Persistent Toe-Walking in a Developmentally Normal 7-year-old Girl

Abstract

1. Ngoc Thien T. Nguyen, MD, MPH* 2. Eyal Ben-Isaac, MD*,† 3. Mikako Warren, MD‡ 1. *Department of Pediatrics, Children’s Hospital Los Angeles, California 2. †Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California 3. ‡Department of Pathology and Laboratory Medicine, Children’s Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, California A 7-year-old, developmentally normal girl with a history of toe-walking presents to an emergency room with complaints of worsening back and leg pain with limp. She has walked on her toes since she learned to ambulate at 18 months. However, in the past she was able to correct her gait when reminded. Family was reassured that these symptoms were most likely benign as the child continued to otherwise do well and had symptom-free periods. In the past 2 years, she developed bilateral lower extremity pain, which was more frequent at night and improved with massaging of the extremities. Initially her symptoms were attributed to growing pains. However, in the past month, massage no longer relieved the pain. In addition, she now has been having back and bilateral knee pain. Her symptoms are more prominent on the right side. Most recently she has been hunching to the right when walking and having extended periods of toe-walking. On examination, she has a right-sided lower thoracic prominence and levoscoliosis of the thoracic region. She exhibits an antalgic gait with toe-walking more prominent on the left side along with a left-sided foot drop. Strength is decreased in the left lower extremity, and sensation is intact throughout. She does not demonstrate clonus or any appreciable cranial nerve abnormalities. Further workup with imaging and pathology revealed the diagnosis. A common benign etiology for lower extremity pain in school-aged children is “growing pains.” There is no …