Student Pages

Lecturer: Craig Payne

Growing Pains/Leg Aches

Commonly misused diagnosis for musculoskeletal pain in children. “Leg Aches” has been proposed as a term to replace growing pains due to confusion in the literature and the dismissing by some health professionals of leg aches as being just ‘growing pains’. The differential diagnosis includes potentially very serious conditions

True syndrome of “growing pains”:
• generally peaks around ages 4 to 5 (can occur up to age 12)
• generally occurs in popliteal fossa
• usually relieved by gentle massage
• only occurs at night (growing pains do not occur during day)
• benign and self limiting – treatment not usually needed.
• May occur in up to 15-30% of children

Intense cramping pain behind knee, in deep musculature of posterior leg or anterior thigh – usually poorly localised; usually lasts up to 20 minutes, later in the day and may wake child from sleep; does not alter gait; no point tenderness on palpation; usually bilateral; does not limit activities the following day. As part of differential, Check for point tenderness, guarded or restricted joint motion and any signs of systemic illness.

Cause of pain is unknown – but unlikely to be solely related to ‘growth’ – other suggested (speculated) factors include muscle fatigue, overexertion, chemical imbalances and genetic factors

Differential diagnosis – bone tumours (deep aching pain that is more localised); hip dysplasia; infections (eg Brodies abscess); juvenile chronic arthritis; spinal disorders; synovitis; Perthes disease; slipped capital femoral epiphysis

Treatment:
• Do not dismiss as growing pains; do not overlook potentially serious problems
• Reassurance of child and parents as to self limiting nature
• Stretching only treatment shown to be effective (ref)
• Massage and/or heating may help some
• NSAID’s can be tried at bedtime if waking from sleep

Online resources:

ePodiatry's resources on growing pains

Podiatry Arena discussion on growing pains

Osteochondroses

Group of bone disorders in the growing skeleton in which centres of ossification undergo an aseptic necrosis, then resorption of bone, and then repair.
80% of osteochondroses occur in lower limb – 28% in foot.

Characteristic pathologic mechanism is impairment of vascular supply to an area of skeletal growth ? cause of this is unknown – common theory is acute or chronic repetitive trauma.

Legg-Calve-Perthes Disease/Perthe’s Disease/ Osteochondrosis of the Femoral Capital Epiphysis

Aseptic necrosis/osteochondroses of neck and proximal epiphysis of femur – femoral head becomes flattened. Most commonly ages 3 – 12. M>F. More common than 1 in 1000 children. Cause unknown. Characterised by ischaemic necrosis, collapse and subsequent repair. 85% present with limp and hip/groin pain. 15% have referred pain to knee – probably from obturator nerve involvement. Usually unilateral (up to 8% bilateral). Have some limitation of rotation and abduction (flexion usually normal) – may have atrophy of thigh muscles. Usually resolves in 2-3 years- with rest, avoidance of aggravating activities, brace to maintain abduction and internal rotation. Better prognosis in younger child. Increased risk for long term osteoarthritis.

Osgood-Schlatter Disease/Osteochondrosis of Tibial Tubercle

Traction apophysitis/osteochondritis of tibial tuberosity. Present with local pain, swelling and tenderness over tibial tubercle, which is exacerbated by activity (especially climbing stairs) – often limping. Reproduce pain by having patient extend knee against resistance. Usually no history of trauma. Usually active children aged 10 to 15 years. M>F. Quadriceps often tight and feet often excessively pronated.
Treatment – activity modification/limitation (especially avoidance of certain activities eg kicking a ball), ice massage, compression, knee brace; quadriceps stretching; foot orthoses may help

Sever’s Disease/Osteochondrosis of the Calcaneal Apophysis

Common – usually 8 to15 years. May be caused by traction from achilles tendon. Pain on palpation of posterior plantar aspect of calcaneus – also lateral pressure may produce pain. Pain initially occurs after activity, then during activity. Can not be diagnosed from x-ray (normal ossification is fragmented and develops from several centres).
Treatment – activity modification and cushioning heal raise; calf muscle stretching. Could also use strapping to hold foot slightly plantarflexed. Orthoses if pronate excessively.

ePodiatry's patient information on Sever's disease / calcaneal apophysitis

Podiatry Arena discussion on Sever's disease

Kohler’s Disease/Osteochondrosis of the Navicular

Navicular is temporarily ‘softened’ and compressed by weightbearing forces. Most commonly ages 3 to 9. M>F. Usually unilateral. Have vague pain and tenderness localised over navicular – also can limp and avoid active inversion. On x-ray get characteristic narrowing of navicular with an irregular increase in density – this deformity is very pronounced.

Treatment:
Acute stage – nonweightbearing
Mild – activity modification and foot orthoses to protect structural alignment
Severe – below knee cast

Freiberg’s Disease - Osteochondrosis of Metatarsal Heads

Can affect any metatarsal head, but 2nd is most common (70%). Usually ages 11-17. F>M.
Due to collapse of articular cartilage.

Painful on walking, tender to palpation (usually more on dorsum), ROM is limited with pain at extremes of motion, may have crepitus, may have swelling.

On x-ray get a flattening of head of metatarsal or an ‘egg crush’ appearance. In adults ? higher chance of developing degenerative joint disease.

Smillie’s classification:
Stage 1 – subchondral bone fracture through epiphysis – x-rays normal.
Stage 2 – bone resorption as revascularisation begins
Stage 3 – medial and lateral portion of metatarsal head protrude
Stage 4 – central fragment “sinks”
Stage 5 – joint destruction

Treatment – activity modification/limitation; accommodative padding to relieve weightbearing or metatarsal bar for ‘roll over’. Below knee casting can be used. Surgical - excision of fragments; metatarsal head removal; wedge osteotomy to change parts of joint surface in contact; or joint implant.

Other Osteochondroses

Diaz or Mouchet’s Disease:
Osteochondrosis of the talus; rare; probably associated with acute trauma in which there is compression of dome of talus; bone often remodels to a normal shape.

Buschke’s Disease:
Osteochondrosis of the cuneiforms. Very rare. Can affect each cuneiform. Shape of cuneiform abnormal for age on x-ray. Treatment – below knee walking cast for 4 to 6 weeks.

Osteochondrosis of Os navicularis:
Has been described as affecting this joint; needs to be differentiated from other pathology of os navicularis/accessory navicular.

Iselin’s disease:
Osteochondrosis of the fifth metatarsal base at attachment of peroneus brevis; need to differentiate from a stress fracture, os vesaleanum or fracture; pain increases on tension on peroneus brevis

Treves’ or Ilfeld’s Disease:
Osteochondrosis of the sesamoids. Tenderness and pain on palpation; significant pain on dorsiflexion.

Thiemann’s Disease:
Osteochondrosis of the phalanges.

Online resources:

ePodiatry's resources on osteochondroses

Heterogenous group of rheumatic disease in children, first described by Still in 1897. Literature is confusing on terminology – often used interchangeably with ‘juvenile rheumatoid arthritis’. Difficult to diagnose (variety of presentations) - no definitive diagnostic test. Diagnosis is usually reserved for those who are under are age of 16 at onset – affects about 1 in 1000.

ARA criteria for diagnosis:
1. Chronic synovial inflammation of unknown origin
2. Onset in children less than 16 years of age
3. Objective evidence of arthritis in one or more joints for 6 consecutive weeks
4. Exclusion of other disease

3 main types of JCA (based on clinical presentations, with various amounts of overlap):
1. Pauciarticular (<5 joints) or monarticular (50% of JCA’s; gradual onset of joint pain – most commonly the knee – usually asymmetric; eye complications are common; other systemic complications absent; peak age of onset 2-5yrs; F>M; another group is more common in males with age of onset > 6yr – M>F)
2. Polyarticular (40% of JCA’s; usually around 10 years; F>M; joint symptoms predominate – usually symmetric; systemic upset mild; have ‘flare ups’) – 10% of these develop a form the same as the adult onset rheumatoid arthritis
3. Systemic (Still’s disease) (10% of JCA’s; usually ages 1-5; acutely ill; usually have recurrent attacks of high fever with minimal joint damage; skin rashes common; joint inflammation is not common initially – polyarticular course)

Adults who had juvenile chronic arthritis have 4 times the mortality rate compared to a control population (French et al, 2001)

Foot joints can be frequently affected (Truckenbrodt et al, 1994; Ferrari, 1998). Inflammation of ankle and small foot joints will lead to alignment deformities in the joints and affect foot biomechanics – especially ankle equinus and subtalar varus or valgus. Can result in flexion contractures of hip, knee and ankle as well as leg length discrepancies. Synovitis of the subtalar joint is common and is responsive to intraarticular cortisone (Remedios et al, 1997).
Plantar pressure measurements have shown reduced toe and medial metatarsal head weightbearing and increased lateral metatarsal head weightbearing (Dhanendran et al, 1980).
On foot x-ray, often see an enlargement and irregularity of tarsal bones – joint space narrowing and joint ankylosis is also common.

Rheumatic Fever

Acute autoimmune reaction/illness following beta-haemolytic streptococcus infection – usually 2-4 weeks post infection. more common in ages 5 to 15 years.
Major manifestations: - ACCES – Arthritic, Carditis, Chorea, Erythema, Subcutaneous nodules
Minor manifestations: - fever, arthralgia, previous rheumatic heart disease, elevated ESR, acute phase reaction, elevated c-reactive protein, leucocytosis.

Joint abnormalities:
• 75% develop joint symptoms – usually large joints
• after repeated attacks of arthritis ? develop a deforming non-erosive arthropathy (Jaccoud’s).
• on x-ray --> flexion and lateral deviation of digits; periarticular osteoporosis; joint space narrowing

Treatment:
Salicylates (dramatic response can help confirm diagnosis); antibiotics

Long term sequelae:
• damage to heart valves (? risk for thrombus)
• cardiac failure
• bacterial endocarditis

Links to lectures:

Lecture 1; Lecture 2; Lecture 3; Lecture 4; Lecture 5; Lecture 6; Lecture 7; Lecture 8; Lecture 9; Lecture 10;