Pediatric Leg Disorder

Aka: Pediatric Leg Disorder, Lower Extremity Abnormality in Children, Lower Extremity Abnormalities in Children, Pediatric Leg Evaluation

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II. Precautions

  1. See Limping Child for acute painful gait
  2. This Pediatric Leg Disorder topic addresses the more chronic, progressive pediatric leg abnormalities

III. History

  1. Distinguish between 2 types of Gait Abnormality (critical first step)
    1. Acute, Antalgic Gait (painful) resulting in Limping Child (urgent evaluation)
      1. See Limping Child
    2. Chronic, progressive, nonantalgic gait or other leg abnormality (non-Traumatic)
      1. Described here
  2. Past medical history and growth and development
    1. Prenatal and birth history
    2. Breech Delivery (Congenital Hip Dysplasia, Femoral Anteversion)
    3. Developmental Milestones
    4. Medical history (Trauma, surgery or hospitalizations)
    5. Dietary intake (adequate Calcium, Vitamin D)
  3. History of Present Illness
    1. Timing
      1. Age of onset and duration
      2. Progression
    2. Associated findings (red flags)
      1. Pain with activity and limiting play
      2. Limping, tripping or falling

IV. Exam: Systemic Signs

  1. Growth
    1. Height and weight with growth percentiles and Body Mass Index
    2. Normal growth decreases likelihood of underlying systemic condition (e.g. Rickets, metabolic bone disease)
  2. Facial Appearance
    1. Abnormal facies may suggest genetic disorder (e.g. fragile X)
  3. Neurologic
    1. See Developmental Delay
    2. See Muscle Weakness in Children
    3. Neuromuscular disorders
    4. Cerebral Palsy
    5. Muscular Dystrophy
  4. Skin
    1. Ecchymosis
      1. Nonaccidental Trauma
    2. Midline spinal skin changes (e.g. dermal sinus, midline Lipoma, sacral dimple)
      1. See Cutaneous Signs of Dysraphism
    3. Neurocutaneous Syndrome (e.g. Cafe-Au-Lait Macule)
      1. See Neurofibromatosis
    4. Inflammation (redness, warmth, swelling)
      1. Infection (e.g. Septic Arthritis)
      2. Rheumatologic Disorders

V. Exam: Gait

  1. See Gait Evaluation in Children
  2. Distinguish between painful (antalgic) and non-painful (nonantalgic) Abnormal Gait
  3. Antalgic Gait
    1. Stance phase on unaffected limb is shortened due to pain
    2. Refusal to bear weight especially with limited range of motion, systemic symptoms, fever
      1. Septic Arthritis
  4. Nonantalgic gait
    1. See Abnormal Gait
    2. Includes Steppage Gait, Trendelenburg Gait, Circumduction Gait, Equinus Gait
    3. Intoeing
    4. Out-toeing

VI. Exam: General Musculoskeletal

  1. General
    1. Expose the extremities (in shorts, underwear, diaper)
    2. Evaluate for symmetry
    3. Evaluate for Leg Length Discrepancy (>2 cm difference is significant)
  2. Joint Inflammation (Joint Swelling, warmth, and painful range of motion)
    1. Inflammatory Arthritis
    2. Septic Arthritis (non-weight bearing)
    3. Reactive Arthritis
  3. Muscle
    1. Muscular atrophy: Disuse atrophy or neurologic disorder
    2. Calf hypertrophy: Muscular Dystrophy
  4. Joint Laxity
    1. Associated angular deformities (e.g. Genu Varum, Genu Valgum)
    2. Congenital Hip Dysplasia
    3. Connective Tissue Disorders
  5. Bone Tenderness
    1. Fracture or bone Contusion
    2. Bone Tumor (may present with palpable bone mass)
    3. Osteomyelitis
  6. Spine
    1. Evaluate spinal flexion and extension
    2. Evaluate for Scoliosis, lumbar lordosis, thoracic kyphosis

VII. Exam: Hip and Pelvis

  1. See Hip Exam
  2. See Hip Rotation Evaluation in Children
  3. See Hip Range of Motion
  4. Gluteal or thigh skin fold asymmetry
    1. Congenital Hip Dysplasia
  5. Galeazzi Sign (one knee higher than the other)
    1. Limb Length Discrepancy
    2. Congenital Hip Dysplasia
  6. FABER Test or Pelvic Compression Test positive
    1. Sacroiliac Joint Disorder
  7. Trandelenburg Test positive
    1. Congenital Hip Dysplasia
    2. Weak hip adductors
    3. Leg Length Discrepancy
  8. W-Sitting Position
    1. Associated with Femoral Anteversion (but NOT a cause of Femoral Anteversion)
    2. Patient sits on floor with each heel adjacent to the ipsilateral hip
      1. Hips flexed and externally rotated
      2. Knees maximally flexed
  9. Hip resting position flexed and externally rotated
    1. Slipped Capital Femoral Epiphysis
      1. Hip unable to be abducted or internally rotated
    2. Hip Joint effusion
      1. Hip abducted
  10. Hip internal rotation lost
    1. Aseptic Necrosis of the Femoral Head
    2. Slipped Capital Femoral Epiphysis
    3. Intraarticular hip disorder
  11. Limited hip abduction
    1. Congenital Hip Dysplasia (positive Ortolani Maneuver or Barlow Test)
  12. Pelvic compression resulting in pain
    1. Sacroiliac joint disorder
    2. Pelvis Trauma

VIII. Exam: Leg

  1. Foot Deformity
    1. See Pediatric Foot Evaluation
    2. See Gait Evaluation in Children
    3. See Foot Anatomy
    4. Consider common foot disorders
      1. Clubfoot (tiptoe walking, fixed equinus position)
      2. Metatarsus Adductus (foot cause of In-Toeing)
      3. Calcaneovalgus Deformity (Out-toeing)
      4. Pes Planus (flat arch while standing)
  2. Rotational Deformity
    1. Torsional Profile (Leg Rotation Evaluation in Children)
    2. Foot Progression Angle (In-Toeing, Out-toeing)
    3. Thigh-Foot Angle (tibial torsion)
    4. Hip Rotation Evaluation in Children (Femoral Anteversion)
  3. Angular Deformity
    1. Nearly all newborns start with Genu Varum
      1. Neutral position by age 2 years
      2. Genu Valgum by age 3-6 years
      3. Returns to neutral or slightly valgus position (esp girls), by age 7-11 years old
    2. Evaluate standing knee alignment
      1. Intercondylar distance
      2. Intermalleolar distance
      3. Tibiofemoral angle
    3. Risk Factors
      1. Osteogenesis Imperfecta
      2. Rickets
      3. Renal Osteodystrophy
      4. Skeletal Dysplasia
      5. Klinefelter Syndrome
      6. Rheumatologic Disorders (Genu Valgum-like deformity)
    4. Disorders
      1. Genu Varum (bow leg)
      2. Genu Valgum (knock knee)

IX. Differential Diagnosis

  1. Acute, Antalgic Gait (painful) resulting in Limping Child
    1. See Causes of Limp in Children
    2. See Leg Pain
    3. See Foot Pain
  2. Chronic, progressive, nonantalgic gait or other leg abnormality
    1. See Gait Evaluation in Children
    2. See Abnormal Gait in Children
    3. Intoeing
      1. See In-Toeing
      2. Metatatarsus adductus (onset age <1 year)
      3. Internal Tibial Torsion (onset age 1 to 3 years)
      4. Femoral Anteversion (onset age 3 to 6 years, usually bilateral)
    4. Out-toeing
      1. See Out-toeing
      2. Femoral Retroversion (resolves by age 1-2 years)
      3. Pes Planus (resolves by age 10 years)
      4. External Tibial Torsion (onset age 4-7 years)
    5. Genu Varum (Bowed Legs)
      1. See Genu Varum
      2. Typically resolves in normal development by age <2 years
      3. Rickets
      4. Skeletal dysplasia
      5. Blount's disease (Obesity)
      6. Tibial Bowing
        1. Anterolateral bowing (Neurofibromatosis association)
        2. Posteromedial bowing (In utero calcaneovalgus foot, will spontaneously correct)
      7. Load-bearing, high-impact sports (teens)
    6. Genu Valgum (Knock-Knee)
      1. See Genu Valgum
      2. Typical onset by age 1 to 3 years and resolves in normal development by age 8 years
      3. Rickets
      4. Diastrophic dysplasia
      5. Morquio's Syndrome
      6. Ellis-van Creveld or Chondroectodermal Dysplasia
      7. Spondyloepiphyseal Dysplasia
      8. Pseudoachondroplasia

X. References

  1. Baird (2025) Am Fam Physician 111(2): 125-39 [PubMed]
  2. Rerucha (2017) Am Fam Physician 96(4): 226-33 [PubMed]

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