Tools and resources

Lower extremity pain

Updated by: Dr. Allison Duey-Holtz, MSN
Updated on: 5/2012

Lower extremity musculoskeletal pain is common, the possible etiologies are broad, ranging from benign to serious. The goal of this practice guideline is to present the tools for a provider to determine the diagnosis for a child with lower extremity pain in an efficient manner. This practice guideline is a reference for providers when caring for a patient with lower extremity musculoskeletal pain.

Signs and symptoms

The list of differential diagnoses for lower extremity pain is extensive and broad. A thorough history and physical exam will aid the provider in identifying the correct diagnoses. Always be familiar with the child's medical history

Focused history of musculoskeletal pain

Timing of pain

Timing can aid in diagnosis. Acute onset of symptoms suggests a more acute diagnosis such as septic arthritis, osteomyelitis, fracture, or malignancy. In contrast, morning symptoms that improve through the day are more suggestive of a rheumatologic etiology. Pain after activities is suggestive of an overuse syndrome or stress fracture. Night waking pain can be a benign etiology such as growing pains or more serious etiologies such as malignancy or osteoid osteoma. Identify any preceding activities and/or sports played surrounding the symptoms.

Sample questions:

When did the pain start? What makes the pain better/worse? Rate pain on a scale
Is the pain activity related?
Is the pain bad enough to prevent the child from their activities, sports/play or school?
How does the child feel after sports or play activities?
Is the pain night waking versus in the AM or after naps?

Associated systemic features

Serious conditions will typically cause systemic symptoms. Be concerned by children who have stopped playing or teens who are limiting athletics or social activities.
Sample questions:

Presence and time of fevers.
Association with any rashes, weight loss, change in activity, decreased appetite, lethargy and/or a change in sleep patterns.

Nature and location of pain

Children are often better at demonstrating the location of the pain. In verbal children, it may be beneficial ask them to use their index finger to identify the point of maximum tenderness.

Sample questions:

Asking the patient to show them with their finger the one pin point place that hurts the most, where would that be?
- If the child is unable to locate the area of maximum tenderness, ask them to draw a line with their finger demonstrating where the pain starts and stops. In non‐verbal children, rely on the parent's perceptions of where the pain is.
Can you describe the pain? Where does the pain start/stop?

Physical exam

A thorough musculoskeletal examination is important for diagnosis. The focused musculoskeletal examination includes pediatric orthopaedic, neurologic, and rheumatologic aspects. Always start with a presumed non‐painful area, especially in small children, performing the examination of the painful area last.

Musculoskeletal exam features:

Inspect and palpate both lower extremities
- Identify the site of maximal tenderness
Examine the joints for swelling and range of motion
Evaluate range of motion to all upper and lower extremities including bilateral shoulders, elbows, wrists and fingers, hips, knees, ankles, and toes.
- Be aware of the knee‐hip‐back triad. Often hip pain is referred to the knee. Back pain can refer to the hip or radicular pain from the spine will present with pain down the leg.
- When evaluating knee pain always include evaluation of the hip.
Include palpation of all extremities.
- Assess for joint range limitation, warmth, and swelling. Neuromuscular exam
Evaluate the undressed child through several gait cycles pay attention to each limb and joint.
- Running may help uncover subtle gait abnormalities.
- To minimize the affected limb's pain, the amount of time spent in the stance phase decreases and that spent in the swing phase increases (Barkin, Barkin & Barkin, 2000; Herring, 2007; Laine, Kaiser & Diab, 2010; Leet & Skaggs, 2000; Renshaw, 1995; Wyndam, 2007).
Examine deep tendon reflexes, tone, clonus, sensation, straight leg raise, muscle wasting, evaluation of the feet and toes for clawing, or deformity (Herring, 2007; Leet & Skaggs, 2000; Morrissy & Weinstein, 2006; Wenger & Rang, 1993).
- A positive exam finding from above is suggestive of an etiology from either the spinal cord or a nerve root.

Causes

The etiology of musculoskeletal pain, with or without a limp, is broad. Below are commonly seen etiologies for musculoskeletal pain. The diagnoses can be grouped into the following categories:

Trauma: (i.e. strains/sprains, fractures, dislocations)
Infection: septic arthritis, osteomyelitis, brodies abscess
Immune‐mediated: toxic synovitis, juvenile rheumatoid arthritis, Lyme disease, Strep reactive arthritis, osteoid osteoma
Acquired: slipped capital femoral epiphysis (SCFE), Legg‐Calve‐Perthes disease
Neoplastic: leukemia/lymphoma, Ewing's sarcoma, osteosarcoma
Referred: discitis, psoas abscess, spine or hip pathology
Benign musculoskeletal: Growing pains, tendonitis/apophysitis Additional, non‐painful etiologies that can cause a limp to consider include:
- Congenital: developmental dysplasia of the hip
- Non‐painful limp: leg length discrepancy, scoliosis
- Neurologic: cerebral palsy, myelomeningocele, or underlying neuromuscular pathology

Risk factors

The vast majority of parents/care takers will identify a history of trauma for any source of musculoskeletal pain, especially in the young and non‐verbal. Most often the etiology of musculoskeletal pain is related to accidental injury. However, it is important for a provider to always remember the vast number of other causes of musculoskeletal pain.

Complications

While most musculoskeletal pain can be traced to a benign condition, one must remember infection and neoplastic processes can mimic many other diseases. The purpose of these guidelines is to provide the provider with the tools to work up patients with lower extremity pain in a timely manner, which in result will prevent further morbidity and medical complications

Recommendations for providers considering referral to pediatric orthopedic specialist

Pre work-up

Work‐up algorithm

History of trauma in lower extremity pain

Imaging

Imaging tests table for lower pain extremity

Laboratory tests

Test	Condition	Expected finding
CBC	Infection Inflammation Malignancy	Elevated WBC & Platelets Elevated WBC & Platelets Cytopenia
CRP	Infection Inflammation Malignancy	Elevated Elevated Elevated
ESR	Infection Inflammation Malignancy	Elevated Elevated Elevated
ASO	Acute rheumatic fever Unresolved/undetected Group A hemolytic strep	Markedly increased & usually very ill child Increased ASO, sore throat
AntiDNAse B	Acute rheumatic fever Unresolved/undetected Group A hemolytic strep	Positive & usually very ill child Positive
ANA	SLE False positive	Markedly positive Mildly positive
Lyme	Lyme disease False positive titer (exposed but no disease)	Titer positive and Western Blot positive
Synnovial Cell Count	Septic arthritis Transient synovitis JIA	Turbid fluid; WBC >50,000 to over 100K, PMNS >75% Clear yellow synovial fluid; WBC 5, 000‐15K, PMNs <25% 25,000‐100,000K
Blood Cx	Infection	+/‐ positive
Joint/Bone Cx	Infection	+/‐ positive
Stool Cx	Reactive arthritis with diarrhea	Salmonella,Shigella, Yersinia, Campylocbacter
Urine Cx	Reactive arthritis	Neisseria gonorrhoeae or Chlamydia
Serum ferritin	Restless Leg Syndrome	Meet NIH RLS criteria Serum Ferritin < 50mcg

Treatment and Referral of Pediatric Lower Extremity Pain

Musculoskeletal complaints most commonly are from diagnoses treated by orthopedic and sports medicine providers. Occasionally, the underlying etiology
causing musculoskeletal pain is from a problem not usually treated by orthopedic sub‐specialists. Below are common conditions that present with lower
extremity pain and/or limp. Included are initial interventions orthopedic providers implement.

Clinics at the CHW Orthopedic Center & Sports Medicine Program include:

Cerebral Palsy Clinic
Concussion
Fracture
General Orthopaedic
Scoliosis Sports
Medicine Trauma
Well child lower extremity screening clinic

Clinic locations: Children’s Wisconsin‐Milwaukee; CHW‐Greenway; CHW‐New Berlin (concussion only)
To schedule an appointment :
Central Scheduling (414) 607-5280 or toll free (877) 607-5280
Orthopedic nurse line: (414) 266-2513
Sports line (414) 604-6512

Diagnosis	History, Physical and Test findings	Treatment and Referral
Accessory navicular	Medial foot pain + x‐ray findings	conservative treatment with Non‐steroidal anti‐inflammatory drugs (NSAIDS) activity modification possible immobilization or orthosis referral to CHW Orthopedics or Sports Medicine with no improvement
Apophysitis/ musculoskeletal conditions: ‐Osgood‐ Schlatter ‐Patella femoral pain ‐Sindig‐Larsen‐Johanssen Syndrome ‐Severs	Tender to palpation over apophysis +/‐ x‐ray findings	NSAIDS or Naproxen twice a day may consider short one to two week immobilization or bracing physical therapy (PT) 1‐2 times per week for 6‐8 weeks to include range of motion of affected joint(s), strengthening of lower extremities including hamstring/quadriceps/gluteus/calf muscles, with a return to sports program Local options: CHW main campus and CHW Green Sports Medicine Physical Therapy follow up in 6 weeks, consider referral to CHW Sports Medicine with no improvement of symptoms
Cerebral palsy	Neurology deficits with motor impairment Hypertonia Non painful limp	Referral to CHW Multi Disciplinary Cerebral Palsy Clinic or CHW Physical Medicine and Rehabilitation
Complex regional pain syndrome	Pain after an injury, lower limb most common; pain to light touch that is disproportionate to mechanism of injury; evaluate for autonomic symptoms (skin temp different; color changes, absence of sweating)	NSAIDS or Naproxen twice a day begin PT for desensitization discontinuation of any bracing refer to CHW Pain & Palliative Care
Developmental dysplasia of hip	Check history for female, first born, breech, and family history. + Ortalani and Barlow, asymmetric thigh fold, + galeazzi, + klisic	refer to CHW Pediatric Orthopedics with positive exam findings or imaging studies (ultrasound or x‐ray)
Discitis	Back pain, +/‐fever, decreased spinal motion, often systemic symptoms and systemically ill	Referral to CHW emergency room treat with IV antibiotic therapy with inpatient admission. involvement of CHW orthopedics consider LSO immobilization for pain control
Foreign Body	Possible history of foreign body, red, swollen, +/‐ x‐ray findings	remove of foreign body antibiotic prophylaxis as needed if surgical excision required referral to CHW general surgery or orthopedics if bone involvement
Fracture	Swelling/pain with motion/palpation: + x‐ray findings: If tender over physis assume fracture	splint and refer to CHW orthopaedics if non‐displaced and closed fracture urgent care or emergency department if open fracture, displacement, or angulation present
Gonococcal/ Chlamydial arthritis	+ Sexual activity; arthritis of one or more joints; sometimes accompanying dermatitis and systemic signs and symptoms; +/‐ positive nucleic acid amplification (NAAT) tests of synovial fluid, urine, vagina/cervix	involvement of local subspecialists as needed , (i.e. infectious disease and/or rheumatology), orthopaedics if septic joint I&D and antibiotic treatment if septic joint antibiotic treatment if aseptic joint and chlamydia likely plus pain management
Growing Pains	Late evening or night time lower extremity pains, usually bilateral, resolve with pain reliever/massage, not typically during day. X‐rays negative/Labs negative	conservative management using symptomatic NSAIDS, massage, warmth, and other supportive measures until the syndrome resolves with time may try a course of PT with muscle stretching and exercise Restless Leg Syndrome may present as growing pains. Consider referral to CHW
Juvenile inflammatory arthritis	Morning pain, often multiple joint involvement, chronic, younger than sixteen, +/‐CBC, ESR, ANA, AntiDNAse B, ASO	symptomatic relief can be obtained with NSAIDS referral to a CHW Pediatric Rheumatology
Kohler’s disease	Pain/swelling mid foot, limp, + x‐ray findings navicular bone	restrict weight bearing and splint (ie prowalker) consider refer to CHW orthopedics
Legg‐Calve‐Perthes disease	White males 4‐10yo, hip and groin pain, decreased internal hip rotation, x‐ray findings: flattening and fragmentation of femoral head	restrict activities and refer to CHW Orthopedics
Limb length discrepancy	+/‐limp, not painful, + galeazzi, + AP leg length films	refer to CHW Orthopedics
Lyme Arthritis	Exposure to endemic area, +/‐target rash, swelling/pain joints, +Lyme titer with +western blot	refer to cdc.gov for most recent treatment guidelines OR refer to Red Book: Report of the Committee on Infectious Disease (most recent edition) involvement of local subspecialists as needed (i.e. infectious disease and/or rheumatology)
Neoplasm	Progressive or intermittent, deep seated, gnawing pain, often worse at night, +/‐ constitutional symptoms, +/‐ elevated labs, +/‐ x‐ray findings	expedited referral to Children's/Froedtert pediatric musculoskeletal tumor specialist or pediatric oncologist
Non accidental Trauma	Injury doesn’t match story, child non‐ ambulatory with high suspicion fractures, + x‐ ray findings of affected area	treat injuries and begin further workup to evaluate for non accidental trauma based upon CHW facility guidelines admit to hospital for safety of patient and further work up
Osteochondritis dissecans	Pain +/‐ swelling affected joint, increase with activity, +/‐ catch/locking, + x‐ray findings or older child/teen	treat initially with activity restrictions, immobilization, and non weight bearing to affected limb NSAIDS refer to CHW Sports Medicine
Osteomyelitis	Local tenderness/swelling bone, limp,+/‐ fever, elevated CBC, ESR, and CRP	refer to emergency room emergent
Restless Leg Syndrome	Sleep disturbance, normal physical exam, no systemic symptoms, meet NIH RLS guidelines criteria	Referral to pediatric sleep center
Rickets	No supplemental vitamin d, darker skin, genu varum and x‐rays findings: widening/cupping of the metaphysis; abnormal labs	treatment of rickets by primary care provider with involvement of CHW endocrine team as needed refer to CHW Orthopedics for treatment of genu varum
Scoliosis	Thoracic/lumbar prominence on Adams forward bend test/ asymmetric shoulders/pelvis; Rarely painful; x‐ray PA/lateral scoliosis shows scoliosis	refer to CHW Orthopedics‐scoliosis/spine conditions clinic
Septic joint	Pain with joint motion, redness, swelling, warmth, restricted joint motion, non‐weight bearing or limp, fever, elevated CBC, CRP, ESR +/‐blood cultures	emergent ultrasound hip joints to evaluate for septic hip refer CHW Emergency room septic joint work up protocol
Slipped Capital femoral epiphysis	Often seen 10‐14yo teens, M>F, overweight, groin/knee pain, pain internal hip rotation, limp, + AP/frog lateral Pelvis x‐ray	emergent strict non‐weight bearing refer to emergency room for surgical stabilization
Spondylolysis / Spondylolisthesis	Pain with back extension, AP/Lat/Oblique lumbar sacral spine films +/‐ findings	refer to CHW Orthopedics‐scoliosis/spine conditions clinic NSAIDS as needed for pain consider activity limitations until seen by subspecialty providers
Strain/sprain	Tender to palpation over soft tissue, +/‐ laxity, swelling, no significant pain with weight bearing	NSAIDS range of motion brace begin ambulation as tolerated refer to physical therapy if needed refer to CHW Orthopedics with recurrent sprains
Tarsal coalition	Pain in foot with activity, often flat foot and restricted subtalar foot motion, +/‐ x‐ray findings	refer to CHW Orthopedics
Toxic synovitis	Mild pain with hip motion, ambulatory, afebrile, normal CBC, CRP, ESR Labs needs to be evaluated	If ambulatory, afebrile, no constitutional symptoms, normal CBC, ESR, CRP, provider comfortable NSAIDS follow up in 2 to 3 days ambulation as tolerated limit sports If any of following symptoms refer to CHW Emergency for septic joint work up protocol Non-weight bearing Febrile or constitutional symptoms Moderate‐severe pain Elevated WBC, CRP or ESR

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