Paediatric Limping Gait

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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]

Limping gait is not typical in the paediatric population.[2] 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.[3] However, there are medical conditions where limiping gait is a sign of an emergency condition and can be life-threatening.[4]. 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[edit | edit source]

ADD flowchart from video

The above flowchart was presented by Palisano et al[5] 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"[edit | edit source]

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[edit | edit source]

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:

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 [2][4][5]
Gait Pattern Description/Clinical Observations Common Causes
Antalgic gait[4][5] 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)[5] Posterior trunk lean with a hyperextended hip seen at loading response during stance[6] Weakness of gluteus maximus muscle
  • developmental dysplasia of the hip[5]

Cerebral palsy[5]

Steppage (equinus) gait Exaggerated hip and knee flexion during swing phase secondary to lacking active dorsiflexion of the foot

*** neurological examination indicated ***[2]

Vaulting gait Weight-bearing knee locked in hyperextension at the end of the stance phase requiring the child to "vault" over the stance extremity
Circumduction gait[5] The involved limb is moved in a semi-circular movement utilising[7] a combination of hip hiking, forward rotation of the pelvis, and abduction of the hip[5] in order to clear the swinging limb over the ground[7]
  • Painful foot[5]
  • Leg length discrepancy (inequality)[5]

*** neurological examination indicated ***[2]

Stooped gait[4] Bilateral hip flexion throughout 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."[8]

  • common cause of hip[8][2] and leg[2] pain in children
  • inflammation and pain tends to be short-term[8]
  • condition is benign and can make mobility self-limiting[8]
  • most common in children under the age of 10 years[2]

Clinical signs: fever without elevated leukocytes seen in white blood cell count (WBC)[2]

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[8]
Aetiology:[edit | edit source]
  • exact aetiology is unknown[8]
  • in the paediatric population, it is common to have a history of recent upper respiratory tract infection[2][8], pharyngitis, bronchitis, or otitis media[8]
  • other potential etiologies include: recent traumatic injury[8] or viral symptoms to include vomiting, diarrhea, or common cold symptoms[9]
Intervention:[edit | edit source]
  • inflammation typically resolves on its own within seven days[2] to two weeks[8]
  • role of rehabilitation: [2]
    • energy conservation and activity limitation/modification
    • stretching
    • pain management (however typically self-resolving within 24-48 hours[8])

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."[10]

  • knee[2] and hip[10] 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. [10]
  • most common in children under the age of 5 years[2]

Clinical signs: fever with elevated leukocytes in a WBC[2], resistance to move the affected joint[10], joint pain[10], joint warmth[10], and significant swelling of the involved joint[2]

Potential rehabilitation examination findings:

  • Limited joint range of motion
  • Painful joint palpation[10]
Aetiology:[edit | edit source]
  • most often caused by a bacterial organism in children[2][10]
  • can occur after a foreign object penetrates a joint[2]
Intervention:[edit | edit source]
  • Joint aspiration (draining)[2]
  • Antibiotics management [2]
  • Severe cases may require joint immobilisation up to 3 days[10]
  • Proper medical treatment resolves symptoms within a week[2], however the patient should return for medical reassessment if no improvement is seen within 5-6 days[10]
  • Role of rehabilitation:[2]
    • 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[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" [11]

  • Acute hematogenous osteomyelitis affecting the metaphysis of the long bones occurs more frequently in children[12] compared to adults, where the vertebrae are more commonly involved[11]
    • Knee most commonly affected in children, and can include the distal femur and proximal tibia[2]
  • Most common in children under the age of 3 years[2]
  • Requires immediate referral, medical intervention and treatment to begin as soon as possible[2]

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).[2]

Potential rehabilitation examination findings:[12]

  • 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:[edit | edit source]
  • 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[2][11]
Intervention:[edit | edit source]
  • 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"[11]
  • Vacuum-assisted wound closure devices can be effectively utilised to speed the closure of large or deep wounds resulting from extensive debridement[11]
  • Medical treatments can require 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]

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.[3]

Vascular Causes[edit | edit source]

Key clinical indications: no fever or a history of 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.[13]

  • Most common in children aged 3-12 years[13], with the highest rate of occurrence at 4-8 years[2]
  • Male to female ratio 4:1 to 5:1[2] [13]
  • Other risk factors include (1) low socioeconomic status, (2) dietary issues, (3) secondhand smoke exposure, and (4) perinatal human immunodeficiency virus (HIV) infection[2][13]

Clinical signs:

  • Sudden onset of limping gait without fever, swelling, or recent traumatic event[2]
  • Antalgic gait acutely progressing to Trendelenburg gait chronically [2][13]
  • Subjective report of pain: initially may have no complaints of pain but as the disease progresses may report pain with activity[2][13]
    • If pain is present, common to be localised to the hip or referred to the knee, thigh, or abdomen[2][13]
    • 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 [2][13]
  • Decreased hip abduction and internal (medial) rotation ranges of motion. [2]
  • Disuse atrophy of thigh and buttock musculature[13]
  • Leg length discrepancy[13]
Aetiology:[edit | edit source]
  • 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[13]
Intervention:[edit | edit source]

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[2] [14][15]
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[14]
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[14]
  • 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[14]
longest phase, can last multiple years
4 Residual [2]or Healed[14] Stage
  • bone regrowth is complete
  • femoral head achieves its final shape[14]
continues until skeletal maturity[15]


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.[15]

Table 3.0 Herring (Lateral Pillar) Classification[15]
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.[13]

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.[13]

Non-operative Interventions:

  • Recommended patient population: children aged 6 years or younger or lateral pillar A classification[13]
  • Activity: mobility and activity limitations to included decreased weight-bearing recommended, physiotherapy still indicated within activity limitations[13] (see role of rehabilitation section below)
  • Current literature does not support the use of bracing, casting, or orthotics[13]
  • Pain management including use of non-steroidal anti-inflammatory drugs (NSAIDS)[2][13]
  • Referral to orthopedist for disease monitoring[13]
  • Up to 60% of patients will only require non-operative interventions[2]

Operative Interventions:[13]

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 weightbearing 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."[16]

  • Most common in pre-adolescents and adolescents[16], with the highest rate of occurrence at 10-15 years[2]
  • Other risk factors include obesity, male gender, can be associated with certain genetic predispositions[2][16]
  • diagnosis can be difficult due to either atypical presentation (i.e. knee or thigh pain) or a chronic nature of the presentation[16]
  • 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[17]") of the hip.

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[2]


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[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[16]

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.[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 more than 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 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 development of SCFE and patients with endocrine disorders, renal disorders, and Down syndrome[16]
Intervention:[edit | edit source]

Medical interventions typically include surgical fixation with the goals (1) decreasing femoral displacement, (2) maintaining range of motion, and (3) preventing premature degenerative arthritis.[2][16]

In situ fixation with Percutaneous Screws  

  • The aim is to prevent further slippage of the epiphysis
  • Up to 6-weeks ostoperatively: stable slips can weighbear as tolerated, unstable slips are limited to partial weightbearing status[16]

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 postoperatively: limited to partial weightbearing status[16]

Femoral Osteotomy

  • Indicated for more severe deformity with a slip greater than 30 to 45 degrees[16]

Osteochondroplasty

  • Indicated for mild and moderate chronic deformity cases where a prominent metaphyseal bump causes pain and restricts range of motion[16]

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 patient's lifetime as they may experience degenerative changes of the involved hip later in life
  • if they experiences complications such as avascular necrosis or chondrolysis, will require guidance on how to modify activities, decrease weight bearing through the involved limb, and gentle range of motion to mobility maintenance

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] range 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."[18]

  • Also known as an osteochondral lesion[18]
  • It is a local injury to the articular surface of the bone cause 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][18]
  • Can occur throughout the lifespan, however the majority of case occur in ages 10 to 20 years[18]
  • Male to female ratio 2:1[18]

Stable fragments: 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: may remain in place or become a loose body within the joint

Clinical signs:

Potential rehabilitation examination findings

  • catching and locking during passive range of motion[2]
  • decreased or painful range of motion[18]
Aetiology:[edit | edit source]
  • The etiology is not a fully understood and is likely multi-factorial in origin
  • Causes can include:
Intervention:[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. [18]

Stable lesions: [18]

  • conservative management is preferred with immobilization and protective weightbearing
  • failure of conservative treatment may be treated with retroarticular or transarticular drilling techniques

Unstable or displaced lesions: [18]

  • 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 lesion:[2]

  • improving range of motion
  • increasing weightbearing activities and tolerance
  • strengthening to knee stabilising musculature


When providing post-surgical treatment:[2]

  • pain management
  • range of motion
  • gradual increase in weightbearing 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."[19]

  • also known as osteochondrosis, tibial tubercle apophysitis, or traction apophysitis of the tibial tubercle[19]
  • this is a common cause of anterior knee pain in the skeletally immature (male 12-15 years, female 8-12 years) athletes[19]
  • commonly associated with soccer[2][19], basketball[2][19], volleyball[2] [19] and football players, sprinters, and gymnasts[19]
  • syndrome onset is gradual and commonly associated with repetitive activities of the knee[2][19]
  • while the syndrome is benign, recovery can be long and result in an absence from sport[19]

Clinical signs:

  • tenderness over tibial tubercle[2][19]
  • bony lump along the tubial tubercle[2]

Potential rehabilitation examination findings

  • 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 suspect able to injury after periods of rapid growth
    • in rare causes 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.[19]

Intervention:[edit | edit source]

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

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


Role of rehabilitation:

Will need to gradually correct underlying predisposing biomechanical factors in a balanced way with rest from activity and pain management.

  • Swelling management
  • gradual strengthening activities, especially of the quadriceps
  • gradual weightbearing activities and tolerance
  • stretching
  • activity modification and therapeutic rest
  • supportive brace as needed

Sever's Disease[edit | edit source]

Definition

Clinical signs:

Potential rehabilitation examination findings

Aetiology:[edit | edit source]
Intervention:[edit | edit source]

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.

Resources[edit | edit source]

  • bulleted list
  • x

or

  1. numbered list
  2. x

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 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. 5.00 5.01 5.02 5.03 5.04 5.05 5.06 5.07 5.08 5.09 5.10 5.11 5.12 5.13 Palisano RJ, et al. Campbell's physical therapy for children. St. Louis, Missouri: Elsevier; 2017.
  6. Dutton M, Dutton's Orthopaedic Examination, Evaluation, and Intervention. 5th ed. New York: McGraw Hill; c2020.
  7. 7.0 7.1 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.
  8. 8.00 8.01 8.02 8.03 8.04 8.05 8.06 8.07 8.08 8.09 8.10 Whitelaw CC, Varacallo M. Transient synovitis. InStatPearls [Internet] 2022 Sep 4. StatPearls Publishing.
  9. 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
  10. 10.0 10.1 10.2 10.3 10.4 10.5 10.6 10.7 10.8 10.9 Ifeanyi I. Momodu, Vipul Savaliya. Septic Arthritis. InStatPearls [Internet] 2022 July 3. StatPearls Publishing.
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