LowerExtremityPainCLINICALGUIDELINESforWorkup

Definition
Lowerextremitymusculoskeletalpainiscommon,thepossibleetiologiesarebroad,rangingfrombenigntoserious.The goalofthispracticeguidelineistopresentthetoolsforaprovidertodeterminethediagnosisforachildwithlower extremitypaininanefficientmanner.Thispracticeguidelineisareferenceforproviderswhencaringforapatientwith lowerextremitymusculoskeletalpain.

Signsandsymptoms Thelistofdifferentialdiagnosesforlowerextremitypainisextensiveandbroad.Athoroughhistoryand physicalexamwillaidtheproviderinidentifyingthecorrectdiagnoses.Alwaysbefamiliarwiththechilds medicalhistory

FocusedHistoryofMusculoskeletalPain TimingofPain Timingcanaidindiagnosis.Acuteonsetofsymptomssuggestsamoreacutediagnosissuchassepticarthritis, osteomyelitis,fracture,ormalignancy.Incontrast,morningsymptomsthatimprovethroughthedayaremore suggestiveofarheumatologicetiology.Painafteractivitiesissuggestiveofanoverusesyndromeorstressfracture. Nightwakingpaincanbeabenignetiologysuchasgrowingpainsormoreseriousetiologiessuchasmalignancyor osteoidosteoma.Identifyanyprecedingactivitiesand/orsportsplayedsurroundingthesymptoms. Samplequestions: Whendidthepainstart?Whatmakesthepainbetter/worse?Ratepainonascale Isthepainactivityrelated? Isthepainbadenoughtopreventthechildfromtheiractivities,sports/playorschool? Howdoesthechildfeelaftersportsorplayactivities? IsthepainnightwakingversusintheAMorafternaps? AssociatedSystemicFeatures Seriousconditionswilltypicallycausesystemicsymptoms.Beconcernedbychildrenwhohavestoppedplayingorteens whoarelimitingathleticsorsocialactivities. Samplequestions: Presenceandtimeoffevers. Associationwithanyrashes,weightloss,changeinactivity,decreasedappetite,lethargyand/orachangein sleeppatterns.
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Nature&LocationofPain Childrenareoftenbetteratdemonstratingthelocationofthepain.Inverbalchildrenitmaybebeneficialaskthemto usetheirindexfingertoidentifythepointofmaximumtenderness. Samplequestions: Askingthepatienttoshowthemwiththeirfingertheonepinpointplacethathurtsthemost,wherewouldthat be? o Ifthechildisunabletolocatetheareaofmaximumtenderness,askthemtodrawalinewiththeirfinger demonstratingwherethepainstartsandstops.Innonverbalchildren,relyontheparentsperceptionsof wherethepainis. Canyoudescribethepain?Wheredoesthepainstart/stop? PHYSICALEXAM Athoroughmusculoskeletalexaminationisimportantfordiagnosis.Thefocusedmusculoskeletalexaminationincludes pediatricorthopaedic,neurologicandrheumatologicaspects.Alwaysstartwithapresumednonpainfularea,especially insmallchildren,performingtheexaminationofthepainfularealast.Musculoskeletalexamfeatures Inspectandpalpatebothlowerextremities o Identifythesiteofmaximaltenderness Examinethejointsforswellingandrangeofmotion Evaluaterangeofmotiontoallupperandlowerextremitiesincludingbilateralshoulders,elbows,wristsandfingers, hips,knees,ankles,andtoes. o Beawareofthekneehipbacktriad.Oftenhippainisreferredtotheknee.Backpaincanrefertothehipor radicularpainfromthespinewillpresentwithpaindowntheleg. o Whenevaluatingkneepainalwaysincludeevaluationofthehip. Includepalpationofallextremities. o Assessforjointrangelimitation,warmth,andswelling. Neuromuscularexam Evaluatetheundressedchildthroughseveralgaitcyclespayattentiontoeachlimbandjoint. o Runningmayhelpuncoversubtlegaitabnormalities. o Tominimizetheaffectedlimbspain,theamountoftimespentinthestancephasedecreasesandthatspent intheswingphaseincreases(Barkin,Barkin&Barkin,2000;Herring,2007;Laine,Kaiser&Diab,2010;Leet& Skaggs,2000;Renshaw,1995;Wyndam,2007). Examinedeeptendonreflexes,tone,clonus,sensation,straightlegraise,musclewasting,evaluationofthefeetand toesforclawingordeformity(Herring,2007;Leet&Skaggs,2000;Morrissy&Weinstein,2006;Wenger&Rang, 1993). o Apositiveexamfindingfromaboveissuggestiveofanetiologyfromeitherthespinalcordoranerveroot.

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Causes
Theetiologyofmusculoskeletalpain,withorwithoutalimp,isbroad.Belowarecommonlyseenetiologiesfor musculoskeletalpain.Thediagnosescanbegroupedintothefollowingcategories: Trauma:(i.e.strains/sprains,fractures,dislocations) Infection:septicarthritis,osteomyelitis,brodiesabscess Immunemediated:toxicsynovitis,juvenilerheumatoidarthritis,Lymedisease,Strepreactivearthritis,osteoid osteoma Acquired:slippedcapitalfemoralepiphysis(SCFE),LeggCalvePerthesdisease Neoplastic:leukemia/lymphoma,Ewing'ssarcoma,osteosarcoma Referred:discitis,psoasabscess,spineorhippathology Benignmusculoskeletal:Growingpains,tendonitis/apophysitis Additionalnonpainfuletiologiesthatcancausealimptoconsiderinclude: Congenital:developmentaldysplasiaofthehip Nonpainfullimp:leglengthdiscrepancy,scoliosis Neurologic:cerebralpalsy,myelomeningocele,orunderlyingneuromuscularpathology

RiskFactorsThevastmajorityofparents/caretakerswillidentifyahistoryoftraumaforanysourceofmusculoskeletal pain,especiallyintheyoungandnonverbal.Mostoftentheetiologyofmusculoskeletalpainisrelatedtoaccidental injury.However,itisimportantforaprovidertoalwaysrememberthevastnumberofothercausesofmusculoskeletal pain. ComplicationsWhilemostmusculoskeletalpaincanbetracedtoabenigncondition,onemustrememberinfectionand neoplasticprocessescanmimicmanyotherdiseases.Thepurposeoftheseguidelinesistoprovidetheproviderwiththe toolstoworkuppatientswithlowerextremitypaininatimelymanner,whichinresultwillpreventfurthermorbidity andmedicalcomplications

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RecommendationsforProvidersconsideringreferraltoPediatricOrthopaedicspecialist o PreWorkup WorkupAlgorithm

Yes No
PerformLabs (Pleasereferto labsectionfor correctlabsto AbnormalExamwithor withoutconstitutional symptoms

HistoryofTrauma

Perform Radiographs

Normal

Perform Radiographs

Differential

Abnormal

Fracture/dislocation SoftTissue OveruseApophysitis Sprain

JointPain

BoneorMusculoskeletalPain AccessoryNavicular Tarsalcoalition LeggCalvePerthes SlippedCapitalFemoral Epiphysis Kohlers Foreignbody Rickets(+/pain) Scoliosis(+/pain)

Treatmentoptions

LeggCalvePerthes SlippedCapital FemoralEpiphysis Osteochondritis dissecans

BoneorMusculoskeletalPain Osteomyelitis, Neoplasm Sacroilitis Abscess Discitis

JointPain +/ effusion
Transientsynovitis Septicjoint Reactive Inflammatory Arthritis

Treatand/orreferas appropriate Consider further workupas needed,

physealtenderness Adapted fromDuey Treatasfractureifpthas

Spondylolysis/listhesis (+/pain) Nonpainful+limp

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Developmental DysplasiaoftheHip Leglengthdiscrepancy Page4

Imaging
LocationofPain Hip Femur Knee Ankle Radiographs Pelvis Femur Knee Tibia Ankle Foot Foot ViewstoObtain AP,frog,lateral AP,lateral AP,lateral,sunrise,notch AP,lateral AP,lateral,mortise AP,lateral,oblique Ultrasound:Effusionofjoints,vascularinjuriessuspected;ex: septichip,infantDDH OtherImagingTests MRI:Softtissueandjoints,largeamountsofeffusion;ex:stress fractures;infection;abscess;neoplasm;ligamentinjury;cartilage evaluation CT:Boneyabnormalitiessuspectedbutnotdefinitivebyxray,ex: intraarticularfracture

LaboratoryTests

Test CBC

Condition Infection Inflammation Malignancy

ExpectedFinding ElevatedWBC&Platelets ElevatedWBC&Platelets Cytopenia Elevated Elevated Elevated Elevated Elevated Elevated Markedlyincreased&usuallyveryillchild IncreasedASO,sorethroat Positive&usuallyveryillchild Positive

CRP

Infection Inflammation Malignancy

ESR

Infection Inflammation Malignancy

ASO

Acuterheumaticfever Unresolved/undetectedGroupA hemolyticstrep Acuterheumaticfever Unresolved/undetectedGroupA hemolyticstrep

AntiDNAseB

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Test ANA

Condition SLE Falsepositive

ExpectedFinding Markedlypositive Mildlypositive TiterpositiveandWesternBlotpositive

Lyme

Lymedisease

Falsepositivetiter(exposedbutno disease) SynnovialCellCount Septicarthritis Transientsynovitis JIA BloodCx Joint/BoneCx StoolCx UrineCx Serumferritin Infection Infection Reactivearthritiswithdiarrhea Reactivearthritis RestlessLegSyndrome Turbidfluid;WBC>50,000toover100K,PMNS>75% Clearyellowsynovialfluid;WBC5,00015K,PMNs<25% 25,000100,000K +/positive +/positive Salmonella,Shigella,Yersinia,Campylocbacter NeisseriagonorrhoeaeorChlamydia MeetNIHRLScriteriaSerumFerritin<50mcg

AdaptedfromJunnila&Cartwright,2006a;Junnila&Cartwright,2006b;Sawyer,J.R.&Kapoor,M.2009,p.220

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TreatmentandReferralofPediatricLowerExtremityPain Musculoskeletalcomplaintsmostcommonlyarefromdiagnosestreatedbyorthopedicandsportsmedicineproviders.Occasionally,theunderlyingetiology causingmusculoskeletalpainisfromaproblemnotusuallytreatedbyorthopedicsubspecialists.Belowarecommonconditionsthatpresentwithlower extremitypainand/orlimp.Includedareinitialinterventionsorthopedicprovidersimplement. ClinicsattheCHWOrthopedicCenter&SportsMedicinePrograminclude: CerebralPalsyClinic Scoliosis Concussion Fracture Trauma GeneralOrthopaedic Wellchildlowerextremityscreeningclinic

SportsMedicine

Cliniclocations:ChildrensHospitalofWisconsinMaincampus;CHWGreenway;CHWNewBerlin(concussiononly) Toscheduleanappointment:CentralScheduling414.607.5280ortollfree877.607.5280 Orthopedicnurseline:414.266.2513 Sportsline414.604.6512

Diagnosis
Accessorynavicular

History,PhysicalandTestfindings
Medialfootpain +xrayfindings

TreatmentandReferral
conservativetreatmentwithNonsteroidalantiinflammatorydrugs(NSAIDS) activitymodification possibleimmobilizationororthosis referraltoCHWOrthopedicsorSportsMedicinewithnoimprovement NSAIDSorNaproxentwiceaday mayconsidershortonetotwoweekimmobilizationorbracing physicaltherapy(PT)12timesperweekfor68weekstoincluderangeofmotionof affectedjoint(s),strengtheningoflowerextremitiesincluding hamstring/quadriceps/gluteus/calfmuscles,withareturntosportsprogram Localoptions:CHWmaincampusandCHWGreenSportsMedicinePhysicalTherapy followupin6weeks,considerreferraltoCHWSportsMedicinewithno improvementofsymptoms

Apophysitis/ musculoskeletalconditions:
OsgoodSchlatter Patellafemoralpain SindigLarsenJohanssenSyndrome Severs

Tendertopalpationoverapophysis +/xrayfindings

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Cerebralpalsy

Neurologydeficitswithmotorimpairment Hypertonia Nonpainfullimp

ReferraltoCHWMultiDisciplinaryCerebralPalsyClinicorCHWPhysicalMedicine andRehabilitation

Complexregionalpainsyndrome

Painafteraninjury,lowerlimbmost common;paintolighttouchthatis disproportionatetomechanismofinjury; evaluateforautonomicsymptoms(skintemp different;colorchanges,absenceof sweating) Checkhistoryforfemale,firstborn,breech, andfamilyhistory. +OrtalaniandBarlow,asymmetricthighfold, +galeazzi,+klisic

NSAIDSorNaproxentwiceaday beginPTfordesensitization discontinuationofanybracing refertoCHWPain&PalliativeCare

Developmentaldysplasiaofhip

refertoCHWPediatricOrthopedicswithpositiveexamfindingsorimagingstudies (ultrasoundorxray)

Discitis

Backpain,+/fever,decreasedspinalmotion, oftensystemicsymptomsandsystemicallyill

ReferraltoCHWemergencyroom treatwithIVantibiotictherapywithinpatientadmission. involvementofCHWorthopedics considerLSOimmobilizationforpaincontrol

ForeignBody

Possiblehistoryofforeignbody,red,swollen, +/xrayfindings

removeofforeignbody antibioticprophylaxisasneeded ifsurgicalexcisionrequiredreferraltoCHWgeneralsurgeryororthopedicsifbone involvement splintandrefertoCHWorthopaedicsifnondisplacedandclosedfracture urgentcareoremergencydepartmentifopenfracture,displacement,orangulation present

Fracture

Swelling/painwithmotion/palpation:+xray findings:Iftenderoverphysisassume fracture

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Gonococcal/ Chlamydialarthritis

+Sexualactivity;arthritisofoneormore joints;sometimesaccompanyingdermatitis andsystemicsignsandsymptoms;+/ positivenucleicacidamplification(NAAT) testsofsynovialfluid,urine,vagina/cervix Lateeveningornighttimelowerextremity pains,usuallybilateral,resolvewithpain reliever/massage,nottypicallyduringday. Xraysnegative/Labsnegative

involvementoflocalsubspecialistsasneeded,(i.e.infectiousdiseaseand/or rheumatology),orthopaedicsifsepticjoint I&Dandantibiotictreatmentifsepticjoint antibiotictreatmentifasepticjointandchlamydialikelypluspainmanagement

GrowingPains

conservativemanagementusingsymptomaticNSAIDS,massage,warmth,andother supportivemeasuresuntilthesyndromeresolveswithtime maytryacourseofPTwithmusclestretchingandexercise RestlessLegSyndromemaypresentasgrowingpains.ConsiderreferraltoCHW symptomaticreliefcanbeobtainedwithNSAIDS referraltoaCHWPediatricRheumatology

Juvenileinflammatoryarthritis

Morningpain,oftenmultiplejoint involvement,chronic,youngerthansixteen, +/CBC,ESR,ANA,AntiDNAseB,ASO

Kohlersdisease

Pain/swellingmidfoot,limp,+xrayfindings navicularbone Whitemales410yo,hipandgroinpain, decreasedinternalhiprotation,xray findings:flatteningandfragmentationof femoralhead +/limp,notpainful,+galeazzi,+APleg lengthfilms Exposuretoendemicarea,+/targetrash, swelling/painjoints,+Lymetiterwith +westernblot,

restrictweightbearingandsplint(ieprowalker considerrefertoCHWorthopedics restrictactivitiesandrefertoCHWOrthopedics

LeggCalvePerthesdisease

Limblengthdiscrepancy

refertoCHWOrthopedics

LymeArthritis

refertocdc.govformostrecenttreatmentguidelines OR refertoRedBook:ReportoftheCommitteeonInfectiousDisease(mostrecent edition) involvementoflocalsubspecialistsasneeded(i.e.infectiousdiseaseand/or rheumatology)

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Neoplasm

Progressiveorintermittent,deepseated, gnawingpain,oftenworseatnight,+/ constitutionalsymptoms,+/elevatedlabs, +/xrayfindings Injurydoesntmatchstory,childnon ambulatorywithhighsuspicionfractures,+x rayfindingsofaffectedarea

expeditedreferraltoCHW/Froedertpediatricmusculoskeletaltumorspecialistor pediatriconcologist

NonaccidentalTrauma

treatinjuriesandbeginfurtherworkuptoevaluatefornonaccidentaltraumabased uponCHWfacilityguidelines admittohospitalforsafetyofpatientandfurtherworkup

Osteochondritisdissecans

Pain+/swellingaffectedjoint,increasewith activity,+/catch/locking,+xrayfindingsor olderchild/teen

treatinitiallywithactivityrestrictions,immobilization,andnonweightbearingto affectedlimb NSAIDS refertoCHWSportsMedicine refertoemergencyroom emergent Referraltopediatricsleepcenter

Osteomyelitis

Localtenderness/swellingbone,limp,+/ fever,elevatedCBC,ESR,andCRP Sleepdisturbance,normalphysicalexam,no systemicsymptoms,meetNIHRLSguidelines criteria Nosupplementalvitamind,darkerskin,genu varumandxraysfindings:widening/cupping ofthemetaphysis;abnormallabs

RestlessLegSyndrome

Rickets

treatmentofricketsbyprimarycareproviderwithinvolvementofCHWendocrine teamasneeded refertoCHWOrthopedicsfortreatmentofgenuvarum refertoCHWOrthopedicsscoliosis/spineconditionsclinic

Scoliosis

Thoracic/lumbarprominenceonAdams forwardbendtest/asymmetric shoulders/pelvis;Rarelypainful;xray PA/lateralscoliosisshowsscoliosis

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Septicjoint

Painwithjointmotion,redness,swelling, warmth,restrictedjointmotion,nonweight bearingorlimp,fever,elevatedCBC,CRP,ESR +/bloodcultures Oftenseen1014yoteens,M>F,overweight, groin/kneepain,paininternalhiprotation, limp,+AP/froglateralPelvisxray Painwithbackextension,AP/Lat/Oblique lumbarsacralspinefilms+/findings Tendertopalpationoversofttissue,+/ laxity,swelling,nosignificantpainwith weightbearing

emergent ultrasoundhipjointstoevaluateforseptichip referCHWEmergencyroomsepticjointworkupprotocol

SlippedCapitalfemoralepiphysis

emergent strictnonweightbearing refertoemergencyroomforsurgicalstabilization refertoCHWOrthopedicsscoliosis/spineconditionsclinic NSAIDSasneededforpain consideractivitylimitationsuntilseenbysubspecialtyproviders NSAIDS rangeofmotionbrace beginambulationastolerated refertophysicaltherapyifneeded refertoCHWOrthopedicswithrecurrentsprains refertoCHWOrthopedics

Spondylolysis/Spondylolisthesis

Strain/sprain

Tarsalcoalition

Paininfootwithactivity,oftenflatfootand restrictedsubtalarfootmotion,+/xray findings Mildpainwithhipmotion,ambulatory, afebrile,normalCBC,CRP,ESR Labsneedstobeevaluated

Toxicsynovitis

Ifambulatory,afebrile,noconstitutionalsymptoms,normalCBC,ESR,CRP,provider comfortable NSAIDS followupin2to3days ambulationastolerated limitsports IfanyoffollowingsymptomsrefertoCHWEmergencyforsepticjointworkupprotocol Nonweightbearing Febrileorconstitutionalsymptoms Moderateseverepain ElevatedWBC,CRPorESR

AdaptedfromHerring,J.A.,(2007);Junnila,J.L.&Cartwright,V.W.,(2006a);Sawyer,J.R.&Kapoor,M.2009;DueyHoltzetal(2012a),(2012b),(2012c)

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Kocher,M.S.,MandigaR.,MurphyJ.M.,Goldmann,D.,Harper,M.,Sundel,R.,EcklundK.,Kasser,J.R.(2003).Aclinical practiceguidelinefortreatmentofsepticarthritisinchildren:Efficacyinimprovingprocessofcareandeffecton outcomeofsepticarthritisofthehip.JournalofBoneandJointSurgery.AmericanVolume,85A(6),994999. Levine,M.R.,Gorman,S.M.,Young,C.F.,&Courtney,D.M.(2008).Clinicalcharacteristicsandmanagementofwound foreignbodiesintheED.AmericanJournalofEmergencyMedicine,26,918922. Liu,C.,Bayer,A.,Cosgrove,S.E.,Daum,R.S.,Fridkin,S.K.,Gorwitz,R.J.,Levine,D.P.(2011).Clinicalpracticeguidelines bytheInfectiousDiseasesSocietyofAmericaforthetreatmentofmethicillinresistantstaphylococcusaureusinfections inadultsandchildren.ClinicalInfectiousDiseases,52,138. Mathews,C.J.,Kingsley,G.,Field,M.,Jones,A.,Weston,A.C.,Phillips,M.,Walker,D.,&Coakley,G.(2007).Management ofsepticarthritis:asystematicreview.RheumatologicDisease,66,440445. Mathison,D.J.&Agrawal,D.(2001).Generalprinciplesoffracturemanagement:Fracturepatternsanddescriptionin children.Retrievedfromhtpp://www.Uptodate.com/contents/generalprinciplesoffracturemanagementfracture patterns Miller,G.(2011).M.D.Diagnosisofcerebralpalsy.Retrievedfromhtpp://www.uptodate.com/contents/diagnosisof cerebralpalsy. Misra,M.,Pacaud,D.,Petryk,A.,CollettSolberg,P.F.,Kappy,M.,onbehalfoftheDrugandTherapeuticsCommitteeof theLawsonWilkinsPediatricEndocrineSociety.(2008).VitaminDdeficiencyinchildrenanditsmanagement:Reviewof currentknowledgeandrecommendations.Pediatrics,122(2),398417. Morrisey,R.T.,Weinstein,S.L.(Eds).(2006).LovellandWintersPediatricorthopaedics(6thed).Philadelphia,PA: LippincottWilliams,andWilkins. Negrini,S.,Grivas,T.,Kotwicki,T.,Rigo,M.,Zaina,F.andtheInternationalSocietyonScoliosisOrthopaedicand RehabilitationTreatment(SOSORT).(2009).Guidelineson"Standardsofmanagementofidiopathicscoliosiswith correctivebracesineverydayclinicsandinclinicalresearch":SOSORTConsensus2008.Scoliosis,4(2),114. Omey,M.L.,Micheli,L.J.(1999).Footandankleproblemsintheyoungathlete.MedicineandScienceinSportsand Exercise,31,S470S486. Ondo,W.G.(2009).Restlesslegssyndrome.NeurologicClinics,27,779799. Renshaw,T.S.&Deluca,P.A.(2006).CerebralPalsy.InTR.Morrissy,&SL.Weinstein(Eds.),LovellandWintersPediatric Orthopaedics,6thed.(pp.593594).Philadelphia,PA:Lippincott,Williams,andWilkins. ScoliosisResearchSociety(2011a).Spondylolysis.Retrievedfrom http://www.srs.org/patient_and_family/spondylolisthesis/index.htm
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