DDH describes a spectrum of conditions related to the development of the hip in infants and young children. It encompasses abnormal development of the acetabulum and proximal femur, and mechanical instability of the hip joint.
Key Assessment points
Referral not indicated
Refer for a Hip Ultrasound scan if:
Baby is under 10 months of age and has...
NB: if baby is less than 12 weeks old, US referral should be urgent, as conservative treatment (Pavlik harness) cannot be commenced over this age.
Refer for Pelvis X-ray if:
Baby is over 10 months of age and has…
Refer to Paediatric Orthopaedics
International Hip Dysplasia Institute https://hipdysplasia.org/Baby Feet positional issues
Positional talipes equinovarus
The foot rests inwards and downwards
The foot rests upwards and outwards
The forefoot curves inward
Does not require a routine hip ultrasound scan OR PHYSIO
Hip ultrasound scan at 6 weeks, PHYSIO IF TIGHT/STIFF
Congenital talipes equinovarus CTEV (clubfoot) is a true, rigid fixed foot, with a smaller leg and calf, and a high riding small heel. This is usually identified on antenatal scans and is treated with Ponseti casting at Southampton Hospital.
Key assessment points
Refer to Paediatric Physiotherapy
Refer to Southampton Paediatric Orthopaedics
Refer to ultrasound for a hip scan
Intra-uterine positioning and a prolonged or difficult labour can cause newborn babies to have a misshapen head.
This is common and will usually improve within the first few weeks after birth. However, if associated with a loss of range of movement in the neck (torticollis), and/or a strong preferential head turn, the problem may persist and the head shape may worsen.
Educate re) encouraging equal movement to right and left when awake, and repositioning baby’s head when asleep, to less preferred side. Encourage regular supervised tummy time. Give appropriate leaflet; “APCP leaflet on Head Turning Preference and Plagiocephaly”
Refer to Paediatrician
Refer to Community Paediatrician
Growing pains are described as acute muscular pain in the legs which can cause nocturnal waking. This condition occurs in about 15% of children as early as 1 year old. The child does not limp and symptoms are relieved by massage and simple analgesics.
• Usually non-articular, in 2/3 of children its located in the shin, calves, thighs or popliteal fossa and is almost always bilateral
• Pain usually appears late in the day, and often wakes the child at night
• Duration ranges from minutes to hours, severity can be mild to severe
• By morning the child is almost always pain-free
• Often parents can predict when the child will have pain on days of increased activity
• Perform The paediatric gait, arms, legs and spine examination (pGALS), check for limp, check joints for restriction/swelling
• Rule out systemic features
• Check skin for a rash, bruising
• Review developmental milestones
• Ensure normal growth (height and weight percentiles)
• Typical growing pain presentation with no indications for concern (fits typical features listed above)
• Reassure parent/guardian. Explain the natural benign course of growing pains, reducing parental anxiety. Advice leaflet Childhood growing pains
Investigations that may be indicated in Primary Care
• Full blood count
• Acute phase reactants (ESR, CRP)
• Biochemistry (bone biochemistry and vitamin D)
• Thyroid function
• Creatine kinase (CK)
• Growth chart (height and weight)
• XR of legs (hips with frog views)
IMPORTANT NEGATIVES: (normal FBC/ESR, joints normal, no CV features)
• There is associated muscle tightness and/or weakness with pain
• A limp with positive Pelvic XR findings
• Concern about bony pathology
• Palpable lump in muscle (bakers cyst, semimembranosis bursitis)
• Poor appetite and/or weight loss
• Poor growth
• Systemic symptoms
• Pain not relieved by massage or analgesics
• Muscle weakness, extreme fatigue
Refer to Paediatric Rheumatologist
• Joint swelling, pain and morning stiffness indicating inflammatory pathology
• Positive pGALS with restricted joint range of motion
Congenital curly toes are a common condition that tend to affect the 3rd, 4th and 5th toes of one or both feet, usually present at birth but can become more noticeable when a child starts walking.
Curly toes are a normal variant and generally don’t require treatment unless they are symptomatic. They generally do not cause any problems. Occasionally the tendons can become tight and pull the tip of the toe underneath the next toe and towards the sole of the foot. Children complain of rubbing or pain and may have problems with finding suitable shoes that fit properly.
• Check passive range of motion of the toes, will they fully correct to a neutral position and is there any tightness in the toe flexor tendons?
• Check for generalised muscle tightness particularly in toe flexor tendons and calf complex (silfverskiold test)
• Check for ‘clawing’ toes or cavus feet
• Overriding toes are flexible/correctable
• Advise on silicone toe spacers and foot wear with a wide toe box
Reassure the parent/guardian that curly toes are entirely normal and give advice leaflet titled "curly toes” and if indicated APCP advice leaflet titled “Choosing Footwear for Children”
Refer to Community Paediatrician or Neurologist
Refer to Community Podiatry Service
Most children under the age of three have flat feet and rolling ankles. The arch on the inside of the foot does not begin to develop until after this age. The arches may be visible when a child is sitting, when the big toe is bent backwards or if the child stands on tiptoe. Full development of an arch is usually between the ages of 5-7 years old. In most children flat feet do not cause any problems.
Key Assessment points
• Ask the child to stand on tip toes. If the arch lifts, the foot is flexible
• Passively lift (extend) the big toe, to see the child’s arch lifts
• Child is asymptomatic
• Flat feet are fully flexible
Reassure the parent/guardian and give APCP advice leaflet titled “Flat Feet in Young Children” and if indicated APCP advice leaflet titled “Choosing Footwear for Children”
Refer to Podiatry/Orthotics
In-toeing gait (walking with feet facing inwards) is a common, normal variance of developing gait and usually does not require intervention or onward referral. In most cases it resolves over time. Occasionally it will persist into adolescence or be a sign of more serious pathology.
• Observe gait pattern and ensure symmetrical
• Check for full range of movement in the lower limb joints, especially the hips.
• Check for abnormal neurology in both the upper and lower limbs
• Child is asymptomatic and up to 9 years of age
Physiotherapy cannot prevent tripping often associated with intoeing. Please DO NOT refer asymptomatic patients, or on parental concern alone. Reassure the parent/guardian and give APCP Advice leaflet titled “Intoeing gait”
Refer to Podiatry or Orthotics
Out-toeing is a common, normal variance of gait and usually does not require intervention or onward referral. It usually improves as a child grows. Out-toeing often runs in families, and can persist into adult life but rarely causes problems. It is commonly seen in later walkers and may be associated with knock knees (genu valgus) and flat feet.
Less Common causes:
· Legg-Calve Perthes Disease /Slipped Capital Femoral Epiphysis, especially when unilateral – due to decreased hip rotation and abduction
• Observe gait pattern and ensure symmetrical
• Check for full range of movement in the lower limb joints, especially hips
• Check for abnormal neurology in both the upper and lower limbs
• Symmetrical asymptomatic out-toeing
• Please DO NOT refer patients on parental concern alone. Reassure the parent/guardian
• If indicated give APCP advice leaflet titled “Choosing Footwear for Children”
· Out-toeing associated with hip/knee/ankle pain
· There is associated muscle tightness and/or weakness
· Asymmetrical hip range of motion (you may wish to request AP/frog lateral Pelvis first)
· Child is over 8/9 years of age with pain and/or significant deformity causing psychological distress
· Persistent pain assocaited with out-toeing that has not improved with physiotherapy/orthotics
Refer to ED/CAU
· Sudden onset of out-toeing following trauma, particularly if asymmetrical and associated with a limp – may suggest Perthes/SCFE
· Flat feet/calcaneo-valgus foot posture is causing pain, rubbing or uneven shoe wear
It is common for children to walk intermittently on their tip toes when they are learning to walk. Idiopathic toe walking (ITW) is an exclusionary diagnosis given to healthy children who persistently walk on their toes after they should typically have achieved a heel‐toe gait.
• Observe gait and ensure symmetrical pattern
• Functional checks; Can the child stand with their heels down and trunk straight, can they squat keeping their heels down, can they walk on their heels?
• Check ankle dorsiflexion and calf muscle length and size
• Check for abnormal neurology in both the upper and lower limbs, including Gowers Sign and muscle tone / clonus.
• Child is under 3 years of age (with no neurological signs and no muscle tightness)
• Educate/reassure parent/guardian re) it is likely to resolve with age.
• Give appropriate leaflet; ‘Toe walking in children’
Refer to Community Paediatrician/ Neurologist
Be aware of pathological causes e.g. Rickets and Blount’s disease, indicated by swellings at the wrist and ankles, a poor dietary history and marked, progressive or asymmetrical bowing.
• Observe the child in supine, standing and observe gait
• Check for symmetry and leg length discrepancy
• Symmetrical asymptomatic genu varum
• Reassure parents. Physiological bow legs will begin to resolve by age two with normal development. No specific treatment is required.
• Consider completing bloods for Vitamin D and recommend supplements if indicated
• Reassure the parent/guardian and if indicated give advice leaflet titled “Bow legs and knock knees in Children”
• Provide information on healthy weight management
Physiological knock knees are seen from three to five years of age; it normally resolves by the age of eight. It may be familial and/ or associated with obesity.
• Determine the patient’s height and weight percentiles
• If concerned, measure the inter-malleolar distance every six months and document progression or resolution
NB: A child who is significantly overweight with increased adipose tissue around the inner thighs may appear knock kneed.
• Symmetrical asymptomatic genu valgum
• Reassure. The majority of physiological knock knees will resolve with normal development by the age of eight; no specific treatment is required
• If indicated give advice leaflet titled “Bowlegs and knock knees in Children”
Heel pain is common in children, especially during puberty when there is an accelerated rate of bone growth and significant changes in hormone levels
Knee pain is common in children, most symptoms are caused by growth, overuse or muscle imbalance.
Common causes of knee pain;
1. Osgood-Schlatter (OS) and Sinding-Larsen-Johansson (SLJ) syndrome are traction apophysitis conditions in growing adolescents. With OS pain is located at the tibial tuberosity and with SLJ at the apex of the patella
2. Anterior knee pain is a dull, aching or sharp pain that can be felt behind, below or to the sides of the patella
3. Patella instability/ dislocation
X-rays: Following trauma, suspicion of OCD: weight-bearing X-ray (AP, lateral)
Bloods: Inflammatory/infective/sinister pathology suspected
Refer to Acute Paediatrician
Paediatric Red Flags
Children presenting with red flags, indicating the possibility of more serious underlying pathology, warrant urgent assessment, with some cases requiring referral directly to the Emergency Department or CAU.
This list is not exhaustive nor a diagnostic tool, but areas to consider
Hip pain is common in children and adolescents and has a broad range of causes, ranging from the benign to the potentially devastating. Transient synovitis, one of the most common causes of hip pain in children, must be differentiated from septic arthritis. Hip pain may be caused by conditions unique to the growing paediatric skeleton including Perthes, slipped capital femoral epiphysis and apophyseal avulsion fractures of the pelvis as well as growth related disorders.
• Assess gait and function
• Check posture, leg length, symmetry
• Check hip range of movement; hip rotation and abduction should be full and symmetrical if there is no pathology
• pGALS: Check spine
• Temperature / observations
Initial GP management
• Exclude serious pathology
· Exclude inflammatory cause (Bloods – if inflammatory processes suspected)
· Direct to Paediatric Physio Website for appropriate information leaflets link
• Tight/Weak muscles / poor core stability/ Persisting or chronic pain
• Reduced weight bearing or gait changes
• Lateral hip pain / ‘snapping hip’ syndrome
• Reduced function/activity levels due to pain, e.g. running, jumping, PE
· Rehab following a period of inactivity/post-surgery
Refer to ED/Acute Paediatricians urgently via the Children’s Assessment Unit (CAU)
· Acute limp or obviously painful or restricted hip movements
· Unable to weight bear
• A fever and/or red flags suggesting serious pathology
• Severe pain, agitated, reduced peripheral pulses or muscle weakness which may indicate neurovascular compromise/ compartment syndrome
• Suspicion of accidental injury
Refer for x-ray
• Urgent X-ray for a limping child, history of trauma or reduced hip ROM
• Routine x-ray for patients with mildly reduced hip range of motion, leg length difference or hip pain indicating pathology such as DDH
Refer to Paediatric Orthopaedics
• A well child with a working diagnosis of transient synovitis but the symptoms fail to resolve within 1 week of onset or for follow-up
· A child presents with limp on multiple different occasions
· There is uncertainty about the diagnosis
· Diagnosis of Perthes/Avascular necrosis/DDH confirmed on x-ray
• Flat feet/calcaneo-valgus foot posture is accentuating lower limb position, causing hip pain, rubbing or uneven shoe wear
PAEDIATRIC RED FLAGS
Back pain in children is becoming increasing common, more so in girls than boys; but is rarely a serious problem. In younger children back pain may be growth related or may indicate more serious pathology such as infection or tumours. In older children back pain is commonly musculo-skeletal; overuse, carrying heavy backpacks, and sprains and fractures may cause pain. Less common conditions include slipped discs and inflammatory diseases. Congenital disorders such as scoliosis may present at any age.
• Red flags, particularly night pain
• Age of menarche in girls, spine ceases growth 2 years after onset
• Activity levels / sports/school attendance / school bags
• Screen time / posture
• Undress, to see the spine check posture / symmetry - kyphosis/scoliosis
• Observe spinal range of movement, gait and function
• Palpate for areas of vertebral tenderness or muscle spasm
• Neurological examination if indicated
• Exclude inflammatory cause (bloods – if inflammatory processes suspected)
• Provide advice on healthy active lifestyle / diet / fitness and posture
• Give info leaflet:- “Your Healthy Back”
• Mechanical or postural back pain
• Tight/Weak muscles / poor core stability/chronic pain
• Reduced function/activity levels due to pain e.g. running, jumping, PE
• Rehab following a period of inactivity/post-surgery
• Back pain associated with obesity
• Postural scoliosis with pain
Refer to Acute Paediatricians via the Children’s Assessment Unit
• Under 5 years old
• In severe pain, agitated or has significant muscle weakness
• Acute onset painful or restricted spinal movements, without trauma
• Suspected spondylolysis/ spondylolysthesis/ structural scoliosis
Refer to Paediatric Orthopaedics/Spinal Team at SGH
• Spondylolysis / spondylolisthesis
• Structural scoliosis/ kyphosis
• Scheurmanns disease
• Disc pathology
• AM stiffness
• Guarded movement / muscle spasm
• FH of AS/RA
• Increased ESR/ CRP/ Rheum facto
CRPS / complex or chronic pain can present in varied ways; including reduced function and hypersensitivity with a pain response disproportionate to the movement or action. Minor injuries precipitate 80% of cases of CRPS eg) an ankle sprain.
• Check for hypersensitivity to touch
• Pain response that is disproportionate to the injury
• Check joint range of movement
• Check gait / weight-bearing
• Check for autonomic changes including: allodynia, swelling, colour changes, skin changes, shiny skin, hair growth, temperature changes
• Education to parents/guardian and child, to explain pain.
For example: “Unlike the useful warning signal of acute pain, persistent or chronic pain messages no longer serve a useful purpose. These messages are not protecting our bodies from further damage. The nerves continue to respond with pain signals, because they have been so over active - like they are stuck on repeat, or amplified.”
Explain importance of regaining normal movement and sensation. Advice that weight bearing, gentle exercise and normal ADL’s should be maintained and encouraged
Give ‘Understanding and overcoming long term pain’ leaflet.
My pain toolkit: www.paintoolkit.org
Understanding pain: www.Retrainpain.org
• Non, or reduced, weight-bearing
• Reduced function / gait changes
• Reduced / painful range of movement
• Autonomic changes / hypersensitivity
• Muscle weakness / tightness
Refer to Paediatricians
• Limited progress with physiotherapy
• Indication for referral to a Specialist Pain Centre/ Rehabilitation facility/ clinical psychology
• Exclude serious organic pathology / red flags
• Exclude serious orthopaedic pathology / red flags
Refer for Investigations
• X-ray/MRI to exclude pathology/used as a reassurance tool
A diagnosis of hypermobile Ehlers-Danos should only be made by a paediatric rheumatologist. Joint hypermobility is now classified using the idea of a spectrum However, it is not validated in children. Use this as a guide:
Refer to Community Paediatricians
Rest palm and forearm flat.
Elbow flexed at 90°.
Extend the metacarpal-phalangeal joint of the 5th finger.
Positive if over 90°
Score 1 point for each side
Arm outstretched forward, with hand pronated.
Passively move thumb to touch the ipsilateral forearm. Check both arms.
If positive score 1 point each side
Arm outstretched. Hand supine.
Elbow extension over 10°.
Standing. Knees locked straight. Knee extension over 10°.
Knees locked straight and feet together.
Bend forward to place the whole palm of both hands flat on the floor, just in front of the feet.
If positive score 1 point
Positive if over 90°