In this section
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
Imaging
Laboratory tests
| Test | Condition | Expected finding |
| CBC |
Infection |
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 |
|
| Apophysitis/ musculoskeletal conditions: ‐Osgood‐ Schlatter ‐Patella femoral pain ‐Sindig‐Larsen‐Johanssen Syndrome ‐Severs |
Tender to palpation over apophysis +/‐ x‐ray findings |
Local options: CHW main campus and CHW Green Sports Medicine Physical Therapy
|
| Cerebral palsy | Neurology deficits with motor impairment Hypertonia Non painful limp |
|
| 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) |
|
| Developmental dysplasia of hip | Check history for female, first born, breech, and family history. + Ortalani and Barlow, asymmetric thigh fold, + galeazzi, + klisic |
|
| Discitis | Back pain, +/‐fever, decreased spinal motion, often systemic symptoms and systemically ill |
|
| Foreign Body | Possible history of foreign body, red, swollen, +/‐ x‐ray findings |
|
| Fracture | Swelling/pain with motion/palpation: + x‐ray findings: If tender over physis assume fracture |
|
| 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 |
|
| 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 |
|
| Juvenile inflammatory arthritis | Morning pain, often multiple joint involvement, chronic, younger than sixteen, +/‐CBC, ESR, ANA, AntiDNAse B, ASO |
|
| Kohler’s disease | Pain/swelling mid foot, limp, + x‐ray findings navicular bone |
|
| 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 |
|
| Limb length discrepancy | +/‐limp, not painful, + galeazzi, + AP leg length films |
|
| Lyme Arthritis | Exposure to endemic area, +/‐target rash, swelling/pain joints, +Lyme titer with +western blot |
|
| Neoplasm | Progressive or intermittent, deep seated, gnawing pain, often worse at night, +/‐ constitutional symptoms, +/‐ elevated labs, +/‐ x‐ray findings |
|
| Non accidental Trauma | Injury doesn’t match story, child non‐ ambulatory with high suspicion fractures, + x‐ ray findings of affected area |
|
| Osteochondritis dissecans | Pain +/‐ swelling affected joint, increase with activity, +/‐ catch/locking, + x‐ray findings or older child/teen |
|
| Osteomyelitis | Local tenderness/swelling bone, limp,+/‐ fever, elevated CBC, ESR, and CRP |
|
| Restless Leg Syndrome | Sleep disturbance, normal physical exam, no systemic symptoms, meet NIH RLS guidelines criteria |
|
| Rickets | No supplemental vitamin d, darker skin, genu varum and x‐rays findings: widening/cupping of the metaphysis; abnormal labs |
|
| Scoliosis | Thoracic/lumbar prominence on Adams forward bend test/ asymmetric shoulders/pelvis; Rarely painful; x‐ray PA/lateral scoliosis shows scoliosis |
|
| Septic joint | Pain with joint motion, redness, swelling, warmth, restricted joint motion, non‐weight bearing or limp, fever, elevated CBC, CRP, ESR +/‐blood cultures |
|
| 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 |
|
| Spondylolysis / Spondylolisthesis | Pain with back extension, AP/Lat/Oblique lumbar sacral spine films +/‐ findings |
|
| Strain/sprain | Tender to palpation over soft tissue, +/‐ laxity, swelling, no significant pain with weight bearing |
|
| Tarsal coalition | Pain in foot with activity, often flat foot and restricted subtalar foot motion, +/‐ x‐ray findings |
|
| 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
If any of following symptoms refer to CHW Emergency for septic joint work up protocol
|
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