creation date: 2026-02-09 18:42
tags: Workups
Limp (Pediatric)
Background
A limp is defined as an abnormality in gait that is caused by pain, weakness, or deformity. With the pediatric population, a refusal to walk or stand also constitute a “limp”.
Pathophysiology
A child may refuse to walk or struggle to walk if doing so is painful. Some conditions may also limit range of motion which may manifest as inability to walk or abnormal gait.
In some cases, the limp may be due to a process that can be life or limb threatening.
Differential Diagnosis
Emergency conditions
- Bacterial septic arthritis
- Osteomyelitis
- Infectious with referred pain to the hip/back of thigh
- Occult fracture
- Slipped capital femoral epiphysis
- Developmental dysplasia of the hip
- Malignancy
- Neuromuscular conditions
- Pyomyositis
- Vasoocclusive crisis (sickle cell disease)
- Spontaneous hemarthrosis (hemophilia)
- Testicular torsion
- Compartment syndrome
Common conditions
- Lower extremity trauma (fractures, soft tissue injury)
- Transient synovitis
- Cellulitis or cutaneous abscess
- Osteochondrosis
- Traction apophysitis
- Acute myositis
- Lyme arthritis
- Plantar wart
Others
- HFM disease
- Legg-Calve-Perthes disease
- Osteochondritis dissecans
- Stress fractures
- Juvenile idiopathic arthritis
- Ascorbic acid deficiency (scurvy)
- Other inflammatory arthritis
- Nonmalignant tumours
- Hypermobility from EDS or other disorder
- Spinal column or neuromuscular disorders
- Somatic symptom disorder
Initial Evaluation
History
A careful history can point towards certain diagnosis and guide radiographic studies.
Pain
Is the limp due to pain? If so:
- Is the pain constant, intermittent, transient?
- What time during the day or following what activity is it worst?
- Has the quality/intensity changed over time?
Pain that is constant, non-mechanical, and/or wakes the patient from sleep is worrisome (bone infections, neoplasms).
Some limps are painless (eg. Legg-Calve-perthes disease).
Onset
Did the limp develop suddenly, gradually, or has always been there?
Sudden or acute onsets:
- Trauma
- Acute infection
Chronic and gradually worsening:
- Inflammatory
- Mechanical
- Neurologic
- Neoplastic
Systemic illness
Is there systemic signs such as:
- Fever
- General malaise
- Weight loss
It is important to appraise medication use as they may mask symptoms (eg. antibiotics may mask infectious processes).
Type
What type of limp does the child have? Different presentations may point towards different pathologies.
Location
Can a site of origin be located through physical exam:
- Point of maximum tenderness
- Sources of referred pain
- Is the pain aggravated by specific motion of specific joint
Associated symptoms that may suggest specific etiologies:
- Morning stiffness
- Incontinence, sciatica, leg weakness (spinal cord related)
- Abdominal pain
- Back pain
- Migratory arthralgias
- Associated rash
Past medical history may also point towards certain diagnoses.
Physical Exam
Physical exam is important to confirm if the site of abnormality is within the lower extremity or elsewhere (eg. spine, abdomen).
If possible, an evaluation of the gait should be done. Presenting may narrow down differential diagnosis:
Antalgic gait: asymmetric gait in the timing with less time spent on affected side
- Associated with unilateral pain somewhere in the lower extremity
Trendelenberg’s gait: shoulder and upper body shift laterally towards the affected side during that leg’s stance phase; results in a lateral swaying motion - Associated with weak hip abductors (incapable of stabilizing pelvis levels during single leg stance); contralateral side drops during swing phase
- Hip pathology
Steppage gait: hip and knee flexes excessively during swing phase (looks like stepping up stairs) and entire foot contacts the ground at once (no heel strike, known as foot-drop) - Can be associated with deep peroneal nerve damage
- Can be associated with underlying neurological disorder (eg. cerebral palsy, hereditary motor sensory neuropathy)
Investigations
Laboratory and imaging studies
In general, these studies are not indicated if the child has an obvious cause for the limp such as:
- Superficial soft tissue injury
- Insect bite or sting
- Plantar wart
- Painful plantar vesicles from HFM disease
- Friction blister
Additionally, a child with a history of acute limp but has normal exam and gait does not require further investigation.
These studies are indicated if the child has the following features:
- Age ≤3 years old
- Signs of infection
- Limitation of join movement on examination, especially at the hip
- Inability to walk
- History of chronic or intermittent limp
Further workup
Depending on the suspected diagnosis, further workup may include:
- Ultrasonography of the joint
- Joint aspiration and synovial fluid analysis
- Culture of soft tissue