What causes a toddler to experience pain while walking and how can it be managed?

Painful Walking in Toddlers: Causes and Management

A toddler experiencing pain while walking requires immediate assessment for common orthopedic and developmental causes, with management focused on identifying the underlying etiology through systematic evaluation of gait patterns, foot examination, and age-appropriate pain assessment.

Systematic Approach to Diagnosis

Initial Pain Assessment

• Use developmentally appropriate pain scales such as the revised Face Legs Activity Cry and Consolability (r-FLACC) scale or Faces Pain Scale-Revised (FPS-R) for toddlers who cannot self-report pain 1
• Behavioral indicators include facial expressions, body movements, crying patterns, and changes in activity level 1
• Document when pain occurs: before walking, during walking, or after activity 1

Key Clinical Examination Points

Examine for visible skin changes:

• Look for blistering, callus formation (hard, thickened, yellowish areas), or redness on the feet 1, 2
• Blistering triggered by friction, walking, heat, or trauma suggests epidermolysis bullosa subtypes 1
• Callus formation under the medial midfoot with pain suggests flatfoot-related mechanical overload 2

Assess gait and biomechanics:

• Observe walking pattern for toe walking, limping, or altered gait 1
• Toe walking prevalence is 2% at age 5.5 years in normally developing children and can cause pain or functional issues 3
• Altered gait patterns can indicate abnormal weight bearing or underlying deformity 1

Check for structural abnormalities:

• Evaluate for flatfoot deformity, contractures, or joint problems 1, 2
• Assess ankle range of motion and tendon tightness 3

Management Strategy

Immediate Pain Relief

• Acetaminophen is the first-line analgesic for mild to moderate pain in toddlers 4
• Ibuprofen can be added for moderate pain with anti-inflammatory benefits 5
• Multimodal analgesia combining pharmaceuticals with non-pharmacological methods is more effective than single approaches 1

Non-Pharmacological Interventions

• Distraction techniques are highly effective and should be used routinely: audio-visual entertainment, play therapy, parental involvement 1, 6
• Ice packs, repositioning, and massage can reduce pain 1
• Cognitive behavioral strategies improve compliance and reduce pain perception 1

Addressing Underlying Causes

For mechanical/biomechanical issues:

• Refer to podiatry for assessment, treatment, and monitoring to minimize pain while walking 1
• Custom-made insoles or orthotic devices redistribute pressure and address underlying biomechanics 2
• Properly fitting shoes with adequate arch support reduce abnormal pressure distribution 2
• Professional debridement of calluses by trained healthcare providers reduces plantar pressure 2

For gait abnormalities:

• Gait analysis systems can diagnose pressure areas and evaluate therapeutic interventions 1
• Correcting foot balance and eliminating areas of abnormal weight bearing reduces pain 1

For toe walking with contracture:

• Treatment based on age and severity of tendon contracture: casting provides good evidence for short-term results, while surgery provides long-term results beyond 1 year 3
• Physical therapy and ankle-foot orthoses restrict toe walking when worn 3

Multidisciplinary Management

• Coordinate care between podiatrist, occupational therapist, and physiotherapist to reduce pain and encourage mobility 1
• This approach is essential for complex cases involving deformity or chronic conditions 1

Critical Pitfalls to Avoid

• Do not treat symptoms in isolation without addressing underlying biomechanical problems, as this leads to rapid recurrence and continued pain 2
• Do not underestimate or inadequately treat children's pain, which is frequently under-recognized 1, 7
• Do not delay referral to specialists when initial conservative measures fail or when structural abnormalities are identified 1, 2
• Stop analgesics and seek medical attention if pain worsens or lasts more than 10 days, new symptoms occur, or redness/swelling develops 4

When to Escalate Care

• Pain persisting despite conservative management requires specialist evaluation 2, 8
• Progressive gait abnormalities or loss of mobility warrant urgent podiatry or orthopedic assessment 1
• Visible blistering with family history suggests genetic conditions requiring specialized dermatology care 1