Paediatric Limping Gait: Difference between revisions

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== Introduction ==
== Introduction ==
<blockquote>"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."   
<blockquote>"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<ref>Leung AK, Lemay JF. [https://d1wqtxts1xzle7.cloudfront.net/42156485/1-s2.0-S0891524504000707-main-libre.pdf?1454699281=&response-content-disposition=inline%3B+filename%3DThe_Limping_Child.pdf&Expires=1702158099&Signature=ZyXIX9k1C63d4v3Iu~98QoKEBHtle5qxs-z0MGBEM59A3fdOInFs9j-EdMkbAYSPlFctSWQLu3jayaitRTnKChB2ffyii8Vg0UI4do5eB6MFNzxAJk7S~zJf6N90s~MQNFKE9zKoJ8G87bYXYQZRuMPzhN5v0GLosvIq7ayROFe1BmVzq51pHXUxgr51NcGY7DSN-lF52o6MMvvndVR9wpKRZnKxS2O6mEbPcWEpIjsUAM2ZjNVTONy5130e5W174prOG-8QHH~275w7i0NAZH2555qlRzKVQuPZz7PljgtPVEjTb6KsE313dJF0wMwHuCuHrlx4ssx4kH8XWNB34A__&Key-Pair-Id=APKAJLOHF5GGSLRBV4ZA The limping child]. Journal of Pediatric Health Care. 2004 Sep 1;18(5):219-23.</ref></blockquote>Limping gait is not typical in the paediatric population.<ref name=":1" /> 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.<ref name=":2">Jowkar R, Sharyf Pour Delavari M, Mohammadi M, Oladi S. [https://www.jimc.ir/article_143849.html Evaluation of Epidemiology and Etiologies of Acute Limping in Children Presented to the Emergency Department of Pediatric Hospital of Amirkola in Babol, Iran]. Journal of Iranian Medical Council. 2021 Oct 1;4(4):244-8.</ref> However, there are medical conditions where limiping gait is a sign of an emergency condition and can be life-threatening.<ref name=":3">Sawyer JR, Kapoor M. [https://www.aafp.org/pubs/afp/issues/2009/0201/p215.html The limping child: a systematic approach to diagnosis]. American family physician. 2009 Feb 1;79(3):215-24.</ref>. Therefore, it is important for the rehabilitation professional to be able to differentiate between potential diagnoses and know when to refer to medical colleagues.  
- Leung and Lemay, 2004<ref>Leung AK, Lemay JF. [https://d1wqtxts1xzle7.cloudfront.net/42156485/1-s2.0-S0891524504000707-main-libre.pdf?1454699281=&response-content-disposition=inline%3B+filename%3DThe_Limping_Child.pdf&Expires=1702158099&Signature=ZyXIX9k1C63d4v3Iu~98QoKEBHtle5qxs-z0MGBEM59A3fdOInFs9j-EdMkbAYSPlFctSWQLu3jayaitRTnKChB2ffyii8Vg0UI4do5eB6MFNzxAJk7S~zJf6N90s~MQNFKE9zKoJ8G87bYXYQZRuMPzhN5v0GLosvIq7ayROFe1BmVzq51pHXUxgr51NcGY7DSN-lF52o6MMvvndVR9wpKRZnKxS2O6mEbPcWEpIjsUAM2ZjNVTONy5130e5W174prOG-8QHH~275w7i0NAZH2555qlRzKVQuPZz7PljgtPVEjTb6KsE313dJF0wMwHuCuHrlx4ssx4kH8XWNB34A__&Key-Pair-Id=APKAJLOHF5GGSLRBV4ZA The limping child]. Journal of Pediatric Health Care. 2004 Sep 1;18(5):219-23.</ref></blockquote>A limping gait is not typical in the paediatric population.<ref name=":1" /> Trauma (e.g. contusions, sprains and strains) is the most common cause of limping in children. While paediatric limping is often self-limiting,<ref name=":2">Jowkar R, Sharyf Pour Delavari M, Mohammadi M, Oladi S. [https://www.jimc.ir/article_143849.html Evaluation of Epidemiology and Etiologies of Acute Limping in Children Presented to the Emergency Department of Pediatric Hospital of Amirkola in Babol, Iran]. Journal of Iranian Medical Council. 2021 Oct 1;4(4):244-8.</ref> a limping gait can be a sign of certain life-threatening medical conditions.<ref name=":3">Sawyer JR, Kapoor M. [https://www.aafp.org/pubs/afp/issues/2009/0201/p215.html The limping child: a systematic approach to diagnosis]. American family physician. 2009 Feb 1;79(3):215-24.</ref> Therefore, it is crucial that rehabilitation professionals can differentiate between different causes of limping in children and know when to refer to medical colleagues.  


== Limping Gait Differential Diagnosis ==
== Limping Gait Differential Diagnosis ==
'''ADD flowchart from video'''
<blockquote>
==== Clinical Spotlight: "Growing Pains" ====
"Growing pains in children are characterised by intermittent poorly localised nocturnal pains in children, usually affecting the legs without any obvious cause. This condition is fairly common presentation in primary care set-ups and the parents often seek consultation of the primary care physicians or family doctors. As per Nelson’s text book of paediatrics, [growing pain] affects about 10–20% of children."<ref name=":16">Khuntdar BK, Mondal S, Naik S, Mohanta MP. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10071917/ Prevalence of growing pains in a general paediatric OPD: A descriptive, observational and cross-sectional study]. Journal of Family Medicine and Primary Care. 2023 Jan;12(1):117.</ref>


The above flowchart was presented by Palisano et al<ref name=":4">Palisano RJ, et al. Campbell's physical therapy for children. St. Louis, Missouri: Elsevier; 2017.</ref> 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. 
According to the literature, there is no clear definition of growing pains,<ref name=":16" /> and many different causes have been proposed. However, these causes are either poorly supported by research, or there is inconsistent evidence. These include:<ref>O’Keeffe M, Kamper SJ, Montgomery L, Williams A, Martiniuk A, Lucas B, Dario AB, Rathleff MS, Hestbaek L, Williams CM. [https://www.researchgate.net/profile/Mary-Okeeffe-2/publication/362197053_Defining_Growing_Pains_A_Scoping_Review/links/62fe0a61aa4b1206fabb6d5c/Defining-Growing-Pains-A-Scoping-Review.pdf Defining growing pains: a scoping review]. Pediatrics. 2022 Aug 1;150(2).</ref>  


Criteria and flowchart determinants include:
# anatomic causes (e.g. hypermobility, genu valgum, low bone mineral density)
 
# psychological causes
* presence of pain with joint motion or associated long bone palpation
# vascular causes
* history of trauma
# metabolic causes (e.g. low vitamin D levels)</blockquote>
* fever
* neurological examination results
 
Continue reading below for more information on diagnoses commonly seen in clinical practice.<blockquote>
==== 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.</blockquote>


=== Gait Observation ===
=== 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:
There are three major features of limping in children: (1) pain, (2) weakness, and (3) structural or mechanical abnormalities of the spine, pelvis, and lower extremities. It is important that rehabilitation professionals 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:


* [[/www.physio-pedia.com/Gait|Gait cycle]]
* [[Gait]]
* [[/www.physio-pedia.com/Gait Deviations|Gait deviations]]
* [[Gait Deviations]]
* [[/www.physio-pedia.com/Gait Development in the Growing Child|Gait development]]
* [[Gait Development in the Growing Child|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.
Identifying an abnormal gait pattern may help clinicians determine the aetiology of the limping gait. Table 2 describes different gait patterns and common causes of these patterns.
{| class="wikitable"
{| class="wikitable"
|+
|+
Table 1.0 Observational gait analysis for limping differential diagnosis <ref name=":1" /><ref name=":3" /><ref name=":4" />
Table 2. Observational gait analysis for differential diagnosis of limping in children<ref name=":1" /><ref name=":3" /><ref name=":4">Palisano RJ, et al. Campbell's physical therapy for children. St. Louis, Missouri: Elsevier; 2017.</ref>
!'''Gait Pattern'''
!'''Gait Pattern'''
!'''Description/Clinical Observations'''
!'''Description/Clinical Observations'''
!'''Common Causes'''
!'''Common Causes'''
|-
|-
|'''Antalgic gait'''<ref name=":3" /><ref name=":4" />
|'''Antalgic Gait'''<ref name=":3" /><ref name=":4" />
|Shortened stance phase on the painful limb resulting in an increased swing phase on the other limb.
|Shortened stance phase on the painful limb resulting in an increased swing phase on the other limb


* tenderness
* tenderness
Line 53: Line 43:
* Infection
* Infection
|-
|-
|'''Trendelenburg gait'''
|'''Trendelenburg Gait'''
|Downward pelvic tilt during the swing phase away from the involved hip
|Downward pelvic tilt during the swing phase away from the involved hip
|Weakness of the contralateral gluteus medius muscle
|Weakness of the contralateral gluteus medius muscle
Line 59: Line 49:
* developmental dysplasia of the hip
* developmental dysplasia of the hip
* Legg-Calvé-Perthes disease
* Legg-Calvé-Perthes disease
* Slipped capital femoral epiphysis
* slipped capital femoral epiphysis


Bilateral involvement results in waddling gait
Bilateral involvement results in a waddling gait
|-
|-
|'''Lurching gait''' (posterior lurching gait, abductor lurch)<ref name=":4" />
|'''Lurching Gait''' (posterior lurching gait, abductor lurch)<ref name=":4" />
|Posterior  trunk lean with a hyperextended hip seen at loading response during stance<ref>Dutton M, Dutton's Orthopaedic Examination, Evaluation, and Intervention. 5th ed. New York: McGraw Hill; c2020.</ref>
|Posterior  trunk lean with a hyperextended hip seen at loading response during the stance phase of gait<ref>Dutton M, Dutton's Orthopaedic Examination, Evaluation, and Intervention. 5th ed. New York: McGraw Hill; c2020.</ref>
|Weakness of gluteus maximus muscle
|Weakness of gluteus maximus muscle


* developmental dysplasia of the hip<ref name=":4" />
* developmental dysplasia of the hip<ref name=":4" />
[[/www.physio-pedia.com/Cerebral Palsy Introduction|Cerebral palsy]]<ref name=":4" />
[[Cerebral Palsy Aetiology and Pathology|Cerebral palsy]]<ref name=":4" />
|-
|-
|'''Steppage (equinus) gait'''
|'''Steppage (Equinus) Gait'''
|Exaggerated hip and knee flexion during swing phase secondary to lacking active dorsiflexion of the foot
|Exaggerated hip and knee flexion during the swing phase of gait secondary to a lack of active dorsiflexion of the foot
|
|
* Heel-cord contracture<ref name=":4" />
* Heel-cord contracture<ref name=":4" />
* Neuromuscular diseases such as cerebral palsy<ref name=":4" />
* Neuromuscular diseases, such as cerebral palsy<ref name=":4" />
* [[Idiopathic Toe Walking|Idiopathic toe walker]]<ref name=":4" />
* [[Idiopathic Toe Walking|Idiopathic toe walker]]<ref name=":4" />
* [[Introduction to Clubfoot|Clubfoot]]<ref name=":4" />
* [[Introduction to Clubfoot|Clubfoot]]<ref name=":4" />


<nowiki>***</nowiki> neurological examination indicated ***<ref name=":1" />
<nowiki>***</nowiki> a neurological examination is indicated ***<ref name=":1" />
|-
|-
|'''Vaulting gait'''
|'''Vaulting Gait'''
|Weight-bearing knee locked in hyperextension at the end of the stance phase requiring the child to "vault" over the stance extremity
|Weight-bearing knee locked in hyperextension at the end of stance phase, requiring the child to "vault" over the stance extremity
|
|
* [[Leg Length Discrepancy|Leg length discrepancy (inequality)]]<ref name=":3" />
* [[Leg Length Discrepancy|Leg length discrepancy (inequality)]]<ref name=":3" />
* Abnormal knee mobility
* Abnormal knee mobility
|-
|-
|'''Circumduction gait<ref name=":4" />'''
|'''Circumduction Gait<ref name=":4" />'''
|The involved limb is moved in a semi-circular movement utilising<ref name=":5">Nesi B, Taviani A, D’Auria L, Bardelli R, Zuccarello G, Platano D, Benedetti MG, Benvenuti F. [https://www.mdpi.com/2076-3417/13/2/934 The Relationship between Gait Velocity and Walking Pattern in Hemiplegic Patients]. Applied Sciences. 2023 Jan 10;13(2):934.</ref> a combination of hip hiking, forward rotation of the pelvis, and abduction of the hip<ref name=":4" /> in order to clear the swinging limb over the ground<ref name=":5" />
|The involved limb is moved in a semi-circular movement utilising<ref name=":5">Nesi B, Taviani A, D’Auria L, Bardelli R, Zuccarello G, Platano D, Benedetti MG, Benvenuti F. [https://www.mdpi.com/2076-3417/13/2/934 The Relationship between Gait Velocity and Walking Pattern in Hemiplegic Patients]. Applied Sciences. 2023 Jan 10;13(2):934.</ref> a combination of hip hiking, forward rotation of the pelvis, and abduction of the hip<ref name=":4" /> in order to clear the swinging limb over the ground<ref name=":5" />
|
|
* Painful foot<ref name=":4" />
* Painful foot<ref name=":4" />
* Leg length discrepancy (inequality)<ref name=":4" />
* Leg length discrepancy (inequality)<ref name=":4" />
<nowiki>***</nowiki> neurological examination indicated ***<ref name=":1" />
<nowiki>***</nowiki> a neurological examination is indicated ***<ref name=":1" />
|-
|-
|'''Stooped gait'''<ref name=":3" />
|'''Stooped Gait'''<ref name=":3" />
|Bilateral hip flexion throughout gait cycle<ref name=":3" />
|Bilateral hip flexion throughout the gait cycle<ref name=":3" />
|pelvic or lower abdominal pain<ref name=":3" />
|Pelvic or lower abdominal pain<ref name=":3" />
|}
|}


== Infection ==
== Infection ==
'''Key clinical indication''': fever
'''Key Clinical Indication''': fever


=== Transient Synovitis ===
=== Transient Synovitis ===
<blockquote>"Transient synovitis is an acute, non-specific, inflammatory process affecting the joint synovium."<ref name=":0">Whitelaw CC, Varacallo M. [https://www.ncbi.nlm.nih.gov/books/NBK459181/ Transient synovitis]. InStatPearls [Internet] 2022 Sep 4. StatPearls Publishing.</ref> </blockquote>
<blockquote>"Transient synovitis is an acute, non-specific, inflammatory process affecting the joint synovium."<ref name=":0">Whitelaw CC, Varacallo M. [https://www.ncbi.nlm.nih.gov/books/NBK459181/ Transient synovitis]. InStatPearls [Internet] 2022 Sep 4. StatPearls Publishing.</ref> </blockquote>


* common cause of hip<ref name=":0" /><ref name=":1">Eskay K. Paediatric Physiotherapy Programme. Paediatric Limping Gait Course. Plus. 2023.</ref> and leg<ref name=":1" /> pain in children
* Common cause of ''hip''<ref name=":0" /><ref name=":1">Eskay K. Paediatric Physiotherapy Programme. Paediatric Limping Gait Course. Plus. 2023.</ref> and leg<ref name=":1" /> pain in children
* inflammation and pain tends to be short-term<ref name=":0" />
* A benign and self-limiting condition<ref name=":0" />
* condition is benign and can make mobility self-limiting<ref name=":0" />  
* Inflammation and pain tend to be short-lived<ref name=":0" />
* most common in children under the age of 10 years<ref name=":1" />
* Most common in children under the age of 10 years<ref name=":1" />  
'''Clinical signs''': fever without elevated leukocytes seen in white blood cell count (WBC)<ref name=":1" />


'''Potential rehabilitation examination findings''':
===== '''Clinical Signs''' =====


* mild range of motion limitations of hip abduction and internal rotation,
* Fever without elevated leukocytes in the white blood cell count (WBC).<ref name=":1" />
* position of comfort hip in a flexed, abducted, and externally rotated position
* provocative testing includes performing a basic log roll or the [[FABER Test|Patrick (FABER) test]]<ref name=":0" />


===== Aetiology: =====
===== Potential Rehabilitation Examination Findings =====
* exact aetiology is unknown<ref name=":0" />
* Mild range of motion limitations of hip abduction and internal rotation
* in the paediatric population, it is common to have a history of recent upper respiratory tract infection<ref name=":1" /><ref name=":0" />, pharyngitis, bronchitis, or otitis media<ref name=":0" />
* Position of Comfort = hip in a flexed, abducted, and externally rotated position
* other potential etiologies include: recent traumatic injury<ref name=":0" /> or viral symptoms to include vomiting, diarrhea, or common cold symptoms<ref>Kastrissianakis K, Beattie TF. Transient synovitis of the hip: more evidence for a viral aetiology. Eur J Emerg Med. 2010 Oct;17(5):270-3</ref>
* Provocative testing includes performing a basic log roll or the [[FABER Test|Patrick (FABER) test]]<ref name=":0" />


===== Intervention: =====
===== Aetiology =====
* inflammation typically resolves on its own within seven days<ref name=":1" /> to two weeks<ref name=":0" />
* Exact aetiology is unknown<ref name=":0" />
* '''role of rehabilitation''': <ref name=":1" />
* In the paediatric population, it is common to have a history of recent upper respiratory tract infection,<ref name=":1" /><ref name=":0" /> pharyngitis, bronchitis, or otitis media<ref name=":0" />
** energy conservation and activity limitation/modification
* Other potential aetiologies include recent traumatic injury<ref name=":0" /> or viral symptoms, including vomiting, diarrhoea, or common cold symptoms<ref>Kastrissianakis K, Beattie TF. Transient synovitis of the hip: more evidence for a viral aetiology. Eur J Emerg Med. 2010 Oct;17(5):270-3</ref>
** stretching
 
** pain management (however typically self-resolving within 24-48 hours<ref name=":0" />)
===== Interventions =====
* Inflammation typically resolves on its own within seven days<ref name=":1" /> to two weeks<ref name=":0" />
'''Role of Rehabilitation:'''<ref name=":1" />
* Energy conservation and activity limitation/modification
* Stretching
* Pain management (however, pain typically self-resolves within 24-48 hours<ref name=":0" />)


=== Septic Arthritis ===
=== Septic Arthritis ===
<blockquote>"[[Septic (Infectious) Arthritis|Septic arthritis]] is joint inflammation secondary to an infectious etiology, usually bacterial, but occasionally fungal, mycobacterial, viral, or other uncommon pathogens."<ref name=":6">Ifeanyi I. Momodu, Vipul Savaliya. [https://www.ncbi.nlm.nih.gov/books/NBK538176/ Septic Arthritis]. InStatPearls [Internet] 2022 July 3. StatPearls Publishing.</ref></blockquote>
<blockquote>"[[Septic (Infectious) Arthritis|Septic arthritis]] is joint inflammation secondary to an infectious etiology, usually bacterial, but occasionally fungal, mycobacterial, viral, or other uncommon pathogens."<ref name=":6">Ifeanyi I. Momodu, Vipul Savaliya. [https://www.ncbi.nlm.nih.gov/books/NBK538176/ Septic Arthritis]. InStatPearls [Internet] 2022 July 3. StatPearls Publishing.</ref></blockquote>


* knee<ref name=":1" /> and hip<ref name=":6" /> joints commonly effected in children
* The knee<ref name=":1" /> and hip<ref name=":6" /> are joints commonly affected 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)
* 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 medical emergency''''' that can cause significant joint damage. In these cases early diagnosis and treatment are critical for preserving joint function. <ref name=":6" />
* While uncommon, septic arthritis can pose an '''''orthopaedic medical emergency,''''' potentially resulting in significant joint damage. In these cases, early diagnosis and treatment are critical for preserving joint function<ref name=":6" />
* most common in children under the age of 5 years<ref name=":1" />
* Most common in children under the age of 5 years<ref name=":1" />


'''Clinical signs''': fever with elevated leukocytes in a WBC<ref name=":1" />, resistance to move the affected joint<ref name=":6" />, joint pain<ref name=":6" />, joint warmth<ref name=":6" />, and significant swelling of the involved joint<ref name=":1" />
===== '''Clinical Signs''': =====


'''Potential rehabilitation examination findings''':
* Fever with elevated leukocytes in WBC<ref name=":1" />
* Resistance to move the affected joint<ref name=":6" />
* Joint pain<ref name=":6" />
* Joint warmth <ref name=":6" />
* Significant swelling of the involved joint <ref name=":1" />


===== Potential Rehabilitation Examination Findings =====
* Limited joint range of motion
* Limited joint range of motion
* Painful joint palpation<ref name=":6" />
* Painful joint palpation<ref name=":6" />


===== Aetiology: =====
===== Aetiology =====
* most often caused by a bacterial organism in children<ref name=":1" /><ref name=":6" />
* Most often caused by a bacterial organism in children<ref name=":1" /><ref name=":6" />
* can occur after a foreign object penetrates a joint<ref name=":1" />
* Can occur after a foreign object penetrates a joint<ref name=":1" />


===== Intervention: =====
===== Interventions =====
* Joint aspiration (draining)<ref name=":1" />  
* Joint aspiration (draining)<ref name=":1" />  
* Antibiotics management <ref name=":1" />
* Management with antibiotics<ref name=":1" />
* Severe cases may require joint immobilisation up to 3 days<ref name=":6" />
* Severe cases may require joint immobilisation for up to three days<ref name=":6" />
* Proper medical treatment resolves symptoms within a week<ref name=":1" />, however the patient should return for medical reassessment if no improvement is seen within 5-6 days<ref name=":6" />
* Proper medical treatment resolves symptoms within a week.<ref name=":1" /> However, the patient should return for medical reassessment if no improvement is seen within five to six days<ref name=":6" />
* '''Role of rehabilitation''':<ref name=":1" />
'''Role of Rehabilitation''':<ref name=":1" />
** If symptoms are first noted in the therapy clinic, refer to doctor or emergency room right away as can be a '''''medical emergency'''''  
* If symptoms are first noted in the therapy clinic, refer to a doctor or the emergency room right away, as septic arthritis can be a '''''medical emergency'''''  
** After medical treatment:  
* After medical treatment:  
*** regaining range of motion
** regaining range of motion
*** improving weight bearing tolerance and ability
** improving weight-bearing tolerance and ability
*** gait training
** gait training


=== Osteomyelitis ===
=== Osteomyelitis ===
<blockquote>"Bone infection is called [[osteomyelitis]] ... Healthy intact bone is resistant to infection. The bone becomes susceptible to disease with the introduction of a large inoculum of bacteria, from trauma, ischemia, or the presence of foreign bodies" <ref name=":7">Ifeanyi I. Momodu, Vipul Savaliya. [https://www.ncbi.nlm.nih.gov/books/NBK532250/ Osteomyelitis]. InStatPearls [Internet] 2022 May 31. StatPearls Publishing.</ref></blockquote>
<blockquote>"Bone infection is called [[osteomyelitis]] ... Healthy intact bone is resistant to infection. The bone becomes susceptible to disease with the introduction of a large inoculum of bacteria, from trauma, ischemia, or the presence of foreign bodies".<ref name=":7">Ifeanyi I. Momodu, Vipul Savaliya. [https://www.ncbi.nlm.nih.gov/books/NBK532250/ Osteomyelitis]. InStatPearls [Internet] 2022 May 31. StatPearls Publishing.</ref></blockquote>


* Acute hematogenous osteomyelitis affecting the metaphysis of the long bones occurs more frequently in children<ref name=":8">McNeil JC. [https://www.tandfonline.com/doi/full/10.2147/IDR.S257517 Acute hematogenous osteomyelitis in children: clinical presentation and management.] Infection and drug resistance. 2020 Dec 14:4459-73.</ref> compared to adults, where the vertebrae are more commonly involved<ref name=":7" />
* Acute hematogenous osteomyelitis affecting the metaphysis of the long bones occurs more frequently in children<ref name=":8">McNeil JC. [https://www.tandfonline.com/doi/full/10.2147/IDR.S257517 Acute hematogenous osteomyelitis in children: clinical presentation and management.] Infection and drug resistance. 2020 Dec 14:4459-73.</ref> than adults. In adults, the vertebrae are more commonly involved.<ref name=":7" /> The knee is most commonly affected in children - areas commonly affected include the distal femur and proximal tibia<ref name=":1" />
** Knee most commonly affected in children, and can include the distal femur and proximal tibia<ref name=":1" />
* Most common in children under the age of 3 years<ref name=":1" />
* Most common in children under the age of 3 years<ref name=":1" />
* '''''Requires immediate referral''''', medical intervention and treatment to begin as soon as possible<ref name=":1" />
* '''''Requires immediate referral''''' and medical intervention with treatment beginning as soon as possible<ref name=":1" />
 
'''Clinical signs''':  localised bone tenderness, high fever and chills, significant swelling of the joint, and reluctance to bear weight through involved limb.  Significant laboratory findings will include elevated leukocytes, elevated erythrocyte sedimentation rate (ESR,) and elevated C-reactive protein (CRP).<ref name=":1" />


'''Potential rehabilitation examination findings''':<ref name=":8" />
===== Clinical Signs =====
* Localised bone tenderness
* High fever and chills
* Significant swelling of the joint
* Reluctance to bear weight through the involved limb
* Significant laboratory findings will include elevated leukocytes, elevated erythrocyte sedimentation rate (ESR) and elevated C-reactive protein (CRP)<ref name=":1" />


* lower extremity bones are involved: difficulty with weightbearing
===== Potential Rehabilitation Examination Findings =====
* pelvic bone involvement: are able to weightbear to some degree, may display a waddling gait pattern
* If lower extremity bones are involved: difficulty with weight bearing
* vertebral bone involved: back pain, point tenderness, limited flexion or extension, and potentially change in spinal curvature
* Pelvic bone involvement: able to weight bear to some degree, may display a waddling gait pattern
* The child may also report a recent minor blunt trauma to the affected area
* Vertebral bone involved: back pain, point tenderness, limited flexion or extension, and potentially a change in spinal curvature
* The child may also report a recent minor blunt trauma to the affected area<ref name=":8" />


===== Aetiology: =====
===== Aetiology =====


* Often associated with a bloodborne infection
* Often associated with a blood borne infection
* Most commonly caused by bacterial infection by ''Staphylococcus aureus, but can also be of viral, fungal, or parasitic in origin<ref name=":1" />''<ref name=":7" />
* Most commonly a bacterial infection caused by ''Staphylococcus aureus, but can also be viral, fungal, or parasitic in origin<ref name=":1" />''<ref name=":7" />


===== Intervention: =====
===== Interventions =====


* Effective treatment of osteomyelitis requires both medical and surgical specialties:
* Effective treatment of osteomyelitis requires both medical and surgical specialities:
** Surgical debridement of all diseased bone is often required and at times repeated surgical debridement is indicated
** surgical debridement of all diseased bone is often required and, at times, repeated surgical debridement is indicated
** Prolonged and targeted antibiotic therapy is "the cornerstone of treatment for osteomyelitis"<ref name=":7" />
** prolonged and targeted antibiotic therapy is "the cornerstone of treatment for osteomyelitis"<ref name=":7" />
* Vacuum-assisted wound closure devices can be effectively utilised to speed the closure of large or deep wounds resulting from extensive debridement<ref name=":7" />
* Vacuum-assisted wound closure devices can be effectively utilised to speed the closure of large or deep wounds resulting from extensive debridement<ref name=":7" />
* Medical treatments can require as long as two-months<ref name=":1" />
* Medical treatments can be required for as long as two months<ref name=":1" />
 
'''Role of Rehabilitation:'''
'''Role of rehabilitation:'''
 
* After medical treatment:<ref name=":1" />
* After medical treatment:<ref name=":1" />
** regaining range of motion
** regaining range of motion
Line 196: Line 194:
** gait training
** gait training
<blockquote>
<blockquote>
==== Special topic: Kocher criteria ====
==== Special Topic: Kocher Criteria ====
 
According to Jowkar et al.,<ref name=":2" /> the Kocher Criteria can be useful in differentiating between septic arthritis of the hip and transient synovitis as a cause of limping gait in children. A 2022 study by Bisht et al.<ref name=":17">Bisht RU, Burns JD, Smith CL, Kang P, Shrader MW, Belthur MV. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9254023/ The modified Kocher criteria for septic hip: Does it apply to the knee?]. Journal of Children's Orthopaedics. 2022 Jun;16(3):233-7.</ref> found that a modified Kocher criteria can also be useful for predicting a diagnosis of septic arthritis of the knee.
 
'''The Kocher Criteria''':
 
# Unable to weight bear
# Temperature > 38.5°C / 101.3°F
# Erythrocyte sedimentation rate (ESR) > 40mm/hr
# White blood cell count (WBC) > 12,000 cells/mm3
 
 
Scoring for the Kocher Criteria is as follows:<ref>MD Clac. Kocher Criteria for Septic Arthritis. Available from: https://www.mdcalc.com/calc/1817/kocher-criteria-septic-arthritis (accessed 17 December 2023).</ref>
 
* + 1 criterion - 3% probability for septic arthritis
* + 2 criteria - 40% probability for septic arthritis
* + 3 criteria - 93% probability for septic arthritis
* + 4 criteria - 99.6% probability for septic arthritis
 
 
The '''Modified Kocher Criteria''' includes the added category of C-reactive protein (CRP) >2.0 mg/dL.


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.<ref name=":2" /></blockquote>
When using the modified Kocher Criteria, the combination of an inability to bear weight and an elevated CRP has a significant association with septic knee.<ref name=":17" /> </blockquote>


== Vascular Causes ==
== Vascular Causes ==
Children with a limping gait, without a fever or a history of traumatic event.
'''Key Clinical Indications''': no fever or history of a traumatic event.


=== Legg-Calvé-Perthes ===
=== Legg-Calvé-Perthes Disease ===
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.
Also known as: coxa plana, Legg-Perthes, Legg Calvé, Perthes Disease<blockquote>[[Legg-Calve-Perthes Disease|Legg-Calvé-Perthes]] disease is idiopathic osteonecrosis or idiopathic avascular necrosis of the capital femoral epiphysis of the femoral head.<ref name=":9">Ifeanyi I. Momodu, Vipul Savaliya. [https://www.ncbi.nlm.nih.gov/books/NBK513230/ Legg-Calve-Perthes Disease]. InStatPearls [Internet] 2023 July 10. StatPearls Publishing.</ref></blockquote>


* Most common in children aged 3-12 years,<ref name=":9" /> with the highest rate of occurrence at 4-8 years<ref name=":1" />
* Male to female ratio 4:1 to 5:1<ref name=":1" /> <ref name=":9" />
* Other risk factors include (1) low socioeconomic status, (2) dietary issues, (3) secondhand smoke exposure, and (4) perinatal human immunodeficiency virus (HIV) infection<ref name=":1" /><ref name=":9" />


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 =====
* Sudden onset of limping gait without fever, swelling, or recent traumatic event<ref name=":1" />
* Antalgic gait in the acute phase progresses to Trendelenburg gait in the chronic phase<ref name=":1" /><ref name=":9" />
* Subjective report of pain: initially, may have no complaints of pain, but as the disease progresses, may report pain with activity<ref name=":1" /><ref name=":9" />
** if pain is present, it is often localised to the hip or referred to the knee, thigh, or abdomen<ref name=":1" /><ref name=":9" />
** pain with hip rotation commonly refers to the anteriomedial thigh and / or knee


===== Potential Rehabilitation Examination Findings =====
* Decreased hip abduction and internal (medial) rotation range of motion<ref name=":1" /><ref name=":9" />
* Disuse atrophy of the thigh and buttock musculature<ref name=":9" />
* Leg length discrepancy<ref name=":9" />


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.
===== Aetiology =====


* The exact aetiology is unknown - it may be idiopathic or caused by another mechanism that disrupts blood flow to the femoral epiphysis, such as trauma, coagulopathy, or steroid use<ref name=":9" />
===== Interventions =====
Interventions for Legg-Calvé-Perthes disease will depend upon the age of the patient and the disease stage at which it is identified.  There are multiple classification and staging systems for Legg-Calvé-Perthes disease. Two widely used systems are outlined in Tables 3 and 4 below.
{| class="wikitable"
|+Table 3. Waldenstrom classification<ref name=":1" /> <ref name=":10" /><ref name=":11" />
!
!'''Stage Name'''
!'''Findings'''
!'''Timeframe'''
|-
|'''1'''
|'''Initial or Necrosis Stage'''
|
* Blood supply to the femoral head is disrupted
* Bone cell death begins
* Region becomes highly inflamed
* Limping gait will begin during this phase<ref name=":10">OrthoInfo. Perthes Disease. Available from: https://orthoinfo.aaos.org/en/diseases--conditions/perthes-disease (accessed 12 December 2023).</ref>
|Up to 6 months
|-
|'''2'''
|'''Fragmentation Stage'''
|
* Necrotic bone removed, new bone formation occurs
* New bone growth is weaker, and the femoral head is suspectable to compression into a flatter shape<ref name=":10" />
* Acetabulum shape becomes irregular<ref name=":1" />
|1-2 years
|-
|'''3'''
|'''Reossification Stage'''
|
* The highest amount of new bone growth<ref name=":1" />
* New bone is becoming stronger
* Femoral head is taking on its new shape<ref name=":10" />
|Longest phase, can last multiple years
|-
|'''4'''
|'''Residual<ref name=":1" /> or Healed<ref name=":10" /> Stage'''
|
* Bone regrowth is complete
* Femoral head achieves its final shape<ref name=":10" />
|Continues until skeletal maturity<ref name=":11">Orthobullets. Legg-Calve-Perthes Disease. Available from: https://www.orthobullets.com/pediatrics/4119/legg-calve-perthes-disease (accessed 12 December 2023).</ref>
|}


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


The Herring Classification, also known as the Lateral Pillar Classification, is based on the height of the lateral pillar of the capital femoral epiphysis using anterior/posterior imaging of the pelvis. This classification system provides clinically useful and predictive prognostic information.<ref name=":11" />
{| class="wikitable"
|+Table 4. Herring (Lateral Pillar) Classification<ref name=":11" />
!
!'''Clinical Findings'''
!'''Prognosis'''
|-
!'''Group A'''
|
* Lateral pillar maintains full height
* No density changes identified
|Good outcome regardless of age at diagnosis
|-
|'''Group B'''
|
* Lateral pillar maintains >50% height
|Poor outcome in patients with bone age > 6 years
|-
|'''Group B/C'''
|
* Lateral pillar is narrowed (2-3mm) or poorly ossified 
* Maintains approximately 50% height
|(Recently added to increase consistency and prognosis of classification)
|-
|'''Group C'''
|
* Lateral pillar maintains < 50% height
|Poor outcomes regardless of age at diagnosis
|}
The goals of treatment include (1) pain and symptom management, (2) restoration of hip range of motion, and (3) maintaining alignment of the femoral head in the acetabulum.<ref name=":9" />


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.
'''Non-operative Interventions''':


* '''Recommended Patient Population''': children aged 6 years or younger or Lateral Pillar A Classification<ref name=":9" />
* '''Activity''': mobility and activity limitations, including a recommendation for decreased weight-bearing, physiotherapy still indicated within activity limitations<ref name=":9" /> ''(see role of rehabilitation section below)''
* Current literature does not support the use of bracing, casting, or orthotics<ref name=":9" />
* Pain management, including the use of non-steroidal anti-inflammatory drugs (NSAIDS)<ref name=":1" /><ref name=":9" />
* Referral to orthopaedist for disease monitoring<ref name=":9" />
* Up to 60% of patients will only require non-operative interventions<ref name=":1" />


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.
'''Operative Interventions:'''<ref name=":9" />


'''''Femoral or Pelvic Osteotomy'''''


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.
* '''Recommended patient population''': children aged 8 years or older; Lateral Pillar B and B/C have more successful surgical outcomes than Lateral Pillar A or C


'''''Valgus or Shelf Osteotomies'''''


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.
* '''Recommended Patient Population''': children with hinge abduction
* Outcome Goal = to improve abductor mechanism


New and controversial surgical options include '''''hip arthroscopy''''' and '''''hip arthrodiastasis'''''


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.


'''Role of Rehabilitation:'''<ref name=":1" />


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.
* Outcome Goals: preventing deformation of the femoral head and preserving hip range of motion
* Treatment Modalities:
** bedrest
** traction
** reduced weight-bearing status
** strengthening the [[Gluteus Medius|gluteus medius]] muscle
** balance training
** gait training within mobility precautions


=== Slipped Capital Femoral Epiphysis (SCFE) ===
=== 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.
<blockquote>"[[Slipped Capital Femoral Epiphysis|Slipped capital femoral epiphysis]] (slipped upper femoral epiphysis) is a common hip pathology in pre-adolescents and adolescents. It occurs when the femoral epiphysis is abnormally displaced posteriorly and inferiorly relative to the femoral head and neck."<ref name=":12">Johns K; Mabrouk A; Tavarez M. [https://www.ncbi.nlm.nih.gov/books/NBK538302/ Slipped Capital Femoral Epiphysis]. InStatPearls [Internet] 2023 July 25. StatPearls Publishing.</ref></blockquote>


* Most common in pre-adolescents and adolescents,<ref name=":12" /> with the highest rate of occurrence at 10-15 years<ref name=":1" />
* Other risk factors include obesity and the male gender. It can also be associated with certain genetic predispositions<ref name=":1" /><ref name=":12" />
* Diagnosis can be difficult due to either an atypical presentation (i.e. knee or thigh pain) or the chronic nature of an individual's presentation<ref name=":12" />
* Associated medical complications include (1) [[Avascular Necrosis Femoral Head|avascular necrosis]] and (2)  chondrolysis<ref name=":1" /> (which according to the Pediatric Orthopedic Society of North America, is a "rapidly progressive loss of articular cartilage from both the femoral and acetabular sides of the hip<ref>Pediatric Orthopedic Society of North America. Chondrolysis of the Hip. Available from: https://posna.org/physician-education/study-guide/chondrolysis-of-the-hip (accessed 13 December 2023).</ref>") of the hip.


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 =====
'''Acute SCFE'''


* Common with twisting injuries or traumatic falls
* More mild complaints
* Atypical pain presentation in the groin, thigh, knee
* Limited weight-bearing tolerance on the involved side
* Position of Comfort: external rotation with a "shortened" limb<ref name=":1" />


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.


'''Chronic SCFE'''


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.
* More frequently seen
* Patient reports an ongoing history of "vague pain" in the groin or thigh
* No swelling
* Loss of hip internal rotation, flexion and abduction range of motion
* Gluteus medius weakness
* Decreased femoral anteversion
* Position of comfort: external rotation with a "shortened" limb<ref name=":1" />


'''Potential Rehabilitation Examination Findings'''


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.
* Limited internal rotation of the involved limb
* Passive internal rotation may elicit pain
* Loss of hip internal rotation, flexion and abduction range of motion (more chronic cases)
* Positive Drehmann Sign (passive hip flexion to 90 degrees causes obligatory hip external rotation)
* Gait Assessment: shuffling gait, Trendelenburg gait, antalgic gait
* Atrophy of thigh musculature may or may not be present<ref name=":12" />


If SCFE is suspected upon a rehabilitation evaluation or assessment, encourage the patient to reduce weight bearing, limit activities, and refer to a medical doctor as soon as possible.<ref name=":1" /> 


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.
There are multiple grading or classification scales for SCFE:


* '''The Southwick Slip Angle Classification''' grades the severity of SCFE based on the difference in the epiphyseal diaphyseal angle between the involved and the uninvolved (contralateral) hip, both in anteroposterior and lateral radiographs of the hip. Mild cases < 30 degrees, moderate cases 30-50 degrees, and severe cases with > 50 degrees of difference. In bilateral cases, a set reference is used for comparison: 145 degrees on the anteroposterior radiographs and 10 degrees on the lateral radiographs.


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.
SCFE can also be graded based on the percentage of slippage. Grade I is up to 33%, Grade II 34 to 50%, and Grade III over 50%.  
===== Aetiology =====


* Most cases are idiopathic
* There is an association between the development of SCFE and patients with endocrine disorders, renal disorders, and [[Down Syndrome (Trisomy 21)|Down syndrome]]<ref name=":12" />


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.
===== Interventions =====


Medical interventions typically include surgical fixation with the goals of (1) decreasing femoral displacement, (2) maintaining range of motion, and (3) preventing premature degenerative arthritis.<ref name=":1" /><ref name=":12" />


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.
'''''In situ fixation with Percutaneous Screws'''''  


* The aim is to prevent further slippage of the epiphysis
* Up to 6 weeks post-operatively: stable slips can weight bear as tolerated, unstable slips are limited to partial weight bearing status<ref name=":12" />


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.
'''''Open Reduction and Internal Fixation (ORIF)'''''


* The aim is to correct the femoral deformity and stabilise the epiphysis while protecting the femoral head blood supply
* Up to 6 weeks post-operatively: limited to partial weight bearing status<ref name=":12" />
'''''Femoral Osteotomy'''''
* Indicated for more severe deformity with a slip greater than 30 to 45 degrees<ref name=":12" />
'''''Osteochondroplasty'''''
* Indicated for mild and moderate chronic deformity cases where a prominent metaphyseal bump causes pain and restricts range of motion<ref name=":12" />
'''Role of Rehabilitation:'''
After medical treatment:<ref name=":1" />
* regaining range of motion, especially abduction and internal (medial) rotation
* improving weight-bearing tolerance and ability
* gait training
* follow-up and reassessments throughout the patient's lifetime as they may experience degenerative changes of the involved hip later in life
* if they experience complications, such as avascular necrosis or chondrolysis, they will require guidance on how to modify activities, decrease weight bearing through the involved limb, and only do gentle range of motion to maintain motion
== Activity Exacerbation ==
== 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.
'''Key Clinical Indications''': no fever with limping gait exacerbated by an increase in activity


=== Osteochondritis Dissecans ===
=== 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.
<blockquote>[[Osteochondritis Dissecans of the Knee|Osteochondritis dissecans]] ranges "in severity from being asymptomatic to mild pain or advanced cases having symptoms of joint instability and locking. The lesions can progress from stable to fragmentation of the overlying cartilage with the formation of a loose body in the affected joint space."<ref name=":13">Wood D, Davis D, Carter, K. [https://www.ncbi.nlm.nih.gov/books/NBK526091/ Osteochondritis Dissecans]. InStatPearls [Internet] 2023 August 8. StatPearls Publishing.</ref></blockquote>
 
* Also known as an osteochondral lesion<ref name=":13" />
* It is a local injury to the articular surface of the bone caused by the separation of the cartilage from the subchondral bone<ref name=":1" />
* Most commonly occurs in the knee, but can also occur in the [[Osteochondritis Dissecans of the Elbow|elbow]] and ankle<ref name=":1" /><ref name=":13" />
* Can occur throughout the lifespan, but the majority of cases occur in individuals aged 10 to 20 years<ref name=":13" />
* Male to Female ratio 2:1<ref name=":13" />
 
'''''Stable Fragments (lesions)''''': held in place by intact overlying articular cartilage. Progression of the defect to involve the overlying cartilage is possible, which leads to instability of the fragment.
 
'''''Unstable Fragments (lesions)''''': may remain in place or become a loose body within the joint.
 
===== Clinical Signs =====
* Effusion<ref name=":13" /> or swelling<ref name=":1" />
* Pain on palpation<ref name=":1" /><ref name=":13" />
 
===== Potential Rehabilitation Examination Findings =====
* Catching and locking during passive range of motion<ref name=":1" />
* Decreased or painful range of motion<ref name=":13" />
 
===== Aetiology =====
 
* The aetiology is not fully understood and is likely multi-factorial in origin
* Causes can include:
** genetic predisposition<ref name=":1" /><ref name=":13" />
** inflammation<ref name=":13" />
** ischaemia<ref name=":1" /><ref name=":13" />
** spontaneous avascular necrosis<ref name=":13" />
** repetitive trauma<ref name=":1" /><ref name=":13" />


===== Interventions =====
Selection of treatment interventions will depend upon the (1) age at diagnosis, (2) time of presentation, (3) symptom severity, and (5)  lesion stability.<ref name=":13" />


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.
'''''Stable Lesions''''':<ref name=":13" />


* Conservative management is preferred with immobilisation and protective weight bearing
* Failure of conservative treatment may require retroarticular or transarticular drilling techniques


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.
'''''Unstable or Displaced Lesions''''': <ref name=":13" />


* Surgical intervention is required and is typically performed arthroscopically
* The knee is the location most often requiring surgery
* Potential surgical interventions include (1) fixation, (2) debridement, (3) microfracture, and (4) cartilage grafting and / or transplantation


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.
'''Role of Rehabilitation:'''
 
Most often involved in the treatment of stable lesions:<ref name=":1" />
 
* improving range of motion
* increasing weight-bearing activities and tolerance
* strengthening to knee stabilising musculature
 
 
When providing post-surgical treatment:<ref name=":1" />
 
* pain management
* range of motion 
* gradual increase in weight-bearing activities and tolerance


=== Osgood-Schlatter Syndrome ===
=== 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.
<blockquote>"[<nowiki/>[[Osgood-Schlatter Disease|Osgood-Schlatter Syndrome]]] associates atraumatic, insidious onset of anterior knee pain, with tenderness at the patellar tendon insertion site at the tibial tuberosity. The condition is self-limited and occurs secondary to repetitive extensor mechanism stress activities such as jumping and sprinting."<ref name=":14">Smith J, Varacallo M. [https://www.ncbi.nlm.nih.gov/books/NBK441995/ Osgood-Schlatter Disease]. InStatPearls [Internet] 2023 August 4. StatPearls Publishing.</ref></blockquote>
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.
 
* Also known as an osteochondrosis, tibial tubercle apophysitis, or traction apophysitis of the tibial tubercle<ref name=":14" />
* A common cause of anterior knee pain in skeletally immature (male 12-15 years, female 8-12 years) athletes<ref name=":14" />
* Commonly associated with soccer (football),<ref name=":1" /><ref name=":14" /> basketball,<ref name=":1" /><ref name=":14" /> volleyball,<ref name=":1" /> <ref name=":14" /> and is often seen in sprinters and gymnasts<ref name=":14" />
* Onset is gradual and commonly associated with repetitive activities of the knee<ref name=":1" /><ref name=":14" />
* While the syndrome is benign, recovery can be long and result in an absence from sport<ref name=":14" />
 
===== Clinical Signs =====
* Tenderness over the tibial tubercle<ref name=":1" /><ref name=":14" />
* Bony lump along the tibial tubercle<ref name=":1" />


===== Potential Rehabilitation Examination Findings =====
* Slight limping or an antalgic gait<ref name=":1" />


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.
===== Aetiology =====


* Overuse injury in active adolescents
* Occurs secondary to repetitive microtraumas from the strong pull of the patellar tendon at its insertion on the relatively soft tibial tubercle apophysis
** in severe cases, this force can cause a partial avulsion of the tibial tubercle apophysis
** the force is increased with higher levels of activity
** more susceptible to injury after periods of rapid growth
** in rare cases can lead to a complete avulsion fracture


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.
Predisposing factors include poor flexibility of (1) quadriceps and (2) hamstrings or (3) other evidence of extensor mechanism misalignment.<ref name=":14" />


===== Interventions =====
The treatment intervention is determined by the pain level. Symptomatic treatment can include:<ref name=":14" />


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.
* ice 
* NSAIDs
* activity modification
* relative rest from inciting activities<br />
'''Role of Rehabilitation:'''


Will need to gradually correct the underlying predisposing biomechanical factors in a balanced way with rest from activity and pain management:<ref name=":14" />


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.
* swelling management
* gradual strengthening activities, especially of the quadriceps
* gradual weight-bearing activities and tolerance
* stretching
* activity modification and therapeutic rest
* supportive brace as needed<ref name=":1" />


=== Sever's Disease ===
=== 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.
<blockquote>[[Sever's Disease|Sever's disease]] "is a common cause of heel pain in the skeletally immature athlete. It is considered to be the result of an overuse injury to the secondary ossification center by a traction apohysitis at the Achilles tendon insertion site on the calcaneus."<ref name=":15">Smith J, Varacallo M. [https://www.ncbi.nlm.nih.gov/books/NBK441928/ Sever Disease]. InStatPearls [Internet] 2022 September 4. StatPearls Publishing.</ref></blockquote>


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.
* Also known as calcaneal apophysitis
* Self-limiting condition
* Often coincides with the onset of a rapid growth spurt and / or a sudden increase in sports-related activity
* More common in males, with a median age of 12 years for males and 11 years for females
* Most commonly involved sports include (1) basketball, (2) football (soccer), (3) track, (4) cross-country, and (5) gymnastics<ref name=":15" />


===== Clinical Signs =====
* Diagnosis is clinical and does not require imaging studies<ref name=":15" />
* Complaints of heel pain,<ref name=":1" /> can be unilateral or bilateral and usually worse during and after activity
** pain improves with rest and resolves by the next day after activity
* Negative for erythema or ecchymosis
* Mild swelling may be present  around the Achilles insertion on the heel<ref name=":15" />


=====  Potential Rehabilitation Examination Findings =====
* Tenderness over the calcaneal insertion of the Achilles insertion on the heel
* Positive squeeze test
* Aggravated by standing on tiptoes (Sever Sign)
* Lack of heel cord flexibility and / or dorsiflexion weakness <ref name=":15" />
* Limping or antalgic gait<ref name=":1" />


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.
===== Aetiology =====


* Occurs secondary to repetitive microtraumas from the strong pull of the Achilles tendon at its insertion on the relatively soft calcaneal apophysis
** in rare cases, may lead to a full avulsion fracture


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.
Contributing factors include (1) repetitive sports activity (such as running and / or jumping), (2) heel cord tightness, (3) ankle dorsiflexion weakness, (4) poor shock absorption or supportive athletic shoes, and (5) performing on hard surfaces. Poor shock absorption can also come from biomechanical factors such as (1) genu varum, (2) forefoot varus, (3) pes cavus, or (4) pes planus.<ref name=":15" />
 
===== Interventions =====
Interventions include activity modification and / or therapeutic rest as guided by pain.<ref name=":15" />
 
Symptom management includes:<ref name=":1" /><ref name=":15" />
 
* ice
* anti-inflammatory medications
* heel cups or heel lifts
* immobilisation may be needed in severe cases
 
 
'''Role of Rehabilitation:'''
 
* Heel cord stretching<ref name=":15" />
* Inflammation management<ref name=":1" />
* Gastrocnemius and soleus strengthening and weight-bearing activities<ref name=":1" />


== Resources  ==
== Resources  ==
*bulleted list
*x
or


#numbered list
==== Clinical Resources: ====
#x
 
* [https://www.mdcalc.com/calc/1817/kocher-criteria-septic-arthritis Kocher Criteria Calculator]
* [http://journalfeed.org/article-a-day/2017/how-to-tell-a-septic-hip-from-transient-synovitis/ How to Tell a Septic Hip from Transient Synovitis]
 
==== Optional Additional Reading: ====
 
* Jowkar R, Sharyf Pour Delavari M, Mohammadi M, Oladi S. [https://www.jimc.ir/article_143849.html Evaluation of Epidemiology and Etiologies of Acute Limping in Children Presented to the Emergency Department of Pediatric Hospital of Amirkola in Babol, Iran]. Journal of Iranian Medical Council. 2021 Oct 1;4(4):244-8.


== References  ==
== References  ==


<references />
<references />
[[Category:Course Pages]]
[[Category:Paediatrics]]
[[Category:Plus Content]]

Latest revision as of 15:17, 14 January 2024

Original Editor - Stacy Schiurring based on the course by Krista Eskay
Top Contributors - Stacy Schiurring, Jess Bell and Naomi O'Reilly

Introduction[edit | edit source]

"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[1]

A limping gait is not typical in the paediatric population.[2] Trauma (e.g. contusions, sprains and strains) is the most common cause of limping in children. While paediatric limping is often self-limiting,[3] a limping gait can be a sign of certain life-threatening medical conditions.[4] Therefore, it is crucial that rehabilitation professionals can differentiate between different causes of limping in children and know when to refer to medical colleagues.

Limping Gait Differential Diagnosis[edit | edit source]

Clinical Spotlight: "Growing Pains"[edit | edit source]

"Growing pains in children are characterised by intermittent poorly localised nocturnal pains in children, usually affecting the legs without any obvious cause. This condition is fairly common presentation in primary care set-ups and the parents often seek consultation of the primary care physicians or family doctors. As per Nelson’s text book of paediatrics, [growing pain] affects about 10–20% of children."[5]

According to the literature, there is no clear definition of growing pains,[5] and many different causes have been proposed. However, these causes are either poorly supported by research, or there is inconsistent evidence. These include:[6]

  1. anatomic causes (e.g. hypermobility, genu valgum, low bone mineral density)
  2. psychological causes
  3. vascular causes
  4. metabolic causes (e.g. low vitamin D levels)

Gait Observation[edit | edit source]

There are three major features of limping in children: (1) pain, (2) weakness, and (3) structural or mechanical abnormalities of the spine, pelvis, and lower extremities. It is important that rehabilitation professionals 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:

Identifying an abnormal gait pattern may help clinicians determine the aetiology of the limping gait. Table 2 describes different gait patterns and common causes of these patterns.

Table 2. Observational gait analysis for differential diagnosis of limping in children[2][4][7]
Gait Pattern Description/Clinical Observations Common Causes
Antalgic Gait[4][7] 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 a waddling gait

Lurching Gait (posterior lurching gait, abductor lurch)[7] Posterior trunk lean with a hyperextended hip seen at loading response during the stance phase of gait[8] Weakness of gluteus maximus muscle
  • developmental dysplasia of the hip[7]

Cerebral palsy[7]

Steppage (Equinus) Gait Exaggerated hip and knee flexion during the swing phase of gait secondary to a lack of active dorsiflexion of the foot

*** a neurological examination is indicated ***[2]

Vaulting Gait Weight-bearing knee locked in hyperextension at the end of stance phase, requiring the child to "vault" over the stance extremity
Circumduction Gait[7] The involved limb is moved in a semi-circular movement utilising[9] a combination of hip hiking, forward rotation of the pelvis, and abduction of the hip[7] in order to clear the swinging limb over the ground[9]
  • Painful foot[7]
  • Leg length discrepancy (inequality)[7]

*** a neurological examination is indicated ***[2]

Stooped Gait[4] Bilateral hip flexion throughout the gait cycle[4] Pelvic or lower abdominal pain[4]

Infection[edit | edit source]

Key Clinical Indication: fever

Transient Synovitis[edit | edit source]

"Transient synovitis is an acute, non-specific, inflammatory process affecting the joint synovium."[10]

  • Common cause of hip[10][2] and leg[2] pain in children
  • A benign and self-limiting condition[10]
  • Inflammation and pain tend to be short-lived[10]
  • Most common in children under the age of 10 years[2]
Clinical Signs[edit | edit source]
  • Fever without elevated leukocytes in the white blood cell count (WBC).[2]
Potential Rehabilitation Examination Findings[edit | edit source]
  • 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[10]
Aetiology[edit | edit source]
  • Exact aetiology is unknown[10]
  • In the paediatric population, it is common to have a history of recent upper respiratory tract infection,[2][10] pharyngitis, bronchitis, or otitis media[10]
  • Other potential aetiologies include recent traumatic injury[10] or viral symptoms, including vomiting, diarrhoea, or common cold symptoms[11]
Interventions[edit | edit source]
  • Inflammation typically resolves on its own within seven days[2] to two weeks[10]

Role of Rehabilitation:[2]

  • Energy conservation and activity limitation/modification
  • Stretching
  • Pain management (however, pain typically self-resolves within 24-48 hours[10])

Septic Arthritis[edit | edit source]

"Septic arthritis is joint inflammation secondary to an infectious etiology, usually bacterial, but occasionally fungal, mycobacterial, viral, or other uncommon pathogens."[12]

  • The knee[2] and hip[12] are joints commonly affected in children
  • 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 orthopaedic medical emergency, potentially resulting in significant joint damage. In these cases, early diagnosis and treatment are critical for preserving joint function[12]
  • Most common in children under the age of 5 years[2]
Clinical Signs:[edit | edit source]
  • Fever with elevated leukocytes in WBC[2]
  • Resistance to move the affected joint[12]
  • Joint pain[12]
  • Joint warmth [12]
  • Significant swelling of the involved joint [2]
Potential Rehabilitation Examination Findings[edit | edit source]
  • Limited joint range of motion
  • Painful joint palpation[12]
Aetiology[edit | edit source]
  • Most often caused by a bacterial organism in children[2][12]
  • Can occur after a foreign object penetrates a joint[2]
Interventions[edit | edit source]
  • Joint aspiration (draining)[2]
  • Management with antibiotics[2]
  • Severe cases may require joint immobilisation for up to three days[12]
  • Proper medical treatment resolves symptoms within a week.[2] However, the patient should return for medical reassessment if no improvement is seen within five to six days[12]

Role of Rehabilitation:[2]

  • If symptoms are first noted in the therapy clinic, refer to a doctor or the emergency room right away, as septic arthritis can be a medical emergency
  • After medical treatment:
    • regaining range of motion
    • improving weight-bearing tolerance and ability
    • gait training

Osteomyelitis[edit | edit source]

"Bone infection is called osteomyelitis ... Healthy intact bone is resistant to infection. The bone becomes susceptible to disease with the introduction of a large inoculum of bacteria, from trauma, ischemia, or the presence of foreign bodies".[13]

  • Acute hematogenous osteomyelitis affecting the metaphysis of the long bones occurs more frequently in children[14] than adults. In adults, the vertebrae are more commonly involved.[13] The knee is most commonly affected in children - areas commonly affected include the distal femur and proximal tibia[2]
  • Most common in children under the age of 3 years[2]
  • Requires immediate referral and medical intervention with treatment beginning as soon as possible[2]
Clinical Signs[edit | edit source]
  • Localised bone tenderness
  • High fever and chills
  • Significant swelling of the joint
  • Reluctance to bear weight through the involved limb
  • Significant laboratory findings will include elevated leukocytes, elevated erythrocyte sedimentation rate (ESR) and elevated C-reactive protein (CRP)[2]
Potential Rehabilitation Examination Findings[edit | edit source]
  • If lower extremity bones are involved: difficulty with weight bearing
  • Pelvic bone involvement: able to weight bear to some degree, may display a waddling gait pattern
  • Vertebral bone involved: back pain, point tenderness, limited flexion or extension, and potentially a change in spinal curvature
  • The child may also report a recent minor blunt trauma to the affected area[14]
Aetiology[edit | edit source]
  • Often associated with a blood borne infection
  • Most commonly a bacterial infection caused by Staphylococcus aureus, but can also be viral, fungal, or parasitic in origin[2][13]
Interventions[edit | edit source]
  • Effective treatment of osteomyelitis requires both medical and surgical specialities:
    • surgical debridement of all diseased bone is often required and, at times, repeated surgical debridement is indicated
    • prolonged and targeted antibiotic therapy is "the cornerstone of treatment for osteomyelitis"[13]
  • Vacuum-assisted wound closure devices can be effectively utilised to speed the closure of large or deep wounds resulting from extensive debridement[13]
  • Medical treatments can be required for as long as two months[2]

Role of Rehabilitation:

  • After medical treatment:[2]
    • regaining range of motion
    • improving weight bearing tolerance and ability
    • gait training

Special Topic: Kocher Criteria[edit | edit source]

According to Jowkar et al.,[3] the Kocher Criteria can be useful in differentiating between septic arthritis of the hip and transient synovitis as a cause of limping gait in children. A 2022 study by Bisht et al.[15] found that a modified Kocher criteria can also be useful for predicting a diagnosis of septic arthritis of the knee.

The Kocher Criteria:

  1. Unable to weight bear
  2. Temperature > 38.5°C / 101.3°F
  3. Erythrocyte sedimentation rate (ESR) > 40mm/hr
  4. White blood cell count (WBC) > 12,000 cells/mm3


Scoring for the Kocher Criteria is as follows:[16]

  • + 1 criterion - 3% probability for septic arthritis
  • + 2 criteria - 40% probability for septic arthritis
  • + 3 criteria - 93% probability for septic arthritis
  • + 4 criteria - 99.6% probability for septic arthritis


The Modified Kocher Criteria includes the added category of C-reactive protein (CRP) >2.0 mg/dL.

When using the modified Kocher Criteria, the combination of an inability to bear weight and an elevated CRP has a significant association with septic knee.[15]

Vascular Causes[edit | edit source]

Key Clinical Indications: no fever or history of a traumatic event.

Legg-Calvé-Perthes Disease[edit | edit source]

Also known as: coxa plana, Legg-Perthes, Legg Calvé, Perthes Disease

Legg-Calvé-Perthes disease is idiopathic osteonecrosis or idiopathic avascular necrosis of the capital femoral epiphysis of the femoral head.[17]

  • Most common in children aged 3-12 years,[17] with the highest rate of occurrence at 4-8 years[2]
  • Male to female ratio 4:1 to 5:1[2] [17]
  • Other risk factors include (1) low socioeconomic status, (2) dietary issues, (3) secondhand smoke exposure, and (4) perinatal human immunodeficiency virus (HIV) infection[2][17]
Clinical Signs[edit | edit source]
  • Sudden onset of limping gait without fever, swelling, or recent traumatic event[2]
  • Antalgic gait in the acute phase progresses to Trendelenburg gait in the chronic phase[2][17]
  • Subjective report of pain: initially, may have no complaints of pain, but as the disease progresses, may report pain with activity[2][17]
    • if pain is present, it is often localised to the hip or referred to the knee, thigh, or abdomen[2][17]
    • pain with hip rotation commonly refers to the anteriomedial thigh and / or knee
Potential Rehabilitation Examination Findings[edit | edit source]
  • Decreased hip abduction and internal (medial) rotation range of motion[2][17]
  • Disuse atrophy of the thigh and buttock musculature[17]
  • Leg length discrepancy[17]
Aetiology[edit | edit source]
  • The exact aetiology is unknown - it may be idiopathic or caused by another mechanism that disrupts blood flow to the femoral epiphysis, such as trauma, coagulopathy, or steroid use[17]
Interventions[edit | edit source]

Interventions for Legg-Calvé-Perthes disease will depend upon the age of the patient and the disease stage at which it is identified. There are multiple classification and staging systems for Legg-Calvé-Perthes disease. Two widely used systems are outlined in Tables 3 and 4 below.

Table 3. Waldenstrom classification[2] [18][19]
Stage Name Findings Timeframe
1 Initial or Necrosis Stage
  • Blood supply to the femoral head is disrupted
  • Bone cell death begins
  • Region becomes highly inflamed
  • Limping gait will begin during this phase[18]
 Up to 6 months
2 Fragmentation Stage
  • Necrotic bone removed, new bone formation occurs
  • New bone growth is weaker, and the femoral head is suspectable to compression into a flatter shape[18]
  • Acetabulum shape becomes irregular[2]
 1-2 years
3 Reossification Stage
  • The highest amount of new bone growth[2]
  • New bone is becoming stronger
  • Femoral head is taking on its new shape[18]
 Longest phase, can last multiple years
4 Residual[2] or Healed[18] Stage
  • Bone regrowth is complete
  • Femoral head achieves its final shape[18]
 Continues until skeletal maturity[19]


The Herring Classification, also known as the Lateral Pillar Classification, is based on the height of the lateral pillar of the capital femoral epiphysis using anterior/posterior imaging of the pelvis. This classification system provides clinically useful and predictive prognostic information.[19]

Table 4. Herring (Lateral Pillar) Classification[19]
Clinical Findings Prognosis
Group A
  • Lateral pillar maintains full height
  • No density changes identified
 Good outcome regardless of age at diagnosis
Group B
  • Lateral pillar maintains >50% height
 Poor outcome in patients with bone age > 6 years
Group B/C
  • Lateral pillar is narrowed (2-3mm) or poorly ossified
  • Maintains approximately 50% height
 (Recently added to increase consistency and prognosis of classification)
Group C
  • Lateral pillar maintains < 50% height
 Poor outcomes regardless of age at diagnosis

The goals of treatment include (1) pain and symptom management, (2) restoration of hip range of motion, and (3) maintaining alignment of the femoral head in the acetabulum.[17]

Non-operative Interventions:

  • Recommended Patient Population: children aged 6 years or younger or Lateral Pillar A Classification[17]
  • Activity: mobility and activity limitations, including a recommendation for decreased weight-bearing, physiotherapy still indicated within activity limitations[17] (see role of rehabilitation section below)
  • Current literature does not support the use of bracing, casting, or orthotics[17]
  • Pain management, including the use of non-steroidal anti-inflammatory drugs (NSAIDS)[2][17]
  • Referral to orthopaedist for disease monitoring[17]
  • Up to 60% of patients will only require non-operative interventions[2]

Operative Interventions:[17]

Femoral or Pelvic Osteotomy

  • Recommended patient population: children aged 8 years or older; Lateral Pillar B and B/C have more successful surgical outcomes than Lateral Pillar A or C

Valgus or Shelf Osteotomies

  • Recommended Patient Population: children with hinge abduction
  • Outcome Goal = to improve abductor mechanism

New and controversial surgical options include hip arthroscopy and hip arthrodiastasis


Role of Rehabilitation:[2]

  • Outcome Goals: preventing deformation of the femoral head and preserving hip range of motion
  • Treatment Modalities:
    • bedrest
    • traction
    • reduced weight-bearing status
    • strengthening the gluteus medius muscle
    • balance training
    • gait training within mobility precautions

Slipped Capital Femoral Epiphysis (SCFE)[edit | edit source]

"Slipped capital femoral epiphysis (slipped upper femoral epiphysis) is a common hip pathology in pre-adolescents and adolescents. It occurs when the femoral epiphysis is abnormally displaced posteriorly and inferiorly relative to the femoral head and neck."[20]

  • Most common in pre-adolescents and adolescents,[20] with the highest rate of occurrence at 10-15 years[2]
  • Other risk factors include obesity and the male gender. It can also be associated with certain genetic predispositions[2][20]
  • Diagnosis can be difficult due to either an atypical presentation (i.e. knee or thigh pain) or the chronic nature of an individual's presentation[20]
  • Associated medical complications include (1) avascular necrosis and (2) chondrolysis[2] (which according to the Pediatric Orthopedic Society of North America, is a "rapidly progressive loss of articular cartilage from both the femoral and acetabular sides of the hip[21]") of the hip.
Clinical Signs[edit | edit source]

Acute SCFE

  • Common with twisting injuries or traumatic falls
  • More mild complaints
  • Atypical pain presentation in the groin, thigh, knee
  • Limited weight-bearing tolerance on the involved side
  • Position of Comfort: external rotation with a "shortened" limb[2]


Chronic SCFE

  • More frequently seen
  • Patient reports an ongoing history of "vague pain" in the groin or thigh
  • No swelling
  • Loss of hip internal rotation, flexion and abduction range of motion
  • Gluteus medius weakness
  • Decreased femoral anteversion
  • Position of comfort: external rotation with a "shortened" limb[2]

Potential Rehabilitation Examination Findings

  • Limited internal rotation of the involved limb
  • Passive internal rotation may elicit pain
  • Loss of hip internal rotation, flexion and abduction range of motion (more chronic cases)
  • Positive Drehmann Sign (passive hip flexion to 90 degrees causes obligatory hip external rotation)
  • Gait Assessment: shuffling gait, Trendelenburg gait, antalgic gait
  • Atrophy of thigh musculature may or may not be present[20]

If SCFE is suspected upon a rehabilitation evaluation or assessment, encourage the patient to reduce weight bearing, limit activities, and refer to a medical doctor as soon as possible.[2]

There are multiple grading or classification scales for SCFE:

  • The Southwick Slip Angle Classification grades the severity of SCFE based on the difference in the epiphyseal diaphyseal angle between the involved and the uninvolved (contralateral) hip, both in anteroposterior and lateral radiographs of the hip. Mild cases < 30 degrees, moderate cases 30-50 degrees, and severe cases with > 50 degrees of difference. In bilateral cases, a set reference is used for comparison: 145 degrees on the anteroposterior radiographs and 10 degrees on the lateral radiographs.

SCFE can also be graded based on the percentage of slippage. Grade I is up to 33%, Grade II 34 to 50%, and Grade III over 50%.

Aetiology[edit | edit source]
  • Most cases are idiopathic
  • There is an association between the development of SCFE and patients with endocrine disorders, renal disorders, and Down syndrome[20]
Interventions[edit | edit source]

Medical interventions typically include surgical fixation with the goals of (1) decreasing femoral displacement, (2) maintaining range of motion, and (3) preventing premature degenerative arthritis.[2][20]

In situ fixation with Percutaneous Screws  

  • The aim is to prevent further slippage of the epiphysis
  • Up to 6 weeks post-operatively: stable slips can weight bear as tolerated, unstable slips are limited to partial weight bearing status[20]

Open Reduction and Internal Fixation (ORIF)

  • The aim is to correct the femoral deformity and stabilise the epiphysis while protecting the femoral head blood supply
  • Up to 6 weeks post-operatively: limited to partial weight bearing status[20]

Femoral Osteotomy

  • Indicated for more severe deformity with a slip greater than 30 to 45 degrees[20]

Osteochondroplasty

  • Indicated for mild and moderate chronic deformity cases where a prominent metaphyseal bump causes pain and restricts range of motion[20]

Role of Rehabilitation:

After medical treatment:[2]

  • regaining range of motion, especially abduction and internal (medial) rotation
  • improving weight-bearing tolerance and ability
  • gait training
  • follow-up and reassessments throughout the patient's lifetime as they may experience degenerative changes of the involved hip later in life
  • if they experience complications, such as avascular necrosis or chondrolysis, they will require guidance on how to modify activities, decrease weight bearing through the involved limb, and only do gentle range of motion to maintain motion

Activity Exacerbation[edit | edit source]

Key Clinical Indications: no fever with limping gait exacerbated by an increase in activity

Osteochondritis Dissecans[edit | edit source]

Osteochondritis dissecans ranges "in severity from being asymptomatic to mild pain or advanced cases having symptoms of joint instability and locking. The lesions can progress from stable to fragmentation of the overlying cartilage with the formation of a loose body in the affected joint space."[22]

  • Also known as an osteochondral lesion[22]
  • It is a local injury to the articular surface of the bone caused by the separation of the cartilage from the subchondral bone[2]
  • Most commonly occurs in the knee, but can also occur in the elbow and ankle[2][22]
  • Can occur throughout the lifespan, but the majority of cases occur in individuals aged 10 to 20 years[22]
  • Male to Female ratio 2:1[22]

Stable Fragments (lesions): held in place by intact overlying articular cartilage. Progression of the defect to involve the overlying cartilage is possible, which leads to instability of the fragment.

Unstable Fragments (lesions): may remain in place or become a loose body within the joint.

Clinical Signs[edit | edit source]
Potential Rehabilitation Examination Findings[edit | edit source]
  • Catching and locking during passive range of motion[2]
  • Decreased or painful range of motion[22]
Aetiology[edit | edit source]
  • The aetiology is not fully understood and is likely multi-factorial in origin
  • Causes can include:
Interventions[edit | edit source]

Selection of treatment interventions will depend upon the (1) age at diagnosis, (2) time of presentation, (3) symptom severity, and (5) lesion stability.[22]

Stable Lesions:[22]

  • Conservative management is preferred with immobilisation and protective weight bearing
  • Failure of conservative treatment may require retroarticular or transarticular drilling techniques

Unstable or Displaced Lesions: [22]

  • Surgical intervention is required and is typically performed arthroscopically
  • The knee is the location most often requiring surgery
  • Potential surgical interventions include (1) fixation, (2) debridement, (3) microfracture, and (4) cartilage grafting and / or transplantation

Role of Rehabilitation:

Most often involved in the treatment of stable lesions:[2]

  • improving range of motion
  • increasing weight-bearing activities and tolerance
  • strengthening to knee stabilising musculature


When providing post-surgical treatment:[2]

  • pain management
  • range of motion
  • gradual increase in weight-bearing activities and tolerance

Osgood-Schlatter Syndrome[edit | edit source]

"[Osgood-Schlatter Syndrome] associates atraumatic, insidious onset of anterior knee pain, with tenderness at the patellar tendon insertion site at the tibial tuberosity. The condition is self-limited and occurs secondary to repetitive extensor mechanism stress activities such as jumping and sprinting."[23]

  • Also known as an osteochondrosis, tibial tubercle apophysitis, or traction apophysitis of the tibial tubercle[23]
  • A common cause of anterior knee pain in skeletally immature (male 12-15 years, female 8-12 years) athletes[23]
  • Commonly associated with soccer (football),[2][23] basketball,[2][23] volleyball,[2] [23] and is often seen in sprinters and gymnasts[23]
  • Onset is gradual and commonly associated with repetitive activities of the knee[2][23]
  • While the syndrome is benign, recovery can be long and result in an absence from sport[23]
Clinical Signs[edit | edit source]
  • Tenderness over the tibial tubercle[2][23]
  • Bony lump along the tibial tubercle[2]
Potential Rehabilitation Examination Findings[edit | edit source]
  • Slight limping or an antalgic gait[2]
Aetiology[edit | edit source]
  • Overuse injury in active adolescents
  • Occurs secondary to repetitive microtraumas from the strong pull of the patellar tendon at its insertion on the relatively soft tibial tubercle apophysis
    • in severe cases, this force can cause a partial avulsion of the tibial tubercle apophysis
    • the force is increased with higher levels of activity
    • more susceptible to injury after periods of rapid growth
    • in rare cases can lead to a complete avulsion fracture

Predisposing factors include poor flexibility of (1) quadriceps and (2) hamstrings or (3) other evidence of extensor mechanism misalignment.[23]

Interventions[edit | edit source]

The treatment intervention is determined by the pain level. Symptomatic treatment can include:[23]

  • ice
  • NSAIDs
  • activity modification
  • relative rest from inciting activities

Role of Rehabilitation:

Will need to gradually correct the underlying predisposing biomechanical factors in a balanced way with rest from activity and pain management:[23]

  • swelling management
  • gradual strengthening activities, especially of the quadriceps
  • gradual weight-bearing activities and tolerance
  • stretching
  • activity modification and therapeutic rest
  • supportive brace as needed[2]

Sever's Disease[edit | edit source]

Sever's disease "is a common cause of heel pain in the skeletally immature athlete. It is considered to be the result of an overuse injury to the secondary ossification center by a traction apohysitis at the Achilles tendon insertion site on the calcaneus."[24]

  • Also known as calcaneal apophysitis
  • Self-limiting condition
  • Often coincides with the onset of a rapid growth spurt and / or a sudden increase in sports-related activity
  • More common in males, with a median age of 12 years for males and 11 years for females
  • Most commonly involved sports include (1) basketball, (2) football (soccer), (3) track, (4) cross-country, and (5) gymnastics[24]
Clinical Signs[edit | edit source]
  • Diagnosis is clinical and does not require imaging studies[24]
  • Complaints of heel pain,[2] can be unilateral or bilateral and usually worse during and after activity
    • pain improves with rest and resolves by the next day after activity
  • Negative for erythema or ecchymosis
  • Mild swelling may be present around the Achilles insertion on the heel[24]
Potential Rehabilitation Examination Findings[edit | edit source]
  • Tenderness over the calcaneal insertion of the Achilles insertion on the heel
  • Positive squeeze test
  • Aggravated by standing on tiptoes (Sever Sign)
  • Lack of heel cord flexibility and / or dorsiflexion weakness [24]
  • Limping or antalgic gait[2]
Aetiology[edit | edit source]
  • Occurs secondary to repetitive microtraumas from the strong pull of the Achilles tendon at its insertion on the relatively soft calcaneal apophysis
    • in rare cases, may lead to a full avulsion fracture

Contributing factors include (1) repetitive sports activity (such as running and / or jumping), (2) heel cord tightness, (3) ankle dorsiflexion weakness, (4) poor shock absorption or supportive athletic shoes, and (5) performing on hard surfaces. Poor shock absorption can also come from biomechanical factors such as (1) genu varum, (2) forefoot varus, (3) pes cavus, or (4) pes planus.[24]

Interventions[edit | edit source]

Interventions include activity modification and / or therapeutic rest as guided by pain.[24]

Symptom management includes:[2][24]

  • ice
  • anti-inflammatory medications
  • heel cups or heel lifts
  • immobilisation may be needed in severe cases


Role of Rehabilitation:

  • Heel cord stretching[24]
  • Inflammation management[2]
  • Gastrocnemius and soleus strengthening and weight-bearing activities[2]

Resources[edit | edit source]

Clinical Resources:[edit | edit source]

Optional Additional Reading:[edit | edit source]

References[edit | edit source]

  1. ↑ Leung AK, Lemay JF. The limping child. Journal of Pediatric Health Care. 2004 Sep 1;18(5):219-23.
  2. ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 2.15 2.16 2.17 2.18 2.19 2.20 2.21 2.22 2.23 2.24 2.25 2.26 2.27 2.28 2.29 2.30 2.31 2.32 2.33 2.34 2.35 2.36 2.37 2.38 2.39 2.40 2.41 2.42 2.43 2.44 2.45 2.46 2.47 2.48 2.49 2.50 2.51 2.52 2.53 2.54 2.55 2.56 2.57 2.58 2.59 2.60 2.61 2.62 2.63 2.64 2.65 2.66 2.67 2.68 2.69 2.70 2.71 2.72 2.73 Eskay K. Paediatric Physiotherapy Programme. Paediatric Limping Gait Course. Plus. 2023.
  3. ↑ 3.0 3.1 Jowkar R, Sharyf Pour Delavari M, Mohammadi M, Oladi S. Evaluation of Epidemiology and Etiologies of Acute Limping in Children Presented to the Emergency Department of Pediatric Hospital of Amirkola in Babol, Iran. Journal of Iranian Medical Council. 2021 Oct 1;4(4):244-8.
  4. ↑ 4.0 4.1 4.2 4.3 4.4 4.5 4.6 Sawyer JR, Kapoor M. The limping child: a systematic approach to diagnosis. American family physician. 2009 Feb 1;79(3):215-24.
  5. ↑ 5.0 5.1 Khuntdar BK, Mondal S, Naik S, Mohanta MP. Prevalence of growing pains in a general paediatric OPD: A descriptive, observational and cross-sectional study. Journal of Family Medicine and Primary Care. 2023 Jan;12(1):117.
  6. ↑ O’Keeffe M, Kamper SJ, Montgomery L, Williams A, Martiniuk A, Lucas B, Dario AB, Rathleff MS, Hestbaek L, Williams CM. Defining growing pains: a scoping review. Pediatrics. 2022 Aug 1;150(2).
  7. ↑ 7.00 7.01 7.02 7.03 7.04 7.05 7.06 7.07 7.08 7.09 7.10 7.11 7.12 Palisano RJ, et al. Campbell's physical therapy for children. St. Louis, Missouri: Elsevier; 2017.
  8. ↑ Dutton M, Dutton's Orthopaedic Examination, Evaluation, and Intervention. 5th ed. New York: McGraw Hill; c2020.
  9. ↑ 9.0 9.1 Nesi B, Taviani A, D’Auria L, Bardelli R, Zuccarello G, Platano D, Benedetti MG, Benvenuti F. The Relationship between Gait Velocity and Walking Pattern in Hemiplegic Patients. Applied Sciences. 2023 Jan 10;13(2):934.
  10. ↑ 10.00 10.01 10.02 10.03 10.04 10.05 10.06 10.07 10.08 10.09 10.10 Whitelaw CC, Varacallo M. Transient synovitis. InStatPearls [Internet] 2022 Sep 4. StatPearls Publishing.
  11. ↑ Kastrissianakis K, Beattie TF. Transient synovitis of the hip: more evidence for a viral aetiology. Eur J Emerg Med. 2010 Oct;17(5):270-3
  12. ↑ 12.0 12.1 12.2 12.3 12.4 12.5 12.6 12.7 12.8 12.9 Ifeanyi I. Momodu, Vipul Savaliya. Septic Arthritis. InStatPearls [Internet] 2022 July 3. StatPearls Publishing.
  13. ↑ 13.0 13.1 13.2 13.3 13.4 Ifeanyi I. Momodu, Vipul Savaliya. Osteomyelitis. InStatPearls [Internet] 2022 May 31. StatPearls Publishing.
  14. ↑ 14.0 14.1 McNeil JC. Acute hematogenous osteomyelitis in children: clinical presentation and management. Infection and drug resistance. 2020 Dec 14:4459-73.
  15. ↑ 15.0 15.1 Bisht RU, Burns JD, Smith CL, Kang P, Shrader MW, Belthur MV. The modified Kocher criteria for septic hip: Does it apply to the knee?. Journal of Children's Orthopaedics. 2022 Jun;16(3):233-7.
  16. ↑ MD Clac. Kocher Criteria for Septic Arthritis. Available from: https://www.mdcalc.com/calc/1817/kocher-criteria-septic-arthritis (accessed 17 December 2023).
  17. ↑ 17.00 17.01 17.02 17.03 17.04 17.05 17.06 17.07 17.08 17.09 17.10 17.11 17.12 17.13 17.14 17.15 17.16 17.17 Ifeanyi I. Momodu, Vipul Savaliya. Legg-Calve-Perthes Disease. InStatPearls [Internet] 2023 July 10. StatPearls Publishing.
  18. ↑ 18.0 18.1 18.2 18.3 18.4 18.5 OrthoInfo. Perthes Disease. Available from: https://orthoinfo.aaos.org/en/diseases--conditions/perthes-disease (accessed 12 December 2023).
  19. ↑ 19.0 19.1 19.2 19.3 Orthobullets. Legg-Calve-Perthes Disease. Available from: https://www.orthobullets.com/pediatrics/4119/legg-calve-perthes-disease (accessed 12 December 2023).
  20. ↑ 20.00 20.01 20.02 20.03 20.04 20.05 20.06 20.07 20.08 20.09 20.10 Johns K; Mabrouk A; Tavarez M. Slipped Capital Femoral Epiphysis. InStatPearls [Internet] 2023 July 25. StatPearls Publishing.
  21. ↑ Pediatric Orthopedic Society of North America. Chondrolysis of the Hip. Available from: https://posna.org/physician-education/study-guide/chondrolysis-of-the-hip (accessed 13 December 2023).
  22. ↑ 22.00 22.01 22.02 22.03 22.04 22.05 22.06 22.07 22.08 22.09 22.10 22.11 22.12 22.13 22.14 22.15 Wood D, Davis D, Carter, K. Osteochondritis Dissecans. InStatPearls [Internet] 2023 August 8. StatPearls Publishing.
  23. ↑ 23.00 23.01 23.02 23.03 23.04 23.05 23.06 23.07 23.08 23.09 23.10 23.11 23.12 Smith J, Varacallo M. Osgood-Schlatter Disease. InStatPearls [Internet] 2023 August 4. StatPearls Publishing.
  24. ↑ 24.0 24.1 24.2 24.3 24.4 24.5 24.6 24.7 24.8 Smith J, Varacallo M. Sever Disease. InStatPearls [Internet] 2022 September 4. StatPearls Publishing.
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