Musculoskeletal Examination

Observe the gait by telling the child to walk back and forth with shoes or socks on. Having the child walk on a cold floor without socks or shoes may distort the gait. ''In-toeing'' and ''out-toeing'' are common in children. Most such gaits are physiologic variants that arise from in utero positioning and resolve spontaneously during the active growing period.

Tell the child to stand in front of you, and inspect the legs. Is bowing present? Commonly, a child may appear bowlegged (genu varum) for 1 to 2 years after starting to walk. Knock-knees (genu valgum) frequently follow bowing and are seen in children 2 to 4 years of age. The normal gait of a child 2 to 4 years of age is wide-based, with a prominent lumbar lordosis.

In a child with a limp, the entire lower extremity from the toes to the hip should be examined for evidence of trauma or localized bone tenderness. Children with abnormalities of the hip frequently localize the area of discomfort to the knee. Any child complaining of knee pain must have his or her hips fully assessed. The presence of a limp and knee pain in a child 3 to 8 years of age, especially a boy, is suggestive of Legg-Calve-Perthes disease, which is aseptic necrosis of the femoral head. The irritable hip syndrome, or toxic synovitis, is another cause of limp in this age group. This condition affects both sexes equally.

Inspect the child's shoes. Is there evidence of abnormal wear?

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