Paediatric Limping Gait

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Introduction

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

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

Limping Gait Differential Diagnosis

ADD flowchart from video

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

Criteria and flowchart determinants include:

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

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

Clinical Spotlight: "growing pains"

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

Gait Observation

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

• Gait cycle
• Gait deviations
• Gait development

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

Table 1.0 Observational gait analysis for limping differential diagnosis

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

Infection

Key clinical indication: fever

Transient Synovitis

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

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

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

Potential rehabilitation examination findings:

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

Aetiology:

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

Intervention:

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

Septic Arthritis

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

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

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

Potential rehabilitation examination findings:

• Limited joint range of motion
• Painful joint palpation

Aetiology:

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

Intervention:

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

Osteomyelitis

"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"

• Acute hematogenous osteomyelitis affecting the metaphysis of the long bones occurs more frequently in children compared to adults, where the vertebrae are more commonly involved
  • Knee most commonly affected in children, and can include the distal femur and proximal tibia
• Most common in children under the age of 3 years
• Requires immediate referral, medical intervention and treatment to begin as soon as possible

Clinical signs:

• Localised bone tenderness
• High fever and chills
• Significant swelling of the joint
• 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).

Potential rehabilitation examination findings:

• lower extremity bones are involved: difficulty with weightbearing
• pelvic bone involvement: are able to weightbear to some degree, may display a waddling gait pattern
• vertebral bone involved: back pain, point tenderness, limited flexion or extension, and potentially change in spinal curvature
• The child may also report a recent minor blunt trauma to the affected area

Aetiology:

• Often associated with a bloodborne infection
• Most commonly caused by bacterial infection by Staphylococcus aureus, but can also be of viral, fungal, or parasitic in origin

Intervention:

• Effective treatment of osteomyelitis requires both medical and surgical specialties:
  • 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"
• Vacuum-assisted wound closure devices can be effectively utilised to speed the closure of large or deep wounds resulting from extensive debridement
• Medical treatments can require as long as two-months

Role of rehabilitation:

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

Special topic: Kocher criteria

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

Vascular Causes

Key clinical indications: no fever or a history of traumatic event.

Legg-Calvé-Perthes Disease

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.

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

Clinical signs:

• Sudden onset of limping gait without fever, swelling, or recent traumatic event
• Antalgic gait acutely progressing to Trendelenburg gait chronically
• Subjective report of pain: initially may have no complaints of pain but as the disease progresses may report pain with activity
  • If pain is present, common to be localised to the hip or referred to the knee, thigh, or abdomen
  • Pain with hip rotation commonly refers to the anteriomedial thigh and / or knee

Potential rehabilitation examination findings:

• Decreased hip abduction and internal (medial) rotation ranges of motion
• Decreased hip abduction and internal (medial) rotation ranges of motion.
• Disuse atrophy of thigh and buttock musculature
• Leg length discrepancy

Aetiology:

• Exact aetiology is unknown, may be idiopathic or caused by another mechanism that disrupts blood flow to the femoral epiphysis, such as trauma, coagulopathy, or steroid use

Intervention:

Intervention 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 Table 2.0 and 3.0 below.

Table 2.0 Waldenstrom classification

	Stage Name	Findings	Timeframe
1	Initial or Necrosis Stage	blood supply to femoral head is disrupted bone cell death begins region becomes highly inflamed limping gait will begin during this phase	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 acetabulum shape becomes irregular	1-2 years
3	Reossification Stage	the highest amount of new bone growth new bone is becoming stronger femoral head is taking on its new shape	longest phase, can last multiple years
4	Residual or Healed Stage	bone regrowth is complete femoral head achieves its final shape	continues until skeletal maturity

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.

Table 3.0 Herring (Lateral Pillar) Classification

	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 interventions include (1) pain and symptom management, (2) restoration of hip range of motion, and (3) maintaining alignment of the femoral head in the acetabulum.

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

Non-operative Interventions:

• Recommended patient population: children aged 6 years or younger or lateral pillar A classification
• Activity: mobility and activity limitations to included decreased weight-bearing recommended, physiotherapy still indicated within activity limitations (see role of rehabilitation section below)
• Current literature does not support the use of bracing, casting, or orthotics
• Pain management including use of non-steroidal anti-inflammatory drugs (NSAIDS)
• Referral to orthopedist for disease monitoring
• Up to 60% of patients will only require non-operative interventions

Operative Interventions:

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:

• Outcome goals: preventing deformation of the femoral head and preserving hip range of motion
• Treatment modalities:
  • bedrest
  • traction
  • reduced weightbearing status
  • strengthening the gluteus medius muscle
  • balance training
  • gait training within mobility precautions

Slipped Capital Femoral Epiphysis (SCFE)

"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."

• Most common in pre-adolescents and adolescents, with the highest rate of occurrence at 10-15 years
• Other risk factors include obesity, male gender, can be associated with certain genetic predispositions
• diagnosis can be difficult due to either atypical presentation (i.e. knee or thigh pain) or a chronic nature of the presentation

Clinical signs:

Acute SCFE

• common with twisting injuries or traumatic falls
• more mild complaints
• atypical pain presentation in groin, thigh, knee
• limited weight bearing tolerance on involved side
• position of comfort: external rotation with a "shortened" limb

Chronic SCFE

• More frequently seen
• patient reports 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

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

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

Aetiology:

• Most cases are idiopathic
• There is an association between development of SCFE and patients with endocrine disorders, renal disorders, and Down syndrome

Intervention:

Role of rehabilitation:

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

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

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

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

Activity Exacerbation

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

Osteochondritis Dissecans

Definition

Clinical signs:

Potential rehabilitation examination findings

Intervention:

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

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

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

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

Osgood-Schlatter Syndrome

Definition

Clinical signs:

Potential rehabilitation examination findings

Intervention:

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

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

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

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

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

Sever's Disease

Definition

Clinical signs:

Potential rehabilitation examination findings

Intervention:

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

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

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

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

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