Acute and Non-acute Lower Extremity Pain in the Pediatric Population

Part III

Allison D. Duey-Holtz, MSN, RN, CPNP; Sara L. Collins, MSN, RN, CPNP; Leah B. Hunt, PA-C, MMSc; Polly F. Cromwell, MSN, RN, CPNP


J Pediatr Health Care. 2012;26(5):380-392. 

In This Article


Lower extremity pain is common in childhood, with etiologies ranging from benign muscular conditions to systemic disease. We are presenting a three-part series of evidence-based practice guidelines to aid the provider in efficiently determining the diagnosis and treatment of a child with lower extremity pain. Part I focused on the history, physical examination, and diagnostic work up (Duey-Holtz, Collins, Hunt, Husske, & Lange, 2012; Duey-Holtz, Collins, Hunt, & Cromwell, 2012). Parts II and III have been divided to include comprehensive treatment guidelines, which are summarized in the Table. In general, the most common diagnoses for musculoskeletal pain can be categorized into the following etiologies:

  • Trauma: strains/sprains, fractures, dislocations, foreign body, non-accidental trauma

  • Infection: septic arthritis, osteomyelitis, diskitis

  • Immune-mediated: toxic synovitis, juvenile idiopathic arthritis, Lyme disease, reactive arthritis

  • Acquired/developmental: slipped capital femoral epiphysis, Legg-Calve-Perthes disease, Kohler disease, tarsal coalition, accessory navicular, osteochondritis desiccans

  • Neoplastic: leukemia/lymphoma, Ewing sarcoma, osteosarcoma

  • Referred: scoliosis, spondylolysis, spondylolisthesis

  • Benign musculoskeletal: growing pains, tendonitis/apophysitis

  • Neurologic: complex regional pain syndrome, restless leg syndrome

  • Metabolic: rickets

The following non-painful conditions can present with a limp or abnormal lower extremity examination results:

  • Developmental: developmental dysplasia of the hip, leg length discrepancy

  • Neurologic: cerebral palsy, syndromes that result in abnormal findings of neuromuscular examinations (Duey-Holtz et al., 2012)

Part III will cover the most common infectious, immune-mediated, acquired, neoplastic, and metabolic etiologies. Along with the following summary of each differential diagnosis, a reference table and algorithm are included (Table and Figure).


Lower extremity pain differential diagnosis algorithm. Data from Gedalia, 2002; Junnilla & Cartwright, 2006; and Sawyer & Kapoor, 2009.