Acute and Non-acute Lower Extremity Pain in Pediatrics

Abstract and Introduction

Introduction

Lower extremity pain is common in childhood, with etiologies ranging from benign muscular conditions to systemic disease. We are presenting a three-part series of evidence-based practice guidelines to aid the provider in efficiently determining the diagnosis and treatment of a child with lower extremity pain. Part I focused on the history, physical examination, and diagnostic workup (Duey-Holtz et al., 2012a,Duey-Holtz et al., 2012). Parts II and III have been divided to include comprehensive treatment guidelines, which are summarized in the Table . In general, the most common diagnoses for musculoskeletal pain can be categorized into the following etiologies:

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  Trauma: strains/sprains, fractures, dislocations, foreign body, non-accidental trauma
  
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  Infection: septic arthritis, osteomyelitis, diskitis
  
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  Immune-mediated: toxic synovitis, juvenile idiopathic arthritis, Lyme disease, reactive arthritis
  
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  Acquired/developmental: slipped capital femoral epiphysis, Legg-Calve-Perthes disease, Kohler disease, tarsal coalition, accessory navicular, osteochondritis desiccans
  
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  Neoplastic: leukemia/lymphoma, Ewing sarcoma, osteosarcoma
  
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  Referred: scoliosis, spondylolysis, spondylolisthesis
  
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  Benign musculoskeletal: growing pains, tendonitis/apophysitis
  
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  Neurologic: complex regional pain syndrome, restless leg syndrome
  
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  Metabolic: rickets
  

The following non-painful conditions can present with a limp or abnormal lower extremity examination results:

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  Developmental: developmental dysplasia of the hip, leg length discrepancy
  
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  Neurologic: cerebral palsy, syndromes that result in abnormal findings of neuromuscular examinations ( Duey-Holtz et al., 2012)
  

The purpose of these treatment guidelines is to focus on the most common sources of pediatric lower extremity pain. Non-painful etiologies that can present as a limp or abnormal gait also will be addressed. Part II will cover traumatic, benign musculoskeletal, referred, and non-painful and neurologic etiologies. Along with the following summary of each differential diagnosis, a reference table and algorithm are included ( Table and Figure 1).



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Figure 1.



Lower extremity pain differential diagnosis algorithm. Data from Gedalia, 2002; Junnilla & Cartwright, 2006a; and Sawyer & Kapoor, 2009.