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Chapter 22 • Lower Extremity Limb Pain
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259
secondary to trauma develops immediately or within
2 hours after an injury; swelling 6 to 24 hours after an
injury is usually of synovial origin such as a meniscal
tear, subluxation, dislocation, or ligamentous damage.
Swelling after 24 hours suggests an inammatory
response.
Is this an acute or a chronic problem?
Key Questions
l
When did the pain rst occur?
l
When did you rst notice a problem?
Pain experienced hours after an injury or physical
activity is usually caused by acute extensor injury or
overuse. Severe ligament sprain is manifested as an
immediately disabling pain at the moment of the
injury.
Determining if the complaint is acute or chronic
helps differentiate the cause. Chronic joint problems
compound each other, whereas intermittent or episodic pain is characteristic of diseases of the musculoskeletal system. In children, limping or not using
the extremity may be a signal that the child is experiencing pain. Parents will often note the loss of
motion in an extremity or an awkward gait; they
often report that the child is unable to perform
routine activities.
How is activity affected?
Key Questions
l
What are your usual activities?
l
What activity makes the pain worse?
l
What movements make the pain worse?
Repetitive microtrauma in the lower extremities from
inappropriate rate and intensity of training, poorly
tting shoes, or unsuitable playing surfaces can
cause stress fractures of the weight-bearing bones of
the lower limbs. Pain is worse over the site of the
fracture.
In children, pain in the groin or referred to the
knee and anterior thigh that is intermittent after activity and gradually becomes constant may indicate
Legg-Calvé-Perthes disease (LCPD).
Intra-articular lesions usually worsen with joint motion and sports activities. Intraosseous tumors are less
sensitive to joint motion.
In children with a septic hip, pain increases with
movement.
What does joint stiffness or locking tell me?
Key Questions
l
Have you had any joint stiffness?
l
Does activity make the stiffness worse or better?
l
Do you have locking of the knee?
Joint Locking
Locking of the knee is an abrupt occurrence where the
patient complains that something “gets in the way” and
is unable to fully extend the knee. Manipulation of the
leg often results in an equally abrupt unlocking. This is
usually a sign of a chronic unstable meniscus tear.
Stiffness is a common feature of any inammatory arthropathy. Arthritic stiffness and pain are alleviated by
activity, whereas mechanical problems are aggravated
by activity.
What does the history of a limp tell me?
Key Questions
l
Is there pain with the limp?
l
Did the limp develop suddenly?
l
Is the limp constant or intermittent?
l
What is the effect of running or climbing stairs?
Limp
Limping is a pathological alteration of a smooth, regular gait pattern and is never normal. Gait can be divided into two phases: stance and swing. The stance
phase starts with the foot in contact with the ground
and ends with the toe being lifted off the ground; the
limb supports all the body weight. The swing phase
begins with the toe elevated from the ground and ends
with the heel strike. During the swing phase, the foot
is not touching the ground; the pelvis rotates forward
and tilts slightly while the trunk maintains a neutral
position. Limp after strenuous running may indicate a
stress fracture.
Quadriceps weakness causes difculty in climbing
stairs. During ambulation, this weakness causes the
knee to be unstable on heel strike, and assistance is
needed to push the knee manually into an extended
position.
Neuromuscular diseases can result in progressive
and painless muscle weakness or spasticity that affects
ambulation in a variety of ways.
Symptoms of pain and limping in children may
be incorrectly attributed to trauma instead of a more
serious problem such as neoplastic tumors or bone
infections.
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Chapter 22 • Lower Extremity Limb Pain
Could this be caused by systemic disease?
Key Questions
l
Have you been treated with antibiotics recently?
l
Have you had any recent immunizations?
l
Does the pain awaken you at night?
l
Is the pain worse at night?
Medications
Certain antibiotics can cause serum sickness in children,
producing joint pain and fever. In adults, uoroquinolone antibiotics can produce tendinitis or tendon rupture.
Night Pain
Intense pain may occur at rest and during the night. At
rst the pain may occur only when the patient changes
position while sleeping. However, sleep becomes disrupted as the pain increases. Report by an adolescent of
night pain is a red ag for the intraosseous pain of a bone
tumor. Pain in the lower limbs in children 6 to 12 years
of age who are in a rapid linear growth period may cause
the child to awaken at night. The cause of these “growing
pains” is unknown, but they are thought to result from
muscle structures that have to catch up with bone growth.
The pains are usually bilateral with no objective ndings.
Could the pain be caused by Lyme disease?
Key Questions
l
Have you been camping or spending time in wooded
areas?
l
Have you noticed any skin rashes?
Lyme Disease
Lyme disease is an infection caused by the tick-borne
spirochete Borrelia burgdorferi. Early symptoms
include diffuse arthralgias, myalgias, fever, chills, and
a characteristic target-like rash. The arthralgia may
involve multiple joints, but the knee is most often
affected. Joint manifestations occur 1 week to 2 years
following the initial illness. Patients may, or may not,
recall the antecedent tick bite or exposure.
What does the health history tell me?
Key Questions
l
Have you had anything like this before?
l
Do you have a chronic disease?
l
Could you have been exposed to any sexually
transmitted infection?
l
Have you been treated with cortisone?
Chronic Conditions
Chronic diseases, such as sickle cell anemia, inammatory bowel disease, Crohn disease, hypothyroidism,
hyperthyroidism, and collagen vascular diseases, are
frequently associated with skin rashes, psoriasis, and
limb and joint pain.
Gonorrhea disseminates to the musculoskeletal
system in 1% to 3% of individuals with the disease.
Of these, more than 80% develop arthritis.
Patients with chronic illness that requires long-term
administration of corticosteroids are at risk for
cortisone-induced necrosis of the hip. Sickle cell
anemia can cause hip pain during a sickle cell crisis.
Viral infections may cause diffuse myalgia.
Is this a mixed condition?
Consider the possibility that a patient may have a
condition that is a mix of factors such as a systemic
disorder that has resulted in an acute injury. Clues to
mixed etiology might include an injury that seems out
of proportion to the extent of the precipitating activity
or the presence of a chronic condition and other
symptoms that might point to an undetected chronic
condition. It is important to evaluate the limb pain in
the context of the whole person.
DIAGNOSTIC REASONING: FOCUSED
PHYSICAL EXAMINATION
Evaluation of musculoskeletal injuries should include
examination of joint stability, deformity, and function.
Examination should be done as soon as possible after
an injury for an accurate diagnosis. Observe for symmetry, and then functionally assess limbs and joints
bilaterally beginning with the unaffected side. Order
the examination so that the most painful tests will be
done last. Figures 22-1 and 22-2 illustrate anatomical
landmarks of the knee and ankle.
Observe the Patient
Subtle clues of child abuse must be considered when
the patient history is not consistent with the type or
extent of injury. Abuse should always be considered in
an infant when symptoms and history suggest a fracture, multiple injuries, rotational injuries, or multiple
bruises in different states of healing. Radiographs may
show previous fractures.
People who have septic joints appear ill, and move-
ment of the joint will increase the pain. Inspect the
patient with minimal clothing obstructing your view of
Chapter 22 • Lower Extremity Limb Pain
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Posterior cruciate
ligament (PCL)
Lateral condyle
of femur
Fibular collateral
(lateral) ligament
Lateral meniscus
Transverse
ligament of knee
Fibula
FIGURE 22-1 Basic anatomy of the right knee. (From Patton K, Thibodeau G: Anatomy and physiology, ed. 9, St. Louis, 2016, Elsevier.)
Femur
Medial condyle
of femur
Anterior cruciate
ligament (ACL)
Medial
meniscus
Tibial tuberosity
Tibial collateral
(medial) ligament
Tibia
meniscofemoral
ligament (Wrisberg
Medial meniscus
Tibial collateral
(medial) ligament
Posterior cruciate
Femur
Posterior
ligament)
Medial condyle
ligament
Anterior cruciate
ligament
Lateral condyle
Lateral meniscus
Fibular collateral
(lateral) ligament
Fibula
Tibia
moving with greater excursion or range of movement
than usual. This makes the gait appear irregular or
Anterior inferior
tibiofibular
ligament
Anterior
talofibular
ligament
Posterior
talofibular
ligament
Calcaneofibular
ligament
jerky.
Look for Limp
Pain, weakness, and deformity cause limping. Limping
will be accentuated if the patient is asked to walk on
the heels or tiptoes.
Common abnormal gaits related to limping are
LATERAL ANKLE
Posterior
tibiotalar
ligament
Tibiocalcaneal
ligament
Tibionavicular
ligament
Trendelenburg gait, antalgic gait, and circumduction
gait. Trendelenburg gait is a ducklike gait that reects
unilateral weakness of the gluteus medius muscle. The
pelvis drops on the unaffected side during weight bearing on the affected side. In antalgic gait, there is an
acute one-sided limp because the patient takes quick
soft steps to shorten the period of weight bearing on the
involved extremity. Stance time on the affected limb is
decreased while stride length of the opposite side is
MEDIAL ANKLE
FIGURE 22-2 The lateral ankle ligaments—anterior and posterior
talofibular (ATF and PTF, respectively) and calcaneofibular (CF).
Also shown are the anterior inferior tibiofibular (AITF) ligament
and the beginning of the interosseous membrane (IM). (From
Auerbach P: Wilderness medicine, St. Louis, 2007, Mosby.)
shortened, allowing a quicker return of weight bearing
to the unaffected limb. This is a reex response to
weight bearing on a painful limb.
Circumduction gait is seen with pathology of the
foot or ankle and reduces discomfort by limiting movement of the ankle. The gait is characterized by a circular outward swing of the leg and external rotation of
the foot that requires less ankle movement. External
movements. A child with a septic hip lies with the thigh
in a position of exion, abduction, and external rotation and cries when the lower limb is moved.
In adults, an internally rotated abducted leg is the
posture assumed with a posterior hip dislocation. An
externally rotated hip and shortened lower extremity
are signs of hip fracture.
General stiffness or limitation of motion of a
joint causes the surrounding joints to accommodate by
rotation of the entire extremity is seen with slipped
capital femoral epiphysis.
Have the patient stand on one foot and then the
other. When standing on one leg, the gluteus medius on
that side maintains the opposite side of the pelvis level,
balancing the trunk over the weight-bearing hip. If the
hip abductors are weak or painful, the opposite side of
the pelvis dips down during the stance phase. With
each step the trunk shifts toward the side of a painful
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Chapter 22 • Lower Extremity Limb Pain
or weak extremity to decrease the force transmitted
through the extremity to the hip.
Assessment of gait is best done either before or after
examination, when patients are less aware that they are
being observed.
Ankle plantar exion and dorsiexion are necessary
for normal gait. If plantar exion is restricted, there is
no push-off and the forefoot and heel come off the
oor at the same time. The result is a higher knee lift,
and the forefoot may slap against the oor. This condition is seen with weakness from peroneal nerve injury
or with the painful dorsiexion associated with shin
splints.
Observe the patient walking with and without shoes.
If a child walks without difculty with shoes off, the
shoes are probably the problem. Inadequate shoe width
is a common source of foot pain in children.
Have Patient Locate the Pain
Have the patient point to the area of pain. Location of
pain and the actual area of pathology may not be consistent. Hip pain often is referred to the knee area because the anterior branch of the obturator nerve passes
close to the hip joint and, if irritated, provides a painful
sensation to the medial side of the knee. True hip joint
pain arises in the trochanteric bursa and is perceived in
the groin area.
Pain in the groin, lateral hip, or knee in a child may
indicate LCPD.
Pain in the groin, buttocks, or lateral hip in a child
may indicate slipped femoral capital epiphysis.
Vague, nebulous discomfort in the front of the
thighs, in the calves, and behind the knees located outside of the joints in a child, may indicate growing
pains.
Note Any Deformities
Fractures generally produce unilateral deformities or
swelling in the extremities. Inammatory and degenerative joint diseases produce observable joint swelling
and deformity that usually occurs bilaterally.
Assess Vital Signs
Elevated temperatures are seen with neoplastic, systemic, and infectious processes such as osteomyelitis,
septic arthritis and septic hip in children, and rheumatic disease. Neonates may not exhibit a fever with a
septic hip, but may refuse to feed, and will exhibit
other symptoms of septicemia such as lethargy and
subnormal temperature. Palpate for quality and presence of pulses in any injured limb and compare to
the opposite side. Assess peripheral pulses for presence, rate, regularity, strength, and equality.
Inspect the Skin and Nails
Chronic venous obstruction in the lower extremities
causes a brownish coloring of the skin, while arterial
insufciency causes thin shiny skin with an absence of
hair and brittle nails.
Lyme disease usually presents with a rash before
joint involvement; however, rash may occur concurrently. The rash, characteristically found on the trunk,
begins as an erythematous papule that develops into an
annular lesion with a clear center. Concentric rings
may develop, giving it a bull’s-eye appearance
(erythema migrans).
Inspect the skin for redness and inammation. Look
for a puncture or an abscess that could be the source of
infection and seeding if a septic joint or osteomyelitis
is suspected. Swelling and redness in a joint or in the
midshaft of the tibia may be caused by osteomyelitis.
Look for an ingrown toenail that may alter gait.
When the nails are trimmed by rounding off the edges,
the hypertrophied and inamed soft tissue fold can
overlap the nail, and ingrowth at the distal margin will
occur. Ingrown toenail pain is enhanced when tighttting shoes compress the soft tissues around the nail.
Look for ecchymosis and bruising. These indicate
trauma as a source for pain and raise the suspicion of
abuse. Ecchymosis indicates underlying bleeding and
disruption of soft tissue or bone. Ecchymosis changes
color over a period of days. Initially the color is dark
red or violet, and in 1 to 3 days the bruise is bluebrown; in 1 week, it is yellow-green; and after 1 week,
it is light brown. Ecchymosis resolves within 2 to
4 weeks.
Ecchymosis in the popliteal fossa after dislocation
of the knee may be a sign of arterial disruption. Hemarthrosis, or bleeding into a joint, usually occurs within
1 to 2 hours after an injury and can occur secondary
to hemophilia or other bleeding disorders, or it can be
associated with visible ecchymoses caused by blood
leaking into soft tissues.
Swelling and redness of a joint indicate underlying
infection or inammation. Edema will present as
an asymmetrical area of swelling. Effusion, or uid
in the joint capsule, distends the joint in a smooth,
symmetrical manner.
Observe the muscles around the painful limb area.
Decreased muscle tone or atrophy from disuse begins
immediately after injury, although it will not be
clinically apparent for approximately 1 week.
Chapter 22 • Lower Extremity Limb Pain
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Asymmetrical gluteal folds may indicate a congeni-
tal dislocated hip (Figure 22-3).
Measure Limb Circumference and Length
Use a tape measure to locate points at which to measure and compare limb circumference. Differences
may be the result of muscle atrophy or edema. Measure
the circumference of both calves in a patient who has
unilateral lower limb edema. Measurements are taken
10 cm inferior to the anterior tibial tuberosity and
compared bilaterally. A difference of 2 to 3 cm is considered a signicant discrepancy and may indicate
deep vein thrombosis (DVT).
To measure leg length, have the patient lie supine
with legs in comparable positions, and measure the
distance from the anterior iliac spine to the medial malleoli of the ankles. If a discrepancy is found, ask the
patient to lie supine with knees exed 90 degrees and
feet at on the table. If one knee is higher, the tibia of
that extremity is longer. If one knee projects further
anteriorly, the femur of that extremity is longer.
Palpate Extremities and Joints
Always palpate those areas that are suspected to be
painless rst and then compare with the affected limb.
Determine if there is edema (e.g., presence of interstitial uid). Induration is interstitial swelling that has
progressed and is now rm. An effusion is a collection
of uid in the joint capsule, which can be the result of
rupture of a vascular structure or a synovial secretory
“clunk”
“clunk”
BARLOW
ORTOLANI
FIGURE 22-3 Ortolani sign for congenital dislocation of the hip. A
“click” is palpable or audible as the hip is reduced by abduction.
If the test is negative, the examination should always be repeated
in 2 to 4 months. (Swartz MH: Textbook of physical diagnosis:
History and examination, ed. 7, Philadelphia, 2014, Saunders.)
response to an inammatory process. The consistency
of the uid is noteworthy. Pus has a thick consistency
and is less uctuant than synovial uid. Hematoma has
a more gel-like consistency. Swelling in an ankle
sprain is diffuse and nonuctuant. Knee ligament
sprain is much more uctuant. To assess for uid in the
knee joint, press above the knee and watch the concave
or shallow areas of the joint become distended and
bulge on either side of the kneecap. Note that swelling
can extend above and below the point of pathology.
In severe knee trauma, rupture of the capsule allows uid to escape into surrounding tissues, and
less distention may be more apparent than with lesser
injuries.
Palpate for uid bulge if the knee is painful. Milk
the uid up into the suprapatellar pouch, then bring
the hand down the lateral aspect of the knee looking for
a medial uid bulge. Palpate deeply to detect muscle
brillation, fasciculation, or tumors.
Feel for heat in the affected joint, which can indicate an inammatory or infectious process. Evaluate
the joint for crepitus, both palpable and auditory.
Tendinitis may produce a grating sensation on palpation of the ligament or a grating sound with movement.
Perform Passive/Active Range of Motion of Hips,
Knees, and Ankles
Range of motion (ROM) may be limited because of
pain, weakness, or deformity.
If there is joint pathology, pain will be the same
with active and passive motion. If the disease is outside
the joint or extra-articular, passive motion may be
painless, whereas active motion produces pain. During
passive tests, move the joint until an end point or end
range is felt to help determine the affected structure.
There are six end points to note when assessing
joint movement: (1) bone-to-bone sensation, felt with
an osteophyte or abnormal bone development;
(2) spasm, which can indicate severe ligamentous
injury; (3) capsular feel or a rm arrested movement
with some give to it, which can indicate chronic joint
effusion, arthritis, or capsular scarring; (4) spring
block or joint rebound at the end of range of movement, caused by an articular derangement or an intraarticular body; (5) tissue approximation, a normal end
feel caused by tissue limiting further movement,
such as the biceps muscle limiting elbow exion; and
(6) empty end feel, present when there is no tissue
resistance, but the patient stops the movement because
of pain. This last condition indicates bursitis, extraarticular abscess, or tumor.
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Chapter 22 • Lower Extremity Limb Pain
Test for Muscle Strength
Test for lower extremity exor and extensor strength
against resistance of both the proximal and distal
muscle groups (Table 22-1). Proximal muscle weakness is seen in myopathic disorders. Distal muscle
weakness is seen secondary to a neuropathic process.
Generally, if the opposite side is normal, strength
should be compared to it.
In the presence of signicant pain, muscle strength
may be unreliable. If the contraction is strong and painful, the pathology is caused by mild musculotendinous
damage. If the contraction is weak and painful, the
pathology is the result of severe musculotendinous
damage. If the contraction is weak and painless, the
pathology results from a neurological lesion (paresis).
Perform a Neurological Examination
A complete assessment of sensory and motor function
and deep tendon reexes should be done on the
affected and contralateral limbs. If systemic illness
is suspected, perform a complete neurological examination. A referral is indicated if initial treatment
does not adequately control pain, if function loss is
progressing, or if the patient is immunocompromised.
LABORATORY AND DIAGNOSTIC STUDIES
Complete Blood Count
A complete blood count (CBC) is obtained to evaluate
for anemia associated with chronic disease, infection,
or neoplasm. An altered white blood cell (WBC) count
may indicate infection or leukemia.
Erythrocyte Sedimentation Rate
An erythrocyte sedimentation rate (ESR) is elevated
when inammation is present. It is a nonspecic test.
Joint Aspiration
Joint aspiration is performed to assess synovial uid
for elevated WBC count, Gram stain, culture and
sensitivity, crystal analysis, presence of glucose, and
consistency or “string test.” This procedure is performed using local anesthesia under sterile technique.
Synovial uid will ow easily when the joint capsule
is penetrated.
Radiography
Obtain at least two radiographic views, anteroposterior
and lateral, because injuries are not always apparent on
a single view. Any evidence of fracture or dislocation
will require orthopedic attention. Sometimes radiographic comparisons with the opposite limb may be
useful. Traumatic knee injuries should include four
radiographic views: anteroposterior, lateral, tunnel (intracondylar notch), and a 30-degree sunrise (patella).
Magnetic resonance imaging (MRI), computed tomography (CT), or bone scanning is usually ordered by a
specialist. MRI is usually used in spine, joint, and soft
tissue imaging. CT scans are usually performed for
bone visualization.
Antinuclear Antibodies
Antinuclear antibody (ANA) tests are positive with
high titers in rheumatoid arthritis (RA) and systemic
lupus erythematosus (SLE). However other conditions,
such as aging, medications, and other connective tissue
disease, can produce positive antibody titers.
Rheumatoid Factor
Rheumatoid factor (RF) is the single most useful test to
conrm a diagnosis of RA and is positive in 80% of
patients with this disease. RF can be positive years
before clinical symptoms appear.
Table 22-1
GRADE MUSCLE STRENGTH TERM
0 No palpable contraction Zero
1 Muscle contracts but part does
2 Muscle moves part but not against
3 Muscle moves part through range
4 Muscle moves part even with
5 Normal strength against resistance
Muscle Strength Test
not move
gravity
against gravity
resistance
present
Trace
Poor
Fair
Good
Excellent
C4 Complement
C4 complement determines serum hemolytic
complement activity, a protein that binds antigenantibody complexes for the purpose of lysis. Complement is increased in active inammatory disease
and in autoimmune disorders such as juvenile rheumatoid arthritis.
C-reactive Protein
C-reactive protein (CRP) indicates the presence of
abnormal plasma protein or a nonspecific response
to inflammation caused by both infectious and noninfectious processes. CRP is elevated in RA and
infection.
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Lyme Titer Enzyme-Linked Immunosorbent Assay
Serology
Enzyme-linked immunosorbent assay (ELISA) detects
antibodies against B. burgdorferi, which causes Lyme
disease. However, it may not detect antibodies for sev-
eral weeks after the onset of infection.
DIFFERENTIAL DIAGNOSIS
Musculoskeletal Inflammation
Tenosynovitis (Tendinitis)
Soft tissue disorders of tendinitis, bursitis, and brosi-
tis tend to co-occur. Tenosynovitis is a term that refers
to inammation of the tendon and tendon sheath.
The patient’s chief concern will be pain that is
worse with movement and swelling around the
affected area. Occupational and recreational history
will provide vital clues to a traumatic or overuse cause
of pain. People with arthritis may have tendinitis
secondary to joint disease. Crepitus may be felt on
palpation of the tendon.
Bursitis
Bursitis is inammation of a sac lined with synovial
uid, most often secondary to traumatic tenosynovitis
of the hips and knees. Bursitis is caused by overuse
and trauma and may be associated with RA. If isometric contraction of a group of muscles causes pain,
the muscles or tendons, or both, may be involved.
Bursitis causes an aching pain that radiates to points
of tendon insertion or further along the limb. Muscle
weakness may also be present. Palpation reveals local
tenderness and swelling without full range of joint
motion.
Joint Inflammation
Osteoarthritis
Osteoarthritis (OA) is a degenerative disease of joint
cartilage that results in osteophyte (spur) development
and synovial inammation. It is the most common form
of arthritis and is present to some extent in all elderly
people. Patients report joint stiffness, pain, and limited
movement, most often of the spine (cervical and
lumbar) and large proximal joints (e.g., knee, hip).
Symptoms may be asymmetrical. Heberden nodes develop on the distal interphalangeal (DIP) joints. Patients
at increased risk have a history of joint trauma, are
obese, or have diabetes mellitus. Acute arthritis is
associated with an increased ESR, and radiographs will
show spurs, joint deformity, and erosive changes.
Rheumatoid Arthritis
Symptoms of RA include morning stiffness of symmetrical small joints in the hands and feet, swelling,
and progressive fatigue. Other symptoms include
fever, weight loss, anorexia, and diaphoresis. Pericarditis, pleuritis, and vasculitis are associated
conditions. Laboratory data may disclose a normochromic, normocytic anemia, an elevated ESR, and
a positive rheumatoid factor in 75% to 90% of
patients. Radiographs may show bony erosion at the
joint margins and joint deformities. Box 22-1 lists
criteria for the diagnosis of RA.
Juvenile Rheumatoid Arthritis
Juvenile rheumatoid arthritis (JRA) is the most common connective tissue disease in children. The patient
presents with fatigue, low-grade fever, weight loss, and
failure to grow. Night pain and morning stiffness that
Osteomyelitis
Osteomyelitis, a pyogenic infection of bone, presents
differently depending on the age of the patient as well
as the bone involved. It should be suspected in any
patient who reports pain in long or at bones and walks
with an antalgic limp. Fever, chills, and vomiting are
present in acute osteomyelitis but may not occur in the
neonate or young infant. Chronic osteomyelitis is characterized by relapse of pain, erythema, swelling, or
purulent discharge. The hallmark symptom is a constant local pain that progressively worsens. The slightest motion of the limb aggravates the pain. The child
keeps the limb motionless. Laboratory ndings show
increased WBCs, ESR, and CRP. Radiographs may
show bone destruction or deep soft tissue swelling at
the site of infection.
Box 22-1
Diagnostic Criteria for
Rheumatoid Arthritis (Four
Criteria Must Be Present)
• Morning stiffness at least 1 hour before improvement for
more than 6 weeks
• Arthritis of three or more joints for more than 6 weeks
• Arthritis of hand joints for more than 6 weeks
• Symmetrical arthritis of same joint
• Rheumatoid nodules
• Positive serum rheumatoid factor
• Radiographic changes showing erosions or bony decalcification
Modified from Arnett FC, Edworthy SM, Bloch DA, et al: The American
Rheumatism Association 1987 revised criteria for the classification of
rheumatoid arthritis, Arthritis Rheum 31:315, 1988.
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Chapter 22 • Lower Extremity Limb Pain
improve with activity are common symptoms. Younger
children may present with irritability, refusal to walk,
or guarding of a joint. The disease may be systemic,
affect fewer than four joints (pauciarticular), or affect
more than four joints (polyarticular). Laboratory ndings show anemia, leukocytosis, and thrombocytosis.
Rheumatoid factor and ANA may be negative. ESR is
elevated.
Septic Arthritis
Septic arthritis is sudden pain and inammation of a
single joint, sometimes associated with systemic signs
such as fever, malaise, and diaphoresis. The hip is a
common site of blood-borne joint infection in neonates, infants, and young children. The presentation
depends on the age of the child. A neonate may be
afebrile but irritable, refusing to feed and failing to
gain weight. In the older child, the onset of pain
and fever is acute, and the child refuses to bear
weight. ROM of the hip is markedly restricted and
very painful.
In adults, migratory joint pain and tenosynovitis
may follow 2 to 4 weeks after a mucosal site infection
with Neisseria gonorrhoeae. Knee, wrist, ankle, and
hand joints are most commonly affected. Joint aspiration shows increased WBCs, and culture of uid or pus
may reveal bacterial, tubercular, fungal, syphilitic, and
viral organisms. The ESR and CRP are also elevated.
Exposure to Chlamydia trachomatis (sexually transmitted) and Chlamydia pneumonia (respiratory tract)
can trigger an autoimmune response when these organisms migrate through the blood to joint tissue; this is
called reactive arthritis.
With hip involvement, ultrasound shows marked
distention of the hip joint with varying degrees of
femoral hip displacement. Septic arthritis is an
emergency situation, and treatment must be initiated
immediately.
Gout
Gout is a joint inammation caused by deposits of
urate crystals and is associated with an inborn error of
uric acid secretion or with metabolic disorders (e.g.,
hemolytic anemia, renal insufciency, sarcoidosis).
Males older than 30 years and those with a family history of gout are most often affected. The patient reports
a recurrent, sudden onset of pain early in the morning
that subsides over several days, especially of the rst
metatarsophalangeal (MTP) joint. The joint is warm,
tender, and red; tophi (chalky subcutaneous deposits of
sodium urate) may be present on extensor surfaces.
Gout can be differentiated from pseudogout by the
presence of calcium pyrophosphate crystals, involvement of large joints, and secondary osteoarthritis.
Laboratory ndings during an acute attack show
elevated serum uric acid level, ESR, and WBC count.
The joint may be aspirated for uid to observe uric acid
crystals and cultured to exclude septic arthritis.
Musculoskeletal Pain Related to Trauma
or Overuse
Hip and Leg
Slipped capital femoral epiphysis. In children un-
dergoing a rapid growth spurt, the onset of knee pain,
an antalgic limp, and leg weakness may indicate a
slipped capital femoral epiphysis (SCFE). Pain may be
of several weeks’ or months’ duration and is exaggerated by strenuous physical activity. Examine the child
in a prone position and assess the symmetry of medial
rotation of the hip. A reduction of medial rotation may
indicate a slipped capital femoral epiphysis (SCFE). A
widening of the epiphyseal plate can be visualized in a
lateral view radiograph.
Transient synovitis of the hip. A nonspecic in-
ammatory condition of the hip, transient synovitis is
the most common cause of a painful hip in children
younger than 10 years. History may reveal a recent
upper respiratory tract infection or minor injury. The
child complains of pain in the anteromedial aspect of
the thigh and knee and walks with an antalgic limp;
there is tenderness on palpation over the anterior aspect of the hip joint. Hip movement is limited and
painful. There may be a low-grade fever. Ultrasound
should be used for diagnosis, and both hips should be
compared. WBC count is usually normal, although the
ESR may be elevated.
Legg-Calvé-Perthes disease. This disease occurs
as osteochondritis of the femoral head epiphysis. It is
characterized by a period of avascular necrosis of the
femoral head, followed by revascularization and bone
healing. It occurs most commonly in boys between the
ages of 3 and 11 years. The child has groin or medial
thigh pain and a limp. The pain may be recurring, and
the child may have been limping for several months.
The loss of medial hip motion is an early sign. There is
a high incidence of hernia, undescended testicles, and
kidney abnormalities in children with this condition.
Radiographs show the ossic nucleus of the femoral
head combined with the widened articular cartilage
space compared with the opposite hip.
Iliopsoas tendinitis. This tendinitis is caused by
frequent repetitive exion of the hip joint and is
Chapter 22 • Lower Extremity Limb Pain
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267
common in weight lifters, oarsmen, and football
players. The patient complains of mildly intense groin
pain on the anterior hip, which worsens with move-
ment. An acute injury involves forced extension of
a exed leg. In younger age groups, radiographic
evaluation is done if evulsion of the epiphysis is
suspected. Test for iliopsoas tendinitis by having the
seated patient place the heel of the affected leg on the
knee of the other leg. This movement will create pain
and a tense iliopsoas muscle (Table 22-2).
Proximal bula fracture. Most proximal bula
fractures are caused by direct trauma to the lateral leg.
However, some fractures can be the result of forces
present or a diminished dorsalis pedal pulse is noted,
the patient needs immediate referral to an orthopedic
surgeon (Figure 22-4).
Stress fracture. Stress fractures occur in adoles-
cents whose bodies are not able to accommodate an
increase in intensity of training. Patients will note pain
with activity several weeks after beginning a sport.
Injury progresses from trabecular microfractures in the
bone to the osteoclastic action exceeding the rate of
osteoblastic bone formation, resulting in the bone
breaking. Plain radiographs may not demonstrate injury, so MRI is used to identify location of injury and
CT is used for follow up.
transferred from a lateral malleolar injury of the ankle,
especially when the force is a combination of compressive and rotational trauma. The peroneal nerve and
anterior tibial artery pass near the bular head, thus
injury to either of these structures can be a complication of a proximal bular fracture. If foot drop is
Table 22-2
TEST DESCRIPTION FINDINGS
LEG/HIP
Iliopsoas
Selected Tests Used to Assess for Lower Extremity Musculoskeletal Disorders
Have seated patient place heel of affected
leg on knee of other leg.
Knee
Chondromalacia patellae. Chondromalacia of the
patella is a change in the patellofemoral joint cartilage
that is most common in adolescent females. The condi-
tion can be caused by trauma, anatomic anomalies, and
Pain with this movement indicates
muscle iliopsoas tendinitis.
KNEE
Foucher sign Look for change in consistency of a mass
Bulge sign Apply lateral pressure to area adjacent to
Drawer sign With patient supine, flex knee 90 degrees
McMurray maneuver With patient supine, maximally flex knee
Collateral ligament test Apply medial or lateral pressure when
Lachman test (cruciate
ligaments)
in popliteal fossa that hardens with
extension and softens with flexion.
patella.
and hip 45 degrees with foot on table;
apply slow, steady anterior pull, and in
same position gently push tibia back.
and hip; externally and internally rotate
tibia with one hand on distal end of
tibia; with other hand, palpate joint.
Extend knee with slight lateral pressure
with tibia internally rotated.
Extend knee with slight internal pressure
on tibia externally rotated.
knee is flexed 30 degrees and when
it is extended.
With knee flexed 30 degrees, pull tibia
forward with one hand while other hand
stabilizes femur.
A positive sign indicates a popliteal tumor
or aneurysm; a negative sign indicates
a Baker cyst.
Medial bulge will appear if fluid is in
knee joint.
Tests for cruciate ligament stability;
abnormal anterior or posterior movement of tibia on femur is a positive
drawer sign and indicates ligamentous
instability.
Pain and a palpable or audible click
are positive findings and indicate a
meniscus injury.
Positive finding in this position indicates
a lateral meniscus injury.
Positive finding in this position indicates
a medial meniscus injury.
Medial or lateral collateral ligament
sprain will show laxity in movement
and no solid end points, depending
on degree of sprain.
Positive test is a mushy or soft end feel
when tibia is moved forward, indicating
damage to anterior cruciate ligament.
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FIGURE 22-4 Typical appearance of a proximal fibular fracture.
(From Crowther CL: Primary orthopedic care, ed. 2, St Louis,
2004, Mosby.)
Chapter 22 • Lower Extremity Limb Pain
misalignment of the patella. Softening of joint cartilage, tufts of patellar cartilage, ssures, or ulcers occur.
Patients present with anterior knee pain that is worse
while climbing stairs or biking. Radiographic studies
of the knee, including tangential and sunrise views,
show irregularities of the patellofemoral joint.
Patellar tendinitis (jumper’s knee). This overuse
syndrome is characterized by inammation in the distal extensors of the knee joint. Patellar tendinitis is
more common in athletes who habitually place excessive strain on their knees from jumping or running.
Determine the quadriceps (Q) angle by measuring the
angle between the center of the patella to the anterior
superior iliac spine and from the center patella to the
tibial tubercle. An angle greater than 10 degrees in
males and 15 degrees in females suggests patellar
tendinitis. People affected complain of dull, achy knee
pain that may have associated clicking or popping. Associated malalignment from femoral anteversion or
ankle varus may be present.
Medial collateral ligament sprain. Medial collat-
eral ligament injuries are common and are the result of
valgus stress to the knee. The patient limps soon after
the injury and may or may not have pain. On physical
examination, there is mild effusion and point tenderness over the medial collateral ligament. To test for
stability of the medial collateral ligament, the knee
is exed about 30 degrees with the patient supine and
one hand is placed over the lateral knee with the other
around the ankle. Apply medial pressure to the knee
while pulling the ankle outward. An instability of the
medial collateral ligament produces a sensation of
opening the medial aspect of the joint. Applying lateral
pressure in the same knee position tests for lateral
ligament sprain. A radiograph is obtained to rule out
fracture.
Medial meniscus tear. Medial meniscus injuries,
more common than lateral meniscus injuries, occur
after a twisting injury to the knee. The patient has pain,
difculty exing the knee, and difculty bearing
weight. There often is a clicking or catching in the
knee joint, and the joint may be swollen and tender.
To examine for medial meniscus injury, perform the
McMurray test to assess for clicking, locking, or a
springy end point of motion. With the patient supine, place
one hand under the heel and ex the knee 90 degrees with
slight abduction. Apply a lateral and medial force to
the knee while extending and adducting it. A palpable
or audible click indicates medial meniscus injury.
Anterior cruciate ligament tear. Ligaments may
be stretched or torn if the knee is twisted or hyperextended. The anterior cruciate ligament (ACL), located
in the center of the knee, is one of the most common
ligaments damaged in knee injuries. An ACL injury is
often associated with an audible pop and a giving-way
sensation in the knee, often with swelling from hemarthrosis. Physical examination reveals a positive
Lachman test. With the patient supine and the knee
exed 20 to 30 degrees, anchor the patient’s foot to the
table; then pull the tibia forward. Anterior motion is a
sensitive test for ACL laxity.
Osgood-Schlatter disease. This condition, most
common in adolescent males, is a painful swelling of
the anterior aspect of the tibial tubercle. It is caused by
strenuous activity, especially of the quadriceps muscles.
The patient will often limp, and the pain will be worse
with activities such as stair climbing and kneeling. Examination will reveal a warm, swollen, tender tibial
tubercle, and exion and extension will increase pain
intensity. Joint examination of the knee is normal.
Baker cyst (popliteal cyst). A popliteal cyst occurs
when uid from the knee joint enters the connecting
bursa and becomes trapped. Patients notice fullness or
swelling of the posterior knee and calf pain aggravated
by walking and alleviated by rest. Examination of the
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