Paediatric Limping Gait

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Introduction

kids typically don't walk with a limp. So if they have a limp, you want to check out why. So there's a lot of differential diagnoses for children who are limping. So we want to first separate it into those that are limping and also have pain, and those that are limping without pain.

Limping Gait and Pain

ADD flowchart from video (with vs without pain)

Make into table

So, under the limping with pain. This could be something like an infection, a vascular compromise, a mechanical failure, or an overuse. And for our children that are limping without pain, but might have some sort of deformity that you notice. This can be from a leg length discrepancy, that club foot, or even developmental dysplasia of the hip.

So this is a nice little flow chart that you can follow for figuring out what you should do with your patient. So if you have a child who has a limp, what you're going to do is you're going to look at okay, do they have pain with active or passive range of motion of the hip, knee, ankle, or palpation over the long bones of the limb or the foot? If no, then you're going to make sure you assess their neuro exam. If their neuro exam is not normal, you want to think about things like CP, (cerebral palsy) myopathies, involvement of the spinal cord. If their neuro exam is normal, you want to think about some congenital hip diseases, if there's a leg length inequalities, clubfoot, or potentially even idiopathic toe walking.

If they do have pain, you want to find out if there's trauma. If there's trauma, okay. You want to think about, okay, what are some acute injuries that could have happened? A contusion, a sprain, a strain, a stress fracture, and even a SCFE (slipped capital femoral epiphysis) that we'll get into a little bit more. If they don't have any history of trauma, they're like, I don't know, it hurts. Nothing I can think about has happened. You then would say, okay, do you have a fever? Because that then helps you separate out some other conditions. So if they have a fever, you're thinking about some things like septic arthritis, osteomyelitis, transient synovitis, an acute rheumatic disease, or discitis. You can see all these itises are these kind of inflammatory conditions. If they don't have a fever, then you're going to be looking at some other sorts of conditions that we're going to get into here soon.

Another thing you can do is look at how old they are. So there are certain diagnoses that are more common in particular ages. So this just gives a nice little breakdown from birth to five years, four to 10 years, and that adolescent stage 11 to 15 years of what you would be most likely to think about looking for in your limping child.

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.

So a lot of times with our children who limp, what we'll see is that they're avoiding behaviours that involve weight-bearing activities. When you look at their gait, they're spending less time in single limb stance on the affected side, usually we'll see limited hip extension at terminal stance on that affected side, and sometimes limited hip flexion at terminal swing and initial contact. So all these things to kind of decrease their full excursion of range of motion and decrease their time in weight bearing.

So here's just a nice little gait observation chart that you can use to look at when children have a limp. What should you think about? So if they have that shortened stance phase on the affected side, we call that that antalgic gait. You want to look to see do they have tenderness or reduced range of motion? Have any radiographs been done? And sometimes these are really from trauma, maybe a toddler's fracture, overuse, infection, or inflammation. If you find that they have this, what we call abductor lurch or this trendelenburg, that kind of lateral trunk leaner or that hip drop, you potentially want to make sure that their pelvis looks okay. Did they have radiographs with their pelvis? And there you want to think about potentially some hip dysplasia or potentially even CP. If they have a toe-to-heel gait, so they have initial contact with their forefoot, they have this toe-walking pattern. It can be called an equinus gait pattern. You want to look, do they have a heel cord contracture? Do they have decreased range of their gastroc and soleus? You want to make sure you do a neuro exam to see is this idiopathic toe walking? Is it clubfoot? Do they potentially have CP? And if we find that they're circumducting their legs, so they're swinging it out and around to kind of get it around, you want to look at their limb length, do a neuro exam, check their range of motion. And this could really be from a painful foot. It could be from leg length discrepancies.

Infection

So let's look at some of these infection causes for a child who limps. So infection is associated with fevers most likely. So if you have a child who limps and they have a fever, you're going to think about things like transient synovitis, septic arthritis, and osteomyelitis.

So transient synovitis. So this is when there's this transient, which means short-term passing inflammation. So what we find is that if you have a child who's recently had an infection, a lot of times it's associated with an upper respiratory infection. And then a little bit after that, they end up with this pain in their hip or their leg. It can be associated with this inflammation that then settles into the hip joint of that hip synovium. And a lot of times we're seeing this in our younger children, so children that are under 10 years of age. So oftentimes clinical signs are that fever, but they don't have elevated leukocytes when they do blood work.

Typically, this resolves within seven days without need for any significant medical management. PT (physical therapy) is really only involved to help with limiting activities, stretching, pain management but tends to resolve on its own. A lot of times these are children that you'll see more in the acute care environment, less so on the outpatient side, unless they're just coming into your clinic because they haven't really been worked up for anything yet.

Next we have septic arthritis, so this is when there's an infection of a joint that's often caused by a bacterial organism. This is really often seen, particularly in the knees and particularly with our young children who are under five years old. Or if you find that a child has had a foreign object penetrate a joint, so you know you have a child that's playing outside and they get a stick through their ankle, okay. So that's something that you're going to be worried about septic arthritis.

Clinical signs are that they have a fever and they have elevated leukocytes and significant swelling of the joint. You want to make sure that if you see this in your clinic, they go to the doctor right away. They often will need aspiration or draining of that joint and antibiotics to manage it. If it's drained and they have antibiotics, this often resolves within about a week. We are often involved, again, mostly on the acute care side with making sure that we're assisting with gaining back active range of motion, helping them with walking and weight-bearing activities. You will often find that these children are very reluctant to weight bear, very reluctant to obtain full range of motion, and will sit in this kind of guarded position, open pack position of their joint that's affected. So making sure they regain full range of motion, walking, weightbearing are really, really important.

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

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

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

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

Vascular Causes

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Activity Exacerbation

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

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.

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.

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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