Lower extremity pain

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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.


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.


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 tests table for lower pain extremity


Laboratory tests

Test  Condition Expected finding


Elevated WBC & Platelets
Elevated WBC & Platelets
 CRP Infection
 ESR Infection
 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
False positive 
Markedly positive
Mildly positive 
Lyme  Lyme disease
False positive titer (exposed but no
Titer positive and Western Blot positive 
Synnovial Cell Count  Septic arthritis
Transient synovitis
Turbid fluid; WBC >50,000 to over 100K, PMNS >75%
Clear yellow synovial fluid; WBC 5, 000‐15K, PMNs <25%
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 
musculoskeletal conditions:
‐Osgood‐ Schlatter
‐Patella femoral pain
‐Sindig‐Larsen‐Johanssen Syndrome
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
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
  • 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
  • splint and refer to CHW orthopaedics if non‐displaced and closed fracture
  • urgent care or emergency department if open fracture, displacement, or angulation
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
  • refer to Red Book: Report of the Committee on Infectious Disease (most recent
  • involvement of local subspecialists as needed (i.e. infectious disease and/or
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
  • 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
  • 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 
  • 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
  • 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

  • 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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