5) The Limping Child Flashcards
Limping
- Any deviation from normal, rhythmic gait
- Never normal
- Many possible etiologies
Antalgic
- Painful limping
Center of gravity
- Located 2 cm anterior to S – 2
- Moves in spiral 5 cm diameter during normal gait
Six determinants of gait
- Pelvic rotation
- Pelvic tilt
- Lateral pelvic motion
- Knee flexion at heel contact
- Knee motion
- Foot and ankle motion
ROM required for normal gait
- Hip: 10 degrees of extension to 30 degrees of flexion
- Knee: 180 degrees extension to 60 degrees of flexion
- Ankle: 10 degrees dorsiflexion to 20 degrees plantarflexion (more than during running)
Muscle function during gait
- Eccentric vs. concentric contraction
- Hip flexors: initiate gait
- Spasticity: Velocity dependent movement
Six anatomic locations to clinically examine limping
- Spine
- Pelvis
- Hip
- Knee
- Ankle
- Foot
Limping disease categories
- Pain
- Neuromuscular imbalance
- Limb length inequality
- Joint restriction
- Limb deformity
Potential etiologies of limping
- Biomechanical
- Circulatory
- Congenital
- Dermatologic
- Infection
- Inflammation
- Neoplastic
- Neuromuscular
- Metabolic
- Traumatic
Limping diagnosis considerations
- Patient age
- Antalgic vs. non-antalgic
- Potential etiologies
- Anatomic location (level of the deformity)
- Disease categories
Congenital limping diagnosis (ex. clubfoot)
- Painless
- Any age
- Limb length discrepancy
- Deformity
Traumatic limping diagnosis (ex. ankle sprain)
- Any age
- Antalgic
- Joint restriction
Limping infectious diagnosis (ex. osteomyelitis)
- Usually < 5 yrs of age
- Antalgic
- Physical examination
Inflammatory limping diagnosis (ex. sever’s disease)
- Ages 7 – 13 yrs
- Antalgic
- Joint restriction (equinus)
Metabolic limping diagnosis (ex. ricket’s)
- Usually < 5 yrs of age
- Painless
- Limb deformity
Circulatory limping diagnosis (ex. Kholer’s disease)
- Usually ages 2 – 6
- Antalgic
- Physical examination (midfoot pain)
Toe walking (uncompensated ankle equinus)
- The etiology may vary
- STJ supination only
- When sustained, it is never normal
Characteristics of “normal” toe walking
- No significant PMH
- Occurs early on
- Occurs intermittently (not constant)
- Child < seven (7) years of age
- Normal physical examination
Characteristics of abnormal toe walking
- Associated abnormalities
- Occurs later, following a period of normal gait
- Is fairly constant
Toe walking physical examination
- Neurological examination: Spasticity, clonus, pathological reflexes ?
- Biomechanical examination: Equinus, limb length discrepancy, CDH ?
Potential toe walking etiologies
- Biomechanical: Equinus (congenital or acquired)
- Neuromuscular: Cerebral palsy, Duchenne muscular dystrophy, etc.
- Idiopathic (ITW) Most common etiology
Toe walking neurological etiologies
- Cerebral Palsy
- Duchenne muscular dystrophy
- Peroneal muscular atrophy (CMT)
- Dystonia musculorum deformans
- Tethered cord syndrome
- Spinal cord tumor
- Acute myopathy
Toe walking diagnosis considerations
- History
- Neurological examination
- Biomechanical examination
- Gait analysis
- Electromyography / kinematic analysis
- Laboratory testing
Diagnostic testing for toe walking
- A thorough perinatal and family history !
- CPK screening
- MRI
