Joint pain and limps - when to refer

Question 1

When is management in the community of a flat foot appropriate? (Physio or podiatrist)

Answer 1

ALL OF THE BELOW

• <6
• No red flags
• painless and flexible.
• no limp or interference with ADLs
• no pain in legs or joints.
• Normal milestones
• No blisters or callosities

Question 2

When to consider specialist referral for children with flat feet

Answer 2

• Red flag features.
• Pain
• Absent medial longitudinal arch when the child is on tiptoes or when big toes are extended.
• Rigid flat feet
• Asymmetrical flat feet.
• Tripping or frequent falls.
• Limp. /Functional limitation.
• Fatigue of the foot muscles
• signs of pressure - calluses/blistering/recurrent ankle sprains.
• Marked hypermobility.
• Morning stiffness, restriction of joint movement, joint swelling (of any joint, not just the foot/ankle), or abnormal joint examination.
• Regression or delayed motor milestones.
• Other features indicative of an underlying diagnosis

Question 3

Red Flag MSK features in a child - Send to ED!

Answer 3

• Evidence of infection - osteomyelitis or septic arthritis
• Evidence of trauma
• SUFE

Question 4

Red Flag MSK features in a child - Urgent rheum referral

Answer 4

• Suspected inflammatory arthritis

- Back pain (with red flags).

Question 5

Red Flag MSK features in a child - Orthopaedic referral

Answer 5

• Limping child in whom SUFE is not suspected.
• Back pain (with red flags).
• Back problems - scoliosis, neurological symptoms, systemic illness
• Bone pain.

Question 6

Red Flag MSK features in a child - Paediatrics

Answer 6

• Suspected neurological problem
• Possible cancer
• Back pain (with red flags).
• Milestone delay or regression.
• Persistent night waking.
• Suspected non-accidental injury
• Bladder or bowel problems.

Question 7

When is management in community of bow legs (genus Varus) appropriate - paeds physio

Answer 7

• Well with no red flags.
• <4
• No pain.
• Not functionally impaired (play, walking, milestones normal).
• Growing and developing normally.

Question 8

When to consider referring children with bow legs for specialist assessment

Answer 8

• Red flags
• > 4 years.
• Bow legs at any age with an acute deformity at the proximal tibia (possible Blount’s disease).
• Severe deformity or femoral intercondylar distance more than 6 cm.
• Unilateral or asymmetrical findings.
• Pain/Limp.
• Joint swelling or abnormal joint examination.
• Functional impairment
• Regression or delayed motor milestones.
• Concern about rickets, metabolic or endocrine disorders, dysplasia or dysmorphism.
• Short stature or disproportionate growth (for example limbs are short compared to the trunk).

Question 9

When is management in community of in-toeing gate appropriate - paeds physio/podiatrist

Answer 9

• no red flag features
• < 10 years.
• No pain.
• No limp or functional impairment.

Question 10

Consider referring children with in-toeing for specialist assessment if

Answer 10

• Red flags
• Sudden onset of in-toeing.
• Associated pain.
• Extreme or persistent changes.
• Unilateral or asymmetric in-toeing.
• Limp, trips or falls, or functional problems.
• Delayed developmental milestones.
• Significant history for an underlying metabolic/ neuromuscular/orthopaedic reason
• Abnormal examination findings

Question 11

When is management of ‘knock knees’ - Genu Valgum appropriate in the community

Answer 11

• no red flag features
• 2 - 5 YO
• no pain or functional impairment.
• deformity is symmetrical (usually not related to disease unless severe and associated with short stature).

Question 12

Consider referring children with knock knees (Genu Valgum) for specialist assessment if:

Answer 12

• <2 years or > 5–6
• Onset occurs in adolescence.
• red flas
• Severe deformity (> 8 cm between ankle malleoli)
• Unilateral or asymmetrical deformity.
• Knee pain.
• Leg length discrepancy.
• Progressive deformity.
• Short stature or significant deviation from the norm for height or weight.
• Limp; or recurrent trips or falls.
• Functional limitation.
• An abnormal joint examination.
• Features of juvenile idiopathic arthritis.
• regression or delay in motor milestones.
• There are concerns about metabolic, neurological, or endocrine disorders, or skeletal dysplasia.

Question 13

When is management of joint hypermobility appropriate in the community

Answer 13

• no red flags
• No pain.
• No functional impairment.
• No suggestion of underlying conditions associated with hypermobility.

Question 14

When should you consider referring joint hypermobility

Answer 14

• Red flags
• diagnostic uncertainty.
• Severe hypermobility that impacts on ADLS (e.g. subluxation/dislocation).
• Asymmetrical joint involvement.
• Acute or single joint soft-tissue injury as a result of repetitive strain.
• Fine motor difficulties.
• Fatigue or hand pain with functional tasks
• Features of connective tissue disorders
• Thin, translucent skin, lack of subcutaneous fat, and easy bruising (this group may be at increased risk of mortality due to vascular fragility and complications such as stroke, aortic dissection, and bowel rupture).
• Family history of sudden early death from aortic aneurysmal dissection/rupture, or spontaneous arterial rupture or uterine rupture in childbirth
• Symptoms that do not improve with rest, and resting leads to ‘gelling’ or stiffness

Question 15

When is is appropriate to manage tip toe walking in the community?

Answer 15

• no red flags
• < 3
• Able to walk with heel strike (suggests idiopathic toe walking) and squat to play on the floor with their heels on the floor.
• Well coordinated when walking or running on toes
• no limp.
• Able to jump (in a school-age child).
• Normal development with no regression.
• Normal examination; no contractures.

Question 16

When to refer children with tip toe walking

Answer 16

• Red flag features.
• > 3
• Asymmetric toe walking.
• Toe walking present for at least half the time they are ambulant.
• Toe walking in response to pain.
• Functional problems
• Changes in gait pattern/recent onset of toe walking
• Delay or regression .
• A diagnosis of autism spectrum disorder, cerebral palsy, muscular dystrophy, or global developmental delay, or a history of admission to neonatal intensive care after birth.
• FH of muscle disease
• FH of metabolic or storage disease

Question 17

what abnormal examination findings may you find on children with tip toe walking

Answer 17

• Not able to heel strike - high calf tone or contractures.
• Abnormal neurological examination, particularly with regard to tone, reflexes, and muscle bulk.
• Positive Gower’s sign getting up from the floor.
• Leg length discrepancy.
• Limited eye contact, rituals (for example lining up toys, rocking).
• Joint pain, swelling, stiffness, clumsiness, limp, weakness.

Question 18

When is it appropriate to manage out-toeing in the community

Answer 18

• no red flags
• <4
• no pain, limp, or functional impairment.

Question 19

When to consider referring out-toeing children to a specialist

Answer 19

• <8 years old with significant deformity affecting gait
• Red flag features.
• Knee, hip, or thigh pain.
• Unilateral out-toeing.
• Recent onset changes, limp.
• Progressive out-toeing in an adolescene
• Decrease in expected internal hip rotation and increased external rotation.
• Severe external tibial torsion.
• Functional problems with mobility.
• Hip disease is suspected.
• diagnosis is uncertain.
• family requires additional reassurance.

Question 20

When is it appropriate to manage heel pain in the community

Answer 20

• no red flag features.
• Milestones are normal with no delay or regression.
• no limp or interference with daily activities.

Question 21

When should you consider referral to a specialist for heel pain?

Answer 21

• Red flag features.
• Visible swelling or abnormality
• Unilateral symptoms, night pain, localised swelling, absence of a precipitating activity.
• Asymmetry or significant hindfoot stiffness.
• Suspected calcaneal fracture.
• Inability to allow the heel to come into contact with the bed, even during sleep.
• Persistent pain that limits function
• symptoms/signs of inflammatory arthropathies.

Question 22

What presentations are consistent with growing pains that does not require specialist referral

Answer 22

• no red flags
• Age 3–12 years.
• Symmetrical pain in lower limbs (joints, muscular, or not localised).
• No pain on waking.
• No limp.
• No limitation of physical activity.
• No abnormalities on physical examination
• Child is achieving major motor milestones.

Question 23

Consider referring children with growing pains for specialist assessment if

Answer 23

• Red flag features.
• Pain not consistent with that of growing pains
• An atypical history.
• Systemic symptoms
• Abnormalities on physical examination
• Impaired function
• Developmental delay or regression of achieved motor milestones.
• School absences.

Question 24

What types of pain are NOT consistent to growing pains

Answer 24

• Unilateral or asymmetric.
• Persistent or increasing in severity.
• Widespread (for example upper limbs and back).
• Occurring in the morning or with activities.
• Localised to a joint.

Question 25

When to consider reffering a ‘clumsy’ child

Answer 25

• red flags
• Functional impairment
• Marked hypermobility.
• Dyspraxia, coordination problems; evidence of progressive uncoordination.
• Learning difficulties.
• Loss of milestones already achieved.
• Morning symptoms (may suggest inflammatory disease).
• Widespread pain.
• Suspicion of joint or muscle disease or child abuse.
• School absenteeism.

Question 26

When can childhood back pain be managed in the community

Answer 26

• no red flags.
• no neurological symptoms.
• Examination is normal.
• no functional impairment