Paediatric Limping Gait

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Introduction

"A limp is defined as any deviation from a normal gait pattern for the child’s age ... The causes of limping are numerous, ranging from trivial to life-threatening conditions. The limping child is often a diagnostic enigma. The challenge is to make an appropriate diagnosis in a timely fashion without exposing the child to unnecessary diagnostic studies." -Leung and Lemay 2004

Limping gait is not typical in the paediatric population. Trauma is the most common cause of limping in children. Examples can include contusion, sprain and strain. Fortunately the majority of paediatric limping cases are patient self-limiting and do not require immediate medical interventions. However, there are medical conditions where limiping gait is a sign of an emergency condition and can be life-threatening.. Therefore, it is important for the rehabilitation professional to be able to differentiate between potential diagnoses and know when to refer to medical colleagues.

Limping Gait Differential Diagnosis

ADD flowchart from video

The above flowchart was presented by Palisano et al as a way to help determine the proper course of treatment and diagnosis based on symptom presentation. This flowchart can also be helpful to determine when a medical referral is indicated.

Criteria and flowchart determinants include:

• presence of pain with joint motion or associated long bone palpation
• history of trauma
• fever
• neurological examination results

Continue reading below for more information on diagnoses commonly seen in clinical practice.

Clinical Spotlight: "growing pains"

And then lastly, here's another one that's really helpful for thinking about, is this just growing pains? So sometimes you'll hear, oh, it's not a big deal, it's just growing pains. So you want to first ask them about the nature of their pain, if it's intermittent, if it's there some days, it's not there some days, it's only a half an hour up to two hours. They have totally pain-free episodes in between. That's more growing pains. If their pain is persistent, increases with severity. That's less likely to be growing pains. Growing pains are often bilateral. Often we'll see them at the anterior thigh, the calf, popliteal fossa, the shins. If children are reporting this unilateral pain or pain in their joints, that's less likely to be growing pains. If the time of day is evenings and nights a lot of times that's growing pains. If you have night pain that remains in the morning, persistent pain all day long, less likely to be growing pains. If their physical exam, diagnostic tests, activity limitations are all normal and they don't have any limitations, more likely to be growing pains. If they have inflammation, if there's findings on x-rays, if they have reduced physical activity, you want to dig a little deeper.

Gait Observation

There are three major factors of paediatric limping gait (1) pain, (2) weakness, and (3)structural or mechanical abnormalities of the spine, pelvis, and lower extremities. It is important for the rehabilitation professional to understand a typical gait pattern and childhood development in order to identify abnormal movement patterns for gait differential diagnosis. Please review the following articles as needed:

• Gait cycle
• Gait deviations
• Gait development

The identification of an abnormal gait pattern may be helpful in identifying the etiology of the limping gait. Table 1.0 provides examples of observational gait differential diagnosis.

Table 1.0 Observational gait analysis for limping differential diagnosis

Gait Pattern	Description/Clinical Observations	Common Causes
Antalgic gait	Shortened stance phase on the painful limb resulting in an increased swing phase on the other limb. tenderness decreased range of motion	Trauma Infection
Trendelenburg gait	Downward pelvic tilt during the swing phase away from the involved hip	Weakness of the contralateral gluteus medius muscle developmental dysplasia of the hip Legg-Calvé-Perthes disease Slipped capital femoral epiphysis Bilateral involvement results in waddling gait
Lurching gait (posterior lurching gait, abductor lurch)	Posterior trunk lean with a hyperextended hip seen at loading response during stance	Weakness of gluteus maximus muscle developmental dysplasia of the hip Cerebral palsy
Steppage (equinus) gait	Exaggerated hip and knee flexion during swing phase secondary to lacking active dorsiflexion of the foot	Heel-cord contracture Neuromuscular diseases such as cerebral palsy Idiopathic toe walker Clubfoot *** neurological examination indicated ***
Vaulting gait	Weight-bearing knee locked in hyperextension at the end of the stance phase requiring the child to "vault" over the stance extremity	Leg length discrepancy (inequality) Abnormal knee mobility
Circumduction gait	The involved limb is moved in a semi-circular movement utilising a combination of hip hiking, forward rotation of the pelvis, and abduction of the hip in order to clear the swinging limb over the ground	Painful foot Leg length discrepancy (inequality) *** neurological examination indicated ***
Stooped gait	Bilateral hip flexion throughout gait cycle	pelvic or lower abdominal pain

Infection

Key clinical indication: fever

Transient Synovitis

"Transient synovitis is an acute, non-specific, inflammatory process affecting the joint synovium."

• common cause of hip and leg pain in children
• inflammation and pain tends to be short-term
• condition is benign and can make mobility self-limiting
• most common in children under the age of 10 years old

Clinical signs: fever without elevated leukocytes seen in white blood cell count (WBC)

Potential rehabilitation examination findings:

• mild range of motion limitations of hip abduction and internal rotation,
• position of comfort hip in a flexed, abducted, and externally rotated position
• provocative testing includes performing a basic log roll or the Patrick (FABER) test

Aetiology:

• exact aetiology is unknown
• in the paediatric population, it is common to have a history of recent upper respiratory tract infection, pharyngitis, bronchitis, or otitis media
• other potential etiologies include: recent traumatic injury or viral symptoms to include vomiting, diarrhea, or common cold symptoms

Intervention:

• inflammation typically resolves on its own within seven days to two weeks
• role of rehabilitation:
  • energy conservation and activity limitation/modification
  • stretching
  • pain management (however typically self-resolving within 24-48 hours)

Septic Arthritis

"Septic arthritis is joint inflammation secondary to an infectious etiology, usually bacterial, but occasionally fungal, mycobacterial, viral, or other uncommon pathogens."

• knee and hip joints commonly effected in children
• it is usually monoarticular (involving one large joint such as the hip or knee) but can be polyarticular (involving multiple or smaller joints)
• While uncommon, septic arthritis can pose an orthopedic emergency that can cause significant joint damage. In these cases early diagnosis and treatment are critical for preserving joint function.
• most common in children under the age of 5 years old

Clinical signs: fever with elevated leukocytes in a WBC, resistance to move the affected joint, joint pain, joint warmth, and significant swelling of the involved joint

Potential rehabilitation examination findings:

• Limited joint range of motion is limited
• Painful oint palpation

Aetiology:

• most often caused by a bacterial organism in children
• can occur after a foreign object penetrates a joint

Intervention:

• Joint aspiration (draining)
• Antibiotics management
• Severe cases may require joint immobilisation up to 3 days
• Proper medical treatment resolves symptoms within a week, however the patient should return for medical reassessment if no improvement is seen within 5-6 days
• Role of rehabilitation:
  • If symptoms are first noted in the therapy clinic, refer to doctor or emergency room right away as can be a medical emergency
  • regaining range of motion
  • improving weight bearing tolerance and ability
  • gait training

Osteomyelitis

Osteomyelitis. So this is when you actually have an infection of the bone that can be caused by bacteria. Sometimes it's by viruses, fungal infections, parasitic infections, but most of the time bacterial infections. A lot of times you'll see this with staph infections. Most common in the knee for our children. And it's a lot of times seen at the distal femur, proximal tibia, and often in children under three years of age. A lot of times it's associated with a bloodborne infection. And what you want to look for is localised bone tenderness, high fever and chills, elevated leukocytes, elevated ESR, (erythrocyte sedimentation rate) elevated CRP, (C-reactive protein) significant swelling of the joint, and reluctance to weight bear.

This requires, again, immediate referral and medical intervention because that abscesses is likely going to need drained and they will need antibiotics.

This can take a little longer to resolve, so maybe two months if they have good medical management and we're going to be helping them with, again, gaining or maintaining range of motion, and working on their gait training and weight-bearing activities when they're cleared to do so.

So here are some nice little criteria that can help you differentiate between osteomyelitis and septic arthritis. So, septic arthritis, you know, really high fever. With both of them you'll often have that kind of, they just feel cruddy. That malaise. If you have that swollen joint and limited range of motion, that's pretty much always present with septic arthritis and it might be present with osteomyelitis. So this, you know, you're looking at the swollen joint, limited range of motion. Not all the time with osteomyelitis, but you are going to have that oedema over where that bone is infected. And then with the septic arthritis, you're having that swollen joint almost always, but it's not really like there's oedema overlying the bone. Back pain is really concerning for spinal osteomyelitis and very uncommon with septic arthritis and really difficulty weight bearing in the lower limb if that's the area that's affected, you're going to see on both sides.

Special topic: Kocher criteria

There are a wide variety of etiologies for acute limping in children; however, our study and previous literature show that most of these diseases are self-limited and do not require costly procedures and long-term hospitalization, but this should not lead to disregard for infection as a differential diagnosis. It seems that Kocher criteria are useful to be applied for differentiating between infection and other etiologies the disorder. In summary, in children with acute limping aged between 3 to 9 years old, with no fever, with weight-bearing capacity, and a good gen- eral condition, transient synovitis can be definitely considered the etiology and this conclusive diagnosis would simply prevent using costly and additional diagnostic measures. It is strongly recommended to perform prospective studies with larger sample size and a more structured questionnaire to cover all possibilities for acute limping and their related factors in children.

Vascular Causes

Next we have vascular conditions and mechanical failures. So these are children who are limping. Don't have a fever or a history of traumatic event. We're particularly talking about Legg-Calvé-Perthes and the slipped capital femoral epiphysis, also referred to as SCFEs.

Legg-Calvé-Perthes

So with Legg-Calvé-Perthes, really what we're looking at is that there's an interruption to the blood flow to the femoral head. So what happens is it's this idiopathic avascular necrosis of the proximal femoral epiphysis that's caused by vascular compromise typically from this medial femoral circumflex artery. So we're talking about this artery that kind of rolls in through here and goes up and supplies everything in the femoral head.

This can affect epiphyseal growth, so it can affect our bone growth. It's most common in children between four and eight years old. And risk factors include low socioeconomic status, dietary issues, so these both could be linked to diet if you have that low socioeconomic status, secondhand smoke exposure, perinatal HIV (human immunodeficiency virus) infection, and male gender. Males are four to five times more likely to present with Legg-Calvé-Perthes.

Clinical signs. No fever, no swelling, no traumatic event. All of a sudden, they'll start to have a limp. They'll have this antalgic gait, shortened stance time on the affected side, we'll often see that Trendelenburg hip drop gait. Pain will often be activity related, often relieved with rest. There will be limitations in hip abduction and medial rotation. So we're looking at reduction in hip abduction and internal or medial rotation ranges of motion. They may also report pain in their groin, medial hip, the greater trochanter or the anterior medial thigh and knee.

So this can be staged out. So for Legg-Calvé-Perthes, there's four stages.

So stage one is the initial stage. This stage can last about six months. So this is when the femoral head starts to slide more lateral, and there's a widening of the medial joint space and decreased size in the ossification centre. You'll also find that there could be subchondral fractures, and you're going to see that the physes can start to be a little irregular.

In stage two, which can last around eight months. The epiphysis is often fragmented. The contour of the acetabulum becomes irregular. New bone is actually starting to get deposited at the tail end of this stage in the subchondral sections of the femoral head.

But really you're going to see in this stage three reossification stage, that's when a lot of that new bone formation is actually seen on the femoral head, and this stage can last up to 52 months.

And then stage four is the residual stage, and this is when the femoral head is fully reossified and there's gradual remodelling of the head shape throughout skeletal maturity. It's still not what a typical femoral head should look like.

Interventions for this will really depend on the age and the stage at which it's identified. Up to 60% of individuals won't require interventions. If you do, these can be a lot of different types, so on the medical side, it can involve surgery, like a femoral osteotomy, an innominate osteotomy, or a shelf arthroplasty. So really a lot of these surgeries are with best outcomes in patients who are over eight years old and have at least 50% of the lateral pillar height. If less is maintained surgical intervention is still possible, but the outcomes are really not so great either way. They can also use NSAIDs, so those non-steroidal anti-inflammatories, limit activity, and potentially have light skeletal traction that they apply to create increased space and reduce the pressure on that hip joint that femoral head.

For us in physical therapy, our big thing is preventing deformation of the femoral head. A lot of times bracing can be used and really what it does is it abducts the leg out to 45 degrees, and this allows the femoral head to be contained within the acetabulum the most efficiently, and you stay there until subchondral reossification is visible on radiographs. Bedrest, traction, reduced weight-bearing status can be used. Oftentimes non-weight bearing with this orthosis is what's used in very severe cases. We also want to make sure that we're preserving hip range of motion. So for this, some things that you want to make sure you're avoiding are impinging the lateral aspect of the femoral head on the acetabulum during abduction of the hip. And you want to make sure you're strengthening the glute med working on balance and gait.

Slipped Capital Femoral Epiphysis (SCFE)

Next we have the slipped capital femoral epiphysis, also referred to as the SCFE. So the SCFE is when you have the growth plate of the proximal femoral epiphysis become weak. And what happens is there's a displacement or a slip between the femoral head and the femoral neck.

This is the most common in children who are 10 to 15 years old. Often these are with children that are overweight or obese, and have a male gender, but can be associated with certain genetic predispositions.

Clinical signs that you're going to look for with the SCFE are that if it's an acute slipped capital femoral epiphysis, this happens with a lot of times a fall or a twisting injury, but it's usually not a huge, horrible traumatic fall. It's something usually a lot milder, and what they'll say is they have severe pain in their groin, thigh, or sometimes they'll even report knee pain. They're unable to bear weight on that side. Their position of comfort will be external rotation, and they'll kind of shorten that affected limb.

In chronic, slipped capital femoral epiphysis, which is the most frequent kind. What you'll find is they report this kind of few month history of vague groin or upper or lower thigh pain. No fever, no swelling, but they do have loss of range of motion, particularly into hip internal rotation, flexion, and abduction. A lot of times we'll see weak glute meds. They'll have decreased femoral anteversion, an antalgic gait, and the affected limb is generally positioned in that external and shortened position as that position of comfort.

You can also have acute on chronic, so this is where they've had vague pain for a while and then there's a sudden exacerbation in their pain.

If a SCFE is suspected in your clinic, you want to reduce weight bearing and impact activities and get them to the physician as soon as possible.

This can be diagnosed with radiographs. Radiographs will often reveal a widening of the growth plate. Decreased density of the metaphysis and a severe SCFE can be graded onto as far as how far it's displaced. Medically to intervene we're talking about decreasing the displacement, maintaining range of motion, and preventing degenerative arthritis that would happen prematurely. These are often stabilised with pinning. Sometimes you can do a hip spica cast instead with immobilisation and stabilisation, but most of the time we're talking about stabilisation with pins and screws or femoral osteotomy. So if it's an unstable or acute SCFE, they're going to go in and do an open reduction and pin, and they're going to try to maintain the appropriate position of that femoral head and neck. This early decompression is really important because it reduces the risk of avascular necrosis developing. And children are non-weight-bearing after this procedure. If it's a stable SCFE, they can do in-situ or percutaneous pinning, so it's a little less invasive. And a lot of times this is weight bearing as tolerated. In our hospital it's really common to see that if one hip has gone and they have a SCFE, the other has a really high risk of it. So sometimes what they'll do is they'll go in, they will do that open reduction and pinning of the unstable SCFE, and then they'll actually do prophylactic pinning of the other hip, and then there'll be weight bearing as tolerated on the side that was done prophylactically and non-weight bearing on the side that was acute and unstable.

From a physical therapy standpoint, particularly following surgery, we're going to be working on gait training with them, achieving range of motion as they're able to and cleared for it, particularly that abduction, medial rotation because these are those areas that they typically would have limited range of motion. And oftentimes patients can return to normal activity within three to six months post-op. And typically what we want to do is really make sure that these children maintain that range of motion, maintain gentle weight-bearing activity throughout their life, because we can see that these individuals who have had a SCFE often will have degenerative changes in their hip later in life, even when they have surgical stabilisation completed.

Complications that can be associated with SCFE are avascular necrosis. And when that femoral head gets displaced or if there's aggressive manipulation, or if they continue to weight bear on it, or if there's penetration of the fixation device when they're going into try to surgically correct it. If the blood supply to the femoral head is affected, then what can happen is you can have that kind of deterioration of the femoral head due to lack of blood supply. Chondrolysis is another one. So this is when there's this dissolution of the articular cartilage and rapid progressive joint stiffness and pain that are associated with it.

So whenever we have any of these complications, we want to make sure we're really modifying activities using crutches, decreasing weight bearing, doing only gentle range of motion just to maintain motion, and often NSAIDs.

Activity Exacerbation

All right. Next, we're going to be talking about conditions that will cause a child to limp that are really exacerbated by activity. So we'll be looking at osteochondritis dissecans, Osgood-Schlatter, and Sever's.

Osteochondritis Dissecans

So osteochondritis dissecans is when there's a local injury to the articular surface of the bone. And there's a separation of the cartilage from the subchondral bone. And this can be from trauma, ischaemia, and some people are just genetically predisposed to have this happen. A lot of times we'll see this in the knee, but it can happen in the elbow and the ankle. It can be associated with traumatic events. Swelling. Definitely no fever. And then there's pain on palpation, particularly at the most common site of an OCD (osteochondritis dissecans) lesion, which is the anterior medial aspect of the knee. There can be catching and locking that's associated with it when you do passive range of motion.

So you want to refer for medical management to confirm it and look at the stability of the lesion. And there is potentially need for surgical management if there's unstable or if it's an unhealing form after a long period of time.

With physical therapy, we often do this with stable forms of a lesion, this osteochondritis dissecans lesion. And for this we're working on range of motion, increasing weight-bearing activities. Really strengthening all those stabilising structures around the knee. And if they did have to have surgery, then we're going to be thinking about pain management. Again, range of motion and gradual increase in weight-bearing activities.

So there's also these osteochondroses as a whole. So this is really any group of diseases where there's localised tissue death or necrosis that occurs that's then followed by full regeneration of healthy bone tissue. So, this is often seen with our Osgood-Schlatters, our Sever's disease. This is also true for the Legg-Calvé-Perthes. So there's three locations. It can be at your intervertebral joints, it can be at your articular joints or at your non-articular joints. A lot of times these conditions are idiopathic, but maybe associated with repetitive stress or trauma.

Osgood-Schlatter Syndrome

So this is really any group of diseases where there's localised tissue death or necrosis that occurs that's then followed by full regeneration of healthy bone tissue. So, this is often seen with our Osgood-Schlatters, our Sever's disease. So let's look a little more at Osgood-Schlatter. This is really when we see this kind of lesion along the tibial tubercle where that patellar tendon attaches.

So the pathology is that there's a traction apophysitis of the tibial tubercle, and this is due to repetitive strain and constant avulsion of that secondary ossification centre on the tibial tuberosity. So this often happens with trauma or it can happen with lots of mechanical overpulls of the extensor muscles of the knee. So we think about our athletes who are involved in a lot of running and jumping and bending, like soccer, or basketball, or volleyball. And then what happens is that there's this eccentric muscle pull and muscle tightness. And with that you have this reduced width of the patellar angle, increased tibial torsion, external tibial torsion, and this really increased bony prominence of that tibial tubercle.

This is more common in boys, but the gender gap is actually kind of narrowing now that more girls are involved in a lot of these sports. Onset, typically for boys, age 13 to 14, girls, 11 to 12, just because they grow and develop a little earlier and typically this resolves, the pain resolves as that tibial tubercle fuses to the tibia at approximately 15 years old.

That acute, severe pain or discomfort that happens with activity, particularly at that location of the tibial tuberosity. No fever. Often they will have a little bit of a limp or an antalgic gait, and that bony lump that's right along that tubial tubercle.

For us first, rest is one of the best things, but then we want to work on pain management. Interventions to reduce swelling, like using that ice cross fiction massage. And then eventually we would get into strengthening activities to strengthen the quad and weightbearing activities as well as stretching. But these are all gradual progression. Really the best thing for these individuals initially is a lot of rest before you start to increase activity so you don't exacerbate the issue. At the beginning. You're going to need to avoid a lot of squatting and jumping activities. Sometimes we'll get them in a supportive brace to be able to help stabilise.

Sever's Disease

So this is really any group of diseases where there's localised tissue death or necrosis that occurs that's then followed by full regeneration of healthy bone tissue. So, this is often seen with our Osgood-Schlatters, our Sever's disease.

So, Sever's disease is the next one. This is when you're going to see heel pain. It's also referred to as calcaneal apophysitis. This is really an osteochondritis of the calcaneus. So what happens is, is when you have repetitive impact, repetitive pulling of the Achilles tendon, where it attaches down at the calcaneus and then what you can see is there's this kind of repetitive shear along that growth plate. What happens is there can be fragmentation or avulsion of the cartilage at that point of attachment. So then what happens is this callus repairs and we can sometimes see fibrosis develop in that region, and then eventual ossification. So typical age of onset is between eight and 15 years old.

So with this, what we'll often hear reported is pain in the heel with activity. Might be seen with resisted plantar flexion. They may or may not have swelling at the heel pad, definitely no fever. They will have a limp or an antalgic gait, and often will have that localised tenderness at that posterior aspect of the heel.

For physical therapy, a lot of times we're going to again, think about interventions to reduce inflammation, so ice, rest, and then progress into strengthening activities. Particularly looking at the gastroc, soleus weight-bearing activities. A lot of times at the beginning, a heel cup or a heel lift is one of the best things you can do to be able to just give that Achilles tendon a little rest. You're just lifting up that heel a little bit so there's a little less tension and traction at that attachment side of the Achilles tendon, so it has time to rest and recover.

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