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Musculoskeletal Development and Problems in Children

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Overview

Although they are a common cause of visits to primary care, most musculoskeletal presentations in children are benign and self-limiting, however, in some cases, referral to secondary care may be necessary.

General Red Flags and Referral

Overview

Admit any of the following patients to the emergency department if any of the following are suspected:

Seek advice from or urgently refer to the relevant specialty if any of the following features are suspected:

  • Rheumatology:
    • Inflammatory arthritis (e.g. constitutional symptoms, joint swelling, early morning stiffness and/or stiffness that improves with movement, systemic illness, motor milestone delay/regression)
    • Back pain with red flags (discussed in back pain below)
  • Orthopaedics:
    • Limp but SUFE is not suspected
    • Back pain with red flags (discussed in back pain below)
    • Bone pain
  • Paediatrics:
    • Neurological disorder (e.g. muscle wasting, weakness, sensory problems)
    • Malignancy (e.g. constitutional symptoms, lymphadenopathy, hepatosplenomegaly)
    • Back pain with red flags (discussed in back pain below)
    • Milestone delay/regression
    • Persistent night waking
    • Suspected non-accidental injury
    • Bladder/bowel problems

Consider further investigations or referral using clinical judgement if any of the following apply:

  • Atypical symptoms
  • Worsening symptoms
  • Unremitting pain, night pain, or thoracic pain
  • Non-mechanical pain
  • Abnormal loss/deterioration of function
  • Significant loss of movement
  • Gait problems
  • Significant lower limb asymmetry
  • Tuberculosis, cancer, HIV, steroid use, multiple fractures
  • Skin changes (e.g. café au lait spots, psoriasis, bruises)

Growing Pains

Overview

Growing pains describe benign, non-inflammatory, recurrent discomfort in young children. The pains are often not due to growth, and the more technical term for them is ‘benign idiopathic nocturnal limb pains of childhood’.

They are equally common in boys and girls and affect children aged 3-12 years old.

Growing pains are a diagnosis of exclusion. Pathological causes of similar features include:

  • Autoimmune/inflammatory conditions (e.g. juvenile idiopathic arthritis)
  • Infection (e.g. septic arthritis or osteomyelitis)
  • Malignancy (e.g. Ewing sarcoma, leukaemia, metastases)
  • Trauma (e.g. sprains and strains, acute or stress fracture, nerve injury)
  • Structural conditions (e.g. slipped upper femoral epiphysis, hypermobility, patellofemoral syndrome)
  • Metabolic disorders (e.g. vitamin D deficiency)
  • Non-inflammatory pain syndromes (e.g. fibromyalgia)

Presentation

Features of growing pains are:

  • Pain that usually affects the legs bilaterally – they are not asymmetrical
  • The pain is never present at the start of the day or after the child has woken up
    • The pain usually starts at night and disappears while the child is sleeping
  • No limp or limitation in physical activity
  • Normal physical examination
  • Normal major motor developmental milestones
  • No red flag features

Back Pain

Overview

Low back pain is common in children and adolescents, but rare in pre-school children. It is often short-lived and not severe but can limit activities.

Presentation

If all of the following are present, back pain can be managed in the community:

  • Child is well with no red flags
  • No neurological symptoms
  • Normal examination
  • No functional impairment (e.g. playing or walking)

Bow Legs (Genu Varum)

Overview

Bow legs describe outward bowing at the knee with the lower leg angled inwards and the thigh angled outwards giving the appearance of an archer’s bow. This is usually bilateral, symmetrical, and self-limiting.

It affects boys and girls equally and usually resolves by 2 years old.

Pathological bow legs can be due to rickets (osteomalacia in children).

Presentation

If all of the following are present, bow legs can be managed in the community:

  • Well and no red flags
  • <4 years old
  • No pain
  • No functional impairment (e.g. no problems with play/walking etc.)
  • Milestones are normal and development is normal

Knock Knees (Genu Valgum)

Overview

Knock knees describe when the knees angle inwards and touch each other when the legs are straightened. They are usually self-limiting and occur bilaterally.

Knock knees are more common in girls and occur between 3-6 years of age. Most cases resolve by 7 years old.

Pathological differential diagnoses of knock knees include:

  • Bone tumours
  • Juvenile idiopathic arthritis
  • Cerebral palsy
  • Slipped upper femoral epiphysis
  • Vitamin D deficiency
  • Ehlers-Danlos syndrome
  • Joint hypermobility
  • Bone dysplasia
  • Metabolic bone disease

Presentation

If all of the following are present, knock knees can be managed in the community:

  • No red flag features
  • Aged 2-5 years
  • No pain or functional impairment
  • Deformity is symmetrical

Flat Foot (Pes Planus)

Overview

Flat foot is common in infants and children and generally resolves by adolescence. It is generally physiologic and painless with no functional consequences, however, it can rarely become stiff, painful, or rigid.

Presentation

If all of the following are present, flat foot can be managed in the community:

  • <6 years old and no red flag features
  • Flat feet are painless and flexible
  • No functional impairment (such as limp, interference with walking/play)
  • No pain in the legs or joints
  • Milestones are normal
  • No blisters or callouses

Curly Toe

Overview

Also known as an underlapping toe, a curly toe is thought to be congenital and can be unilateral or bilateral. In most cases, the underlapping toe corrects itself by 6 years old. In some cases, intervention is needed.

Presentation

If all of the following are present, curly toe can be managed in the community:

  • No red flag features
  • No pain
  • No skin thickening, blisters, or trauma
  • No functional limitation

In-toeing

Overview

In-toeing describes the medial or internal rotation of the foot when the child is moving. It is usually first encountered at 1 year old and can occur due to:

  • Internal tibial torsion – most common cause
  • Femoral anteversion
  • Metatarsus adductus

Other pathological differential diagnoses include:

  • Neurological causes – cerebral palsy, spina bifida
  • Musculoskeletal causes – slipped upper femoral epiphysis, congenital hip dysplasia
  • Metabolic causes – rickets, Blount’s disease, osteogenesis imperfecta

Presentation

If all of the following are present, in-toeing can be managed in the community:

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

Out-toeing

Overview

Out-toeing describes the lateral or external rotation of the foot when walking. It is less common than in-toeing and can be associated with bow legs and flat feet.

It is normal in infancy and resolves by 24 months of age.

Other pathological differential diagnoses include:

Presentation

If all of the following are present, out-toeing can be managed in the community:

  • Child is well
  • No red flag features
  • <4 years old
  • No pain
  • No functional impairment or limp

Heel Pain

Overview

Heel pain is common in young children and adolescents and most causes are benign.

Causes of heel pain include:

  • Calcaneal apophysitis (Sever’s disease) – most common:
    • Pain due to the Achilles tendon pulling on an unossified apophysis resulting in inflammation
    • This is self-relieving and managed by avoiding exacerbating activities
  • Achilles tendonitis – rare <14 years old
  • Retrocalcaneal bursitis – may be due to trauma following overactivity
  • Calcaneal fracture – due to repetitive trauma, a fall from a height, or a direct blow
  • Calcaneal tumours – rare, progressive, dull, deep heel pain and swelling
  • Calcaneal osteomyelitis – erythema, warmth, focal tenderness, oedema
  • Retained foreign body (e.g. stones) – more common in children who go outside without shoes

Presentation

If all of the following are present, heel pain can be managed in the community:

  • Child is well
  • No red flag features
  • No delay/regression in milestones
  • No functional impairment or limp

Clumsy Child

Overview

‘Clumsy’ describes difficulties in fine motor and gross motor coordination. For example, children may fall frequently, and struggle to learn motor skills compared to peers (e.g. writing, dressing, using scissors etc.).

Causes include:

  • Developmental coordination disorder:
    • Common, chronic neurodevelopmental disorder where motor skills are below those expected, interfering with activities of daily living
    • More common in children with co-existing neurodevelopmental disorders such as ADHD, autism, and dyslexia
  • Visual impairment
  • Cerebral palsy
  • Orthopaedic problems
  • Hereditary ataxia
  • Congenital chorea

Presentation

If all of the following are present, clumsy child can be managed in the community:

  • Well
  • No red flags
  • Not in pain
  • Achieving normal milestones, no delay/regression in milestones
  • Not functionally impaired

Hypermobility

Overview

Hypermobile joints are joints that move beyond their normal range of motion. They are common and can be generalised or affect specific joints. It tends to run in families, but its genetic basis is unknown.

Causes:

  • Asymptomatic
  • Joint hypermobility syndrome:
    • Symptomatic joint hypermobility with muscle and joint pain and fatigue which are worse toward the end of an active day
  • Marfan syndrome
  • Ehlers-Danlos syndrome
  • Osteogenesis imperfecta
  • Fragile X syndrome
  • William’s syndrome 

Presentation

If all of the following are present, hypermobility can be managed in the community:

  • Child is well
  • No red flags
  • No pain
  • No functional impairment
  • No features suggesting underlying conditions associated with hypermobility

Late Walking

Overview

Children tend to start waking alone at 12 months of age. By 18 months, children should be able to walk well.

Late walking (including bottom shuffling) can be familial, but can also be due to neurological disorders including:

Presentation

If all of the following are present, late walking can be managed in the community:

  • <18 months old
  • No red flag features
  • No other developmental concerns
  • No features of a neuromuscular disorder (e.g. no wasting, suggesting muscular dystrophy)

Tip toe walking

Overview

Tip toe walking is where children walk predominantly on their toes or forefoot, with an absent heel strike. This is common in young children up to 3 years old and generally resolves by 5 years.

Idiopathic tip toe walking is a diagnosis of exclusion as tip toe talking is associated with many pathological causes.

Causes include:

  • Idiopathic – diagnosis of exclusion
  • Neurological causes – cerebral palsy, hydrocephalus, spina bifida, space-occupying lesions, peripheral neuropathy, muscular dystrophy, movement disorders
  • Developmental causes – autism, intellectual disability, language and communication disorders
  • Anatomical causes – short calf tendon/muscle, limb length discrepancy, club foot, ankylosing spondylitis

Presentation

If all of the following are present, tip toe walking can be managed in the community:

  • They are:
    • Well with no red flags
    • <3 years old
    • Able to walk with a heel strike and squat to play on the floor with their heels – suggests idiopathic toe walking
    • Well-coordinated when walking or running on toes with no limp
    • Able to jump – if their developmental milestones say they should
  • They have:
    • Intermittent/symmetrical toe walking
    • No pain
    • No risk factors
    • No delays/regression in milestones
    • Normal examination
    • No functional impairment (e.g. with play/walking)

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