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Limping is really frequent problem between children and it makes parents to be worried because resource of the limping is not known. Limping can have normal resource. But also, it can be early indicator of sickness that can result in bad way. There are a lot of reasons that can be pointed for limping and walking abnormality in children. Those can be pain and inflammation. Also, can be muscle weakness or abnormal muscle activity, joint abnormalities or leg size inequalities.
Diagnosis: First step is well-made medical story for diagnosis. Medical story should contain the answers for presence of trauma, present sicknesses, and duration of the problems. Short-term severe complaints may be because of trauma, which is the main indication of joint inflammation. Long-term complaints can be due to some chronical disease which needs detailed and more time taking examinations.
Medical story is important especially in babies who cannot explain themselves clearly and the medical story should be started from birth. For example; children with premature birth and has story staying in incubator may diagnosed as cerebral palsy because of the delay in motor (motion) skills. Accordingly, family medical story is very important for diagnosis of genetic diseases.
Examination starts with observations when child walks into the room. Determination of area and intensity of pain can be hard for younger children. Therefore, whole leg (hip, femur, knee, calf, ankle, joint of foot) should be examined in view of sensitivity and motion range. The symptoms of of sensitive joint are swelling, redness, limitation of movement and increasing temperature.
Medical story and physical examination are done for diagnosis. After that, imaging and laboratory examinations should be done. If the pain cannot be localized in imaging, front-back and side X-Ray imagings of total leg must be done for kids. X-Rays are so important especially for excluding especially emergent intervention needed situations. Those images are not just showing fractures due to trauma, but also shows the lesions (bulks) in bone and probable sickness related to growth plaques.
In the light of physical examinations and X-Ray imaging results and children with long-term complaints, advanced imaging techniques like ultrasound (US), computerized tomography (CT), magnetic resonance imaging (MRI) may needed.
Laboratory examinations are very important when joint inflammation is questioning in children. Symptoms of joint inflammation can be evaluated from blood test results by examining diameters like sedimentation, CRP and increasing numbers of leukocytes. Inflammation can be temporary and benign (temporary synovitis) and sceptical arthritis which is microbial inflammation of joint that needs surgical treatment urgently. Advanced laboratory examinations may needed for separative diagnosis in multiple diagnosis cases. Children with normal physical examination and laboratory examinations should be tracked as a part of the treatment.
Painful walk (Antalgesic walk): Antalgesic walk (painful walk) can be originated from lower limb, which is pain in legs and hip, or disease due to lower back. In painful walk, children are trying to shorten the phase of step, less burden to specific painful side or walking by limping.
Trendelenburg walk (duck-like walk): Trendelenburg walk is due to weakness abductor muscle of hip which provides lateral decompression. Abductor muscles provides balance for hip which is not in contact with the ground which is in oscillation phase while walking.
The opponent hip tends to repose to the side when the patient step into a side because of the weakness of abductor muscles, they cannot provide support. This leads to duck-like walk when it is both-sides as in hip dislocation. Besides hip dislocation, Trendelenburg walk can be seen in other diseases like Penthes which causes hip joint’s osseous shape defect
Spastic walk: Spasticity is defined as unintentional strain of motor muscles and it is typical in cerebral palsy patients. In the form of spastic walk, fingertip walk due to tight Achilles tendon, bent walk disorders in the knees due to tense hamstring muscles (thigh posterior group muscles) can be seen. Presence of only one of them can cause hip benting, knee benting and walk on fingertips. Scissor walk in the legs due to the adductor muscles on the inner groin side of the hip can also cause spastic walk.
Short leg walk: This type of walk is seeing in the kids who has inequal leg size. Fingertip walk can be seen for supporting the shorter side. Meanwhile, bending of legs from hip and knee can be observed in longer leg. Clear walk abnormality may not be located for children who doesn’t have lot leg size difference.
Babyhood (1-3 years old): Good evaluated story is very important in this period cause the patient cannot explain theirselves. The story should be evaluated in details. Parents may not think mild trauma or incident can cause limping and thus, may not talk about them.
Examinations are starting with observation of walking pattern of the baby as mentioned above. In this period, walking pattern as adults are not expected. Babies are walking by opening their legs more and breaking their knees and legs more to ensure balance. Babies cannot increase their steps’ distances but they can increase their tempo that causes fast and unbalanced walking. The most frequent reasons that causes painless limping, also named as abnormal walking, are developmental hip dysplasia (hip dislocation), leg length inequalities and neuromuscular diseases (cerebral palsy, spina bifida, etc.)
Besides limping, different walking patterns can be seen in this period;
Toe walking: Painless Toe Walking is one of the most frequent reason of patient’s to apply to orthopaedics clinics. This can be seen without establishing any problems, also named as idiopathic, but also may because of the neuromuscular disease that concerns nerve and movement systems. The patient is walking on top that can be caused from nothing but also due to tension in the calf hindquarter muscles. Leg length inequality should be suspected in unilateral cases. Good evaluated story and diagnosis with physical therapy examinations are so important as we mentioned above.
Walking by stepping in and out: Babies who walks by stepping in is one of the most frequent reasons of parents to apply on orthopaedics specialists. Angular changes in the upper part of the thigh bone (femoral neck) ist the most common reason of this condition. This angular values can be change up to 30 degrees in everybody which determines our most comfortable position while sitting at the same time. Because they can twist their legs inward more readily, those with a greater femoral upper angle (an enhanced femoral anteversion angle) sit comfortably in the W position.
Those with a lower femoral anteversion angle (reduced femoral anteversion angle) sit more comfortably in the cross-legged position with the thigh turned outward.
As a result, newborns in the W position are more likely to experience inward pressing. Most babies have a high upper thigh angle (femoral anteversion angle) and a W sitting and introversion, especially those with a family history. The majority of the time, the pressure is corrected by the shoe, giving the impression that the shoe is correcting the introversion. Because the angular change of the upper part of the thigh, or the angular change of the hip joint, is the most common cause of introversion.
Physical examination and, if necessary, radiographic imaging can check out any other probable diagnosis. On physical inspection, babies that do not have a skeletal defect are merely followed up on. The child’s normal walking will develop with time, and the condition will improve between the ages of 4 and 7.
Waddled walking: Waddled walking is a walking pattern seen in children who appear to be wearing braces on their legs. Bracketed legs (genu varum) can be found in babies, especially between the ages of 1-2, physiologically, that is, naturally. This disease, known as the physiological genu varum, is frequently observed as a result of rickets, which is caused by a vitamin D deficit in the diet. In children who have a brazen leg look that is greater than usual and becomes more apparent with walking, rickets results can be recognized by radiological imaging methods during the physical examination.
Braces can also be caused by illnesses of the leg, such as the genu varum growth plate, which can be diagnosed by X-ray imaging. Blount’s illness causes limb deformity, which is more common in slightly overweight or obese babies and children. Early diagnosis and instrumentation with proper orthoses can stop the illness from progressing in this scenario.
Surgical correction may be needed in extreme situations. As a result, children with a wobbling walking and braces leg look, which is especially noticeable when pressure is applied, should be checked by an Orthopedic and Traumatology Specialist. The severity of the problem determines the treatment choices, which include follow-up, device, and surgical therapy.
Childhood (4-10 Years): Since the child is mature enough to explain themselves, it is easier to evaluate the source of walking irregularity during this period than it is during baby. At the same time, abnormal walking reduces over this time, and by the age of 7, a walking similar to that of an adult has developed. Painful childhood problems should be taken carefully. Before making a diagnosis of pain that arises due to changes in growth plates, which is very frequent during this age and is described as developing pain among people, other probable diseases must be considered out as well. Growing discomfort, or pain induced by growth plates, is common in the heel, foot bones, and beneath the kneecap. After physical exercise, pain and limping are reduced.
Pain that occurs at rest or wakes the kid up at night should be considered based on the child’s history. Advanced imaging procedures, such as magnetic resonance imaging-MR, may be necessary to uncover the underlying issue in children of this age who have resting discomfort and overnight pain.
Teenager (11-15 years): A teenager can provide a doctor with a comprehensive history of limping. It can help pinpoint the exact area of the discomfort. During this stage, displacement of the growth plate of the top section of the thigh, known as femoral head epiphyseal slippage, can cause limping in children that starts suddenly or gets worse over time, especially in obese children. Ligament tears and joint cartilage damage are also common in this age range as a result of sports-related injuries.
Investigation of limping and other walking problems in children is critical, as is explaining the cause to the family and relieving their concern. Limping or an irregular walking in children can be caused by a variety of factors. A limp might be the result of a benign, minor problem or an early indicator of an illness with potentially fatal implications. An Orthopedic Doctor’s evaluation and follow-up of children with walking abnormalities allows for early diagnosis and therapy.