pulmonary emboli.

Thrombophlebitis of deep veins predisposesto deep vein thrombosis (DVT), which is risk factor for pulmonaryemboli. DVT usually produces aching thigh or calf pain, tenderness,and swelling. U/S with Doppler methods is usually diagnostic.

Neuromuscular System

Trauma

Muscle strain,contusions, or peripheral nerve injury may result from trauma toneuromuscular system.

History and physical exam are diagnostic.

Myositis

Muscle pain and tenderness occur in postinfectiousmyositis, which is most commonly due to influenza viral infection.Limp also may occur with dermatomyositis or polymyositis becauseof leg weakness (see Chap. 33,Hypotonia and Weakness).

Reflex Sympathetic Dystrophy

Onset ofthis syndrome of unknown cause is in childhood or adolescence.

Exquisite pain out of proportion toand lasting longer than expected pain is 1 of the hallmarks. Associatedfindings include tenderness, swelling, evidence of autonomic dysfunction(coolness, mottling, increased sweating), and refusal to move limb.

Diagnosis is clinical.

Benign Limb Pain (Growing Pains)

So-calledgrowing pains occur in school-aged children and adolescents andinvolve lower limbs.

Pain is thought to arise from muscleoveruse in active individuals.

Usually occurs in thighs and lowerlegs, particularly in evenings or during nights, sometimes awakeningchild from sleep. May last up to several hours but usually respondsto local heat, massage, or analgesics. Children are asymptomaticnext morning.

Neoplasm

Soft tissuetumors of lower extremity (primarily rhabdomyosarcoma) usually present aspainful or nonpainful mass.

Plain radiographs and MRI define locationand extent of mass. Histologic diagnosis is definitive.

Tumors affecting spinal cord also maybe associated with pain and limp (see Chap.5, Back Pain).

Nonpainful Limp

Long Bones

Leg Length Discrepancy

Discrepancyin length of legs may cause limp.

Common causes of leg length discrepancyinclude avascular necrosis of femoral head, coxa vara, growth plateinjury from previous trauma or infection, metabolic bone disease,neoplasia, and idiopathic.

Leg lengths should be measured fromanterior superior iliac spine to sole of foot.

Congenital Short Femur

Radiographs of extremities with measurementof femurs confirm diagnosis of congenital short femur.

Coxa Vara

At maturitynormal angle between neck and shaft of femur is 150 degrees. Coxavara occurs when this angle is <120 degrees.

Developmental coxa vara is due to endochondralossification defect in femoral neck.

Shortening of limb, limited externalrotation, and decreased abduction of affected hip occur.

Hip and extremity radiographs are diagnostic.

Joints

In addition to developmental dysplasia andcontractures, avascular necrosis of hip can cause limp.

Developmental Dysplasia of Hip

Presentationof developmental dysplasia of hip varies with age. Up until 6 wksof age, Ortolani and Barlow tests may be performed to demonstratehip instability or dislocation.

Ortolani maneuver is useful to detectdislocated hips in resting position. With hips flexed to 90 degrees,affected hip is moved into abduction and head of femur will relocatewith a clunk into acetabulum.

Barlow test detects hips that may bedislocated, but in resting position they are reduced. With hipsflexed to 90 degrees and in abduction, they are brought to midlineand femoral head dislocates.

Plain radiographs can be normal eventhough exam is abnormal. In this circumstance, U/S candelineate relationship of femoral head to acetabulum. Between 6wks and 1 yr of age, most reliable indication of hip dislocationis limitation of hip abduction. Radiographs can be diagnostic, butif diagnosis is uncertain, U/S should be performed.

After 1 yr of age, affected infantswho are walking may have limp. There is usually asymmetry of thighfolds and limitation of hip abduction. Plain radiographs are usuallydiagnostic. Otherwise, U/S or MRI can show relationshipof femoral head to acetabulum.

Contractures

May cause painless limp. Usually obviouson physical exam with limitation of motion of hip, knee, or anklejoint.

Lumbosacral Spine

Scoliosis

Lateralcurvature of spine >10 degrees that is usually lumbar orthoracic. Possible causes include congenital (hemivertebra, congenitalbar, or block vertebra), traumatic, postsurgical, neuromuscular(most frequently seen with cerebral palsy), and idiopathic.

Early diagnosis is important so thatdevelopment of severe curve can be prevented.

In Bend test, which is designed torecognize rotation of spine, children face away from physician,put their hands together as if diving, and bend over to touch theirtoes. Physician looks in straight line from buttocks to nape ofneck. Hump on side of convexity of curve indicates curvature ofspine, and most common type is right thoracic single curve.

Standing scoliosis radiographic seriesshould be performed.

Scheuermann Disease

Exaggerationof normal posterior convex curvature of thoracic spine associatedwith wedging of vertebrae characterizes this disorder of unknowncause, which is found mainly in adolescent boys.

Spine radiographs are diagnostic. See Chap. 5, Back Pain.

Neuromuscular System

Disorders of brain, spinal cord, anteriorhorn cell, peripheral nerve, neuromuscular junction, and musclemay be associated with painless limp and are discussed in Chap. 33, Hypotonia and Weakness.

Diagnostic Approach

Limp isnever normal finding.

Age of child and whether limp is painfulor nonpainful are useful in diagnosis. Localization of pain to particularanatomic structures narrows diagnostic possibilities. History andphysical exam along with appropriate radiographs are diagnosticin many cases.

For trauma, plain radiographs can beperformed and are useful to diagnose fractures. If there is traumainvolving joints, MRI is useful to visualize any alteration in normalanatomy.

In children with arthritis, importantdiagnostic information is presence of fever, duration (acute orchronic), and number of involved joints. Most useful screening testsare CBC with differential, sedimentation rate, and radiographs ofjoints.

With suspected pyogenic arthritis,arthrocentesis should be performed. Tests for ANA, RF, C3, and HLA-B27are useful with chronic arthritis. Arthroscopy may be helpful withrecurrent or chronic effusion. MRI is useful to image all jointcomponents.

Tumor may be suggested by localizedpain and soft tissue mass. Useful tests are plain radiographs followedby CT or MRI. Bone scan can help identify location of metastaticlesions. Histologic diagnosis is definitive.

References

1. Arndt CA, Crist, WM. Common musculoskeletaltumors of childhood and adolescence. N Engl J Med 1999;341:342–352.
2. Behrman RE, et al., eds. Nelson textbook of pediatrics,16th ed. Philadelphia: WB Saunders, 2000.
3. Cassidy JT, Petty RE, eds. Textbook of pediatric rheumatology,4th ed. Philadelphia: WB Saunders, 2001.
4. Crawford AH, Bagamery N. Handbook of pediatric orthopaedics,3rd ed. Cincinnati: Children's Hospital Medical Center,1996.
5. Fleisher GR, Ludwig S, eds. Textbook of pediatric emergencymedicine, 4th ed. Philadelphia: Lippincott Williams & Wilkins,2000.
6. McIntire SC, Farrell JD. The limping child. In: GartnerJC Jr, Zitelli BJ, eds. Common and chronic symptoms in pediatrics.St. Louis: Mosby-Year Book, 1997:63–79.
7. Rudolph AM, ed. Rudolph's pediatrics, 20thed. Stamford, CT: Appleton & Lange, 1996.
8. Scoles PV. Pediatric orthopedics in clinical practice,2nd ed. Chicago: Year Book Medical, 1988.

>'>>'>

Book Source Details

• Book Title: The Diagnostic Approach to Symptoms and Signs in Pediatrics
• Author(s): Paul S. Bellet
• Year of Publication: 2006
• Copyright Details: The Diagnostic Approach to Symptoms and Signs in Pediatrics, Copyright © 2006 Lippincott Williams & Wilkins.

Other Book Chapters Related to Limping

Read excerpts from these other book chapters related to Limping:

Copyright Details: The Diagnostic Approach to Symptoms and Signs in Pediatrics, Copyright © 2008 Williams & Wilkins.

More About Causes of Limping

• Back to symptom: Limping: Introduction (review 64 causes)
• Next Book Extract About Limping: Videos relating to Limping
• All Book Extracts: All Online Book Extracts for Limping

---

More About This Book: Title: The Diagnostic Approach to Symptoms and Signs in Pediatrics Authors: Paul S. Bellet Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 0-78172-899-1

 » Next page: Videos relating to Limping

Rate This Website

What do you think about the features of this website? Take our user survey and have your say:

Website User Survey

Medical Tools & Articles:

Next articles:

• Videos relating to Limping
• Diagnosis Checklist for Limping
• Symptom combinations for Limping
• Common causes of Limping
• Diagnostic tests for Limping

Tools & Services:

• Bookmark this page
• Take a survey relating to Limping
• Symptom Search
• Symptom Checker
• Medical Dictionary
• Give your feedback

Medical Articles:

• Disease & Treatments Search
• Misdiagnosis Center
• Full list of interesting articles

Forums & Message Boards

• Ask or answer a question at the Boards:
• I cannot get a diagnosis. Please help.
• Tell us your medical story.
• Share your misdiagnosis story.
• What is the best treatment for my condition?
• See all the Boards.

homepage | back to top

Common Health Mistakes

Choose ... Alzheimers & Dementia Asthma Child ADHD ADHD in Adults Allergy Hypertension Bipolar Breast Cancer Celiac Disease Crohns Disease Colon Cancer Contraception Diabetes Cancer Depression Erectile Disorder Cholesterol COPD GERD Heartburn/Reflux Metabolic Syndrome Migraine/Headache Multiple Sclerosis Obesity Osteoporosis Overactive Bladder Psoriasis Sexual Disorder Sleep Disorders Smoking The Pill Ulcerative Colitis All Common Mistakes

Symptom
Checker

Choose... Fever Rash Pain Headache Fatigue Cough Other symptoms

Search Specialists by State and City

Choose... GENERAL PRACTICE CARDIAC HEALTH WOMEN'S HEALTH CANCER CARE RADIOLOGY MENTAL HEALTH PATHOLOGY EAR, NOSE, THROAT MEDICINE GENETICS NEUROLOGY DIALYSIS CARE SURGERY ORTHOPEDICS/SPORTS MEDICINE CHILDREN'S HEALTH OTHER SPECIALTIES