Version May 2024
INTRODUCTION — This topic will review the common causes of limp in children. The diagnostic approach to the child with a limp is discussed separately. (See "Evaluation of limp in children".)
DEFINITION — For the purposes of this discussion, limp is defined as an abnormality in gait that is caused by pain, weakness, or deformity. In toddlers and young children, limp also refers to refusal to walk or stand.
CLASSIFICATION OF LIMP — There is no universal classification system for limp. For the purposes of this topic, the many causes of limp will be divided by life- or limb-threatening, common, or other conditions (table 1). In addition, to assist clinicians with narrowing the differential diagnosis in individual patients, a table that identifies etiology by location of abnormality is provided (table 2). (See "Evaluation of limp in children".)
LIFE-THREATENING AND OTHER EMERGENCY CONDITIONS — The clinician should always be alert to the possibility of a life-threatening or other emergency cause for limp (table 1).
Bacterial (septic) arthritis — Bacterial arthritis is an important consideration in all children with the acute onset of fever and joint pain and/or loss of function such as limping. Patients also will typically have swelling, pain, and limited mobility of the affected joint. In addition, other constitutional symptoms (malaise, poor appetite, irritability, and/or tachycardia) are frequently present. Physical examination typically reveals ill appearance, joint effusion, periarticular warmth and tenderness, and severe pain on range of motion, although more subtle presentations may occur. Changes in the adjacent soft tissue are variable and depend upon the duration of infection and the depth of the joint. Of note, swelling, clinically appreciable joint effusion, and soft tissue changes usually do not occur with infections of the hip. The presentation of septic arthritis may be altered if the patient has recently received oral antibiotics; fever may not be as prominent a symptom, and pain and limitation of motion may be modest. Missed septic hip arthritis in children presenting to ED appears to occur most frequently in the very young (one to two years). (See "Approach to hip pain in childhood", section on 'Septic arthritis'.)
The diagnosis of bacterial arthritis is supported by an elevated white blood cell count with a left shift and elevated C-reactive protein and erythrocyte sedimentation rate. Blood culture should also be obtained, although results are negative in the majority of cases. Ultrasonography is helpful in identifying and quantifying joint effusions, particularly for deep joints such as the hip (image 1). Plain radiographs add little to the diagnostic evaluation of joints that are readily accessible to physical examination, such as the knee, but may add additional information for the hip such as widening of the joint space, which is seen occasionally in infants and young children; soft tissue swelling; obliteration of normal fat planes; or changes caused by an associated osteomyelitis, such as periosteal elevation.
Consultation with an orthopedic surgeon with pediatric expertise is mandatory for a patient with concern for a septic hip because emergency drainage is indicated. Urgent aspiration of a potentially infected joint other than the hip joint may be performed by the emergency clinician, if experienced with this procedure, or by a subspecialist. Given the frequency of contiguous osteomyelitis, antibiotic-resistant pathogens, and culture-negative cases, consultation with an expert in infectious diseases may also be warranted. (See "Bacterial arthritis: Treatment and outcome in infants and children", section on 'Indications for consultation'.)
Clinical rules have been developed to aid in differentiating septic arthritis of the hip from transient synovitis. However, these clinical prediction rules do not apply to assessment of joints other than the hip [1]. These rules are discussed in greater detail separately. (See "Approach to hip pain in childhood", section on 'Septic arthritis'.)
Osteomyelitis — Osteomyelitis is an uncommon cause of limp. It is more likely in children younger than five years of age and in children with sickle cell disease, immunodeficiency, or sepsis. More than 80 percent of cases of hematogenous osteomyelitis occur in the long (tubular) bones, usually originating in the metaphyses (figure 1). Most cases of acute hematogenous osteomyelitis in children are caused by gram-positive bacteria, principally Staphylococcus aureus (table 3). (See "Hematogenous osteomyelitis in children: Epidemiology, pathogenesis, and microbiology".)
Although variable, children with hematogenous osteomyelitis usually first complain of extremity pain, refuse to bear weight, or limp. Fever may or may not be present initially. Later in the course of illness, children may develop persistent fever, constitutional symptoms (eg, irritability, decreased appetite or activity), and focal findings of bone inflammation (warmth, swelling, point tenderness). The initial symptoms of hematogenous osteomyelitis in older infants and young children may be nonspecific and mild.
Patients with findings suspicious for osteomyelitis initially warrant blood studies (complete blood count [CBC] with differential, blood culture, C-reactive protein, and erythrocyte sedimentation rate), and plain radiographs of the affected area. Magnetic resonance imaging (MRI) (preferred) or radionuclide bone scanning are indicated to confirm a diagnosis when plain films are negative. Consultation with an orthopedist is appropriate to obtain an aspirate for culture in selected cases. The diagnosis of osteomyelitis is often challenging. The evaluation and approach to patients with suspected osteomyelitis and its treatment are discussed in detail separately. (See "Hematogenous osteomyelitis in children: Evaluation and diagnosis" and "Hematogenous osteomyelitis in children: Management".)
Patients who are immunosuppressed or have recently received antibiotics may have modified presentations of osteomyelitis or bacterial arthritis, which may include limp without fever and less prominent swelling or tenderness. In addition, some patients with osteomyelitis may present early in the course of the illness with localized bony tenderness and limp without fever. Especially in infants and young children, signs and symptoms of bone inflammation may be poorly localized although constitutional symptoms (irritability, decreased appetite, or activity) and limited use of the affected leg are present. (See "Hematogenous osteomyelitis in children: Evaluation and diagnosis", section on 'Clinical suspicion'.)
Infections with referred pain to the lower extremity — Several serious infections can cause fever and an acute or chronic limp with referred pain, typically to the hip or back of the thigh. Examination of the lower extremities may be unrevealing or, for infections associated with iliopsoas irritation (eg, appendicitis or pelvic inflammatory disease), may demonstrate a preference for holding the hip in flexion accompanied by pain and irritability when the examiner attempts to extend the hip (positive psoas sign).
Additional findings vary by the site of infection:
●Appendicitis with periappendiceal abscess – Patients with a periappendiceal abscess often have a history of fever, anorexia, abdominal pain, and vomiting. Typical findings on abdominal examination include right lower quadrant tenderness and signs of peritoneal irritation (eg, guarding or rebound). Patients may complain of right hip pain and demonstrate a limp characterized by a shuffling gait with hips flexed. Diagnostic imaging (eg, ultrasonography of the abdomen) helps confirm the clinical diagnosis. (See "Acute appendicitis in children: Clinical manifestations and diagnosis".)
●Psoas abscess – The presenting symptoms of psoas abscess may be nonspecific, and the onset is often subacute; symptoms may be present for a few weeks and up to six months and include back or flank pain, fever, inguinal mass, limp, anorexia, and weight loss. Pain is present in up to 90 percent of cases with localization to the back, flank, or lower abdomen, with or without radiation to the hip and/or the posterior aspect of the thigh. Fever is present in up to 75 percent of cases, and a psoas abscess may manifest as a fever of unknown origin. On physical examination, a positive psoas sign (pain on hip extension) is frequently present. Unlike septic arthritis, hip pain in patients with psoas abscesses is usually diminished with hip flexion. The diagnosis of a psoas abscess may be suspected on clinical grounds and confirmed on imaging studies. (See "Psoas abscess".)
●Suppurative iliac fossa adenitis with retroperitoneal iliac fossa abscess – Patients with iliac fossa adenitis present with right or left lower quadrant pain often initially attributed to hip abscess, osteomyelitis, or appendicitis but may subsequently develop a palpable mass just above the inguinal ligament [2]. Fever is often present but low grade.
●Spinal epidural abscess – The classical diagnostic triad of spinal epidural abscess consists of fever, spinal pain, and neurologic deficits. However, only a small proportion of patients have all three components at presentation. Fever in a patient with severe, localized back pain, especially if the pain is worsened by palpation or percussion, should suggest the diagnosis of spinal epidural abscess. If untreated, the patient typically develops nerve root pain ("shooting" or "electric shocks" in the distribution of the affected nerve root) followed by neurologic deficits (sensory changes, motor weakness, and bowel of bladder dysfunction) and ending with paralysis, which quickly can become irreversible. Diagnosis requires a high index of suspicion and is best confirmed by MRI of the spine. (See "Spinal epidural abscess".)
●Discitis – Discitis typically presents with the gradual onset of irritability and back pain, limp, or refusal to crawl or walk, without systemic toxicity; fever usually is absent or low grade. In some patients, abdominal pain and/or vomiting may be the only complaints. Most patients have had symptoms for three or more weeks by the time discitis is diagnosed. Examination findings may include:
•Refusal to bend forward
•Percussion tenderness over the involved spine, hip pain and stiffness
•Decreased muscle strength or reflexes in the lower extremities
•With high lesions (T8-L1), ileus
Plain radiographs of the spine may show narrowing of the joint space. MRI of the spine confirms the diagnosis. (See "Back pain in children and adolescents: Causes", section on 'Discitis'.)
●Skeletal tuberculosis – Tuberculous spondylitis (Pott disease) usually affects the lower thoracic and upper lumbar region. Once two adjacent vertebrae are involved, infection can involve the adjoining intervertebral disc space, leading to vertebral collapse. Subsequent kyphosis can lead to cord compression and paraplegia. The most common symptom of tuberculous spondylitis (Pott disease) is local pain, which increases in severity over weeks to months, sometimes in association with muscle spasm and rigidity. A characteristic erect posture and "alderman's" gait may be observed in which the patient walks with short, deliberate steps to avoid jarring of the spine. Constitutional symptoms such as fever and weight loss are relatively uncommon and active chest disease is typically absent. The diagnosis should be considered in patients with a history of risk factors for tuberculosis and characteristic symptoms. Plain radiographs of the spine may show bony changes at the anterior aspect of the vertebral body, loss of the disc space, and/or a paravertebral abscess. MRI, whenever available, identifies soft tissue extension and spinal cord involvement (image 2 and image 3). (See "Bone and joint tuberculosis", section on 'Spondylitis (Pott disease)' and "Tuberculosis disease in children: Epidemiology, clinical manifestations, and diagnosis".)
●Pelvic inflammatory disease – Adolescent females with severe pelvic inflammatory disease may present with a shuffling gait and an examination that demonstrates lower abdominal pain, vaginal discharge, and pelvic examination findings of cervical motion, uterine, or adnexal tenderness. Fever and cervical infection with Neisseria gonorrhoeae or Chlamydia trachomatis are often present. (See "Pelvic inflammatory disease: Clinical manifestations and diagnosis", section on 'Acute symptomatic PID'.)
Occult fracture (child abuse) — Child abuse is a potentially life-threatening etiology that may occasionally present as a limp. Children younger than five years of age are at highest risk of child abuse. Most abusive fractures are accompanied by other findings of abuse (table 4). Metaphyseal corner (or bucket handle fractures) (figure 2 and image 4A-B and image 5) or multiple fractures with different stages of healing are highly suggestive of abuse. Isolated long bone fractures in ambulatory children are less specific but warrant further evaluation when the mechanism is absent or insufficient to explain the injury. Significant concern for physical abuse in children younger than 24 months of age is an absolute indication for obtaining a skeletal survey. Other indications for ordering a skeletal survey and the diagnostic evaluation for physical child abuse are discussed separately (table 5). (See "Physical child abuse: Diagnostic evaluation and management", section on 'Skeletal survey' and "Physical child abuse: Diagnostic evaluation and management".)
Slipped capital femoral epiphysis — Slipped capital femoral epiphysis (SCFE), also called slipped upper femoral epiphysis (SUFE) and physiolysis of the hip, is characterized by a displacement of the capital femoral epiphysis from the femoral neck through the physeal plate. It is one of the most common hip disorders of adolescence and is associated with obesity. (See "Evaluation and management of slipped capital femoral epiphysis (SCFE)", section on 'Epidemiology'.)
The two most common features of the presentation of SCFE are pain and altered gait. The classic presentation is that of an obese adolescent with a complaint of nonradiating, dull, aching pain in the hip, groin, thigh, or knee, and no history of preceding trauma. The pain is increased by physical activity and may be chronic or intermittent. The absence of pain, or pain localized to the knee or thigh instead of the hip, can lead physicians to overlook the diagnosis. Physical examination may demonstrate hip pain on palpation and limitation of hip range of motion, especially internal rotation and flexion. The diagnosis of SCFE usually can be made on plain radiographs, which reveal an apparent posterior displacement of the femoral epiphysis, like ice cream slipping off a cone (image 6). All patients with SCFE warrant prompt referral to an orthopedic surgeon with pediatric expertise. The clinical findings, evaluation, and diagnosis of SCFE are discussed in greater detail separately. (See "Evaluation and management of slipped capital femoral epiphysis (SCFE)".)
Developmental dysplasia of the hip — If not detected in the first year of life, developmental dysplasia of the hip (DDH) may present with limp in childhood, typically during the second year of life shortly after children begin to walk. Findings depend upon whether the child has unilateral or bilateral dislocation:
●Unilateral DDH:
•Asymmetry in the position or number of the inguinal, thigh, or gluteal skin folds (figure 3 and figure 4)
•Limited abduction of the affected hip
•Weakness of the hip abductors on the affected side indicated by a positive Trendelenburg pelvic tilt test (inability to maintain the pelvis horizontally while standing on the ipsilateral leg) (figure 5) and the presence of a Trendelenburg lurch while walking
●Bilateral DDH:
•Symmetric limited hip abduction (<45°)
•Bilateral positive Klisic tests (figure 6)
•Hyperlordosis, widening of the perineum, and short thigh segments (figure 7)
•Waddling gait
The diagnosis of DDH is usually made by physical examination. (See "Developmental dysplasia of the hip: Clinical features and diagnosis".)
Malignancy — Malignant tumors are a rare but important cause of limp in childhood. These tumors may arise as primary malignant bone tumors (eg, Ewing or osteogenic sarcoma) or as metastatic or infiltrative neoplasms (eg, metastatic neuroblastoma, leukemia, or lymphoma). Furthermore, central nervous system and spine tumors may initially come to attention because of ataxia or referred pain with limp. The following features help to identify this life-threatening cause of limp:
●Bone tumors – Primary malignant tumors of bone (eg, Ewing sarcoma and osteogenic sarcoma) can be difficult to diagnose because they often begin with vague symptoms of bone pain and intermittent limp without constitutional symptoms of fever, weight loss, or fatigue. Persistent pain or swelling may be attributed erroneously to a minor injury. Tumor should be considered in children with complaints of bone pain that occurs at night, at rest, and in nonarticular locations. Occasionally, bone tumors will present with pathologic fractures (image 7). The two most common lower extremity sites for malignant bone tumors in children are the distal femur and proximal tibia. Characteristic findings on plain radiographs of the affected site include "onion skinning" (image 8) and the "sunburst" phenomenon (image 9) help establish the diagnosis.
●Leukemia – Approximately 15 percent of children with acute leukemia have a limp at diagnosis [3]. Nighttime bone pain is also reported in up to one-third of all new cases. When evaluating children with nighttime bone pain, other early signs and symptoms of leukemia should be sought and include fever, pallor, bruising, lymphadenopathy, and a palpable spleen or liver. Radiographic changes, such as osteopenia (image 10), leukemic lines (metaphyseal "bands" or lucency) (image 11), periosteal new bone formation, geographic lytic lesions, sclerosis, mixed sclerosis and lysis, or permeative destruction are present in up to 44 percent of patients.
Supportive laboratory findings for leukemia include leukopenia or leukocytosis, anemia, and thrombocytopenia on CBC. The diagnosis is confirmed by findings of lymphoblasts on peripheral smear or bone marrow aspiration.
●Metastatic neuroblastoma – Metastatic spread of neuroblastoma to the bones and bone marrow can cause pain (especially with ambulation). In young children, who cannot complain of pain, bone pain may manifest as a limp or unexplained irritability. Associated findings may include fever, anemia, an abdominal mass, localized back pain with weakness from spinal cord compression, proptosis, Horner syndrome, hypertension, and opsoclonus myoclonus syndrome. Elevation of urinary or serum catecholamine metabolites (ie, vanillylmandelic acid [VMA], and homovanillic acid [HVA]) are present in up to 90 percent of patients. The diagnostic evaluation of neuroblastoma is discussed in greater detail separately. (See "Clinical presentation, diagnosis, and staging evaluation of neuroblastoma".)
Other malignant tumors that can rarely cause limp in children, either due to the location of the primary tumor or to the presence of metastatic disease in the bone include lymphoma [4], Langerhans histiocytosis [5], soft tissue tumors (eg, rhabdomyosarcoma [6]), and tumors of the brain or spinal cord [7]. (For typical presenting signs and symptoms and diagnostic evaluation, please refer to appropriate topic reviews.)
Pyomyositis — Pyomyositis is a purulent infection of skeletal muscle that arises from hematogenous spread, usually with abscess formation. In children, it is classically an infection of the tropics, although it has been recognized in temperate climates with increasing frequency. S. aureus is the most common cause. It develops most often in the lower extremity (sites include the thigh, calf, and gluteal muscles) (picture 1). Pyomyositis presents with fever and pain with cramping localized to a single muscle group. On physical examination, exquisite muscle tenderness, edema, and/or fluctuance of the involved muscle group may be present. The diagnosis should be suspected based on clinical findings, including screening ultrasound and confirmed by MRI and/or culture of pus obtained during muscle drainage. (See "Primary pyomyositis".)
Vasoocclusive crisis (sickle cell disease) — In patients with sickle cell disease, vasoocclusive crisis may present with swollen and painful feet in young children (dactylitis) and lower extremity bone or joint pain with difficulty walking in older children and adolescents. Differentiation from osteomyelitis is an important consideration in patients with fever or prolonged painful episodes and is discussed separately. (See "Acute and chronic bone complications of sickle cell disease".)
Spontaneous hemarthrosis (hemophilia) — Spontaneous hemarthrosis is the most common musculoskeletal manifestation of hemophilia. Spontaneous hemarthroses are characteristic of severe disease (defined as <1 percent of normal factor activity). Bleeding into the joint cavity originates from the synovial vessels. Bleeding episodes often affect a variety of joints, particularly the knees and ankles, which are the major weight-bearing joints. One joint is usually affected at a time, but multiple bleeding sites are not uncommon. The ankles are most commonly affected in children, and the knees, elbows, and ankles in adolescents and adults. In toddlers, early signs of bleeding include irritability and limp. In older children and adolescents, hemarthrosis is manifested by prodromal stiffness and, in some patients, by a characteristic warm sensation, which is followed by acute pain and swelling. The diagnosis of hemarthrosis is made clinically. (See "Clinical manifestations and diagnosis of hemophilia", section on 'Joints and muscle'.)
Testicular torsion — Adolescent boys with testicular torsion may occasionally present with an acute limp without providing the history of testicular or inguinal pain to the caregiver. Testicular or inguinal swelling with tenderness is present on physical examination. (See "Causes of scrotal pain in children and adolescents", section on 'Testicular torsion'.)
Compartment syndrome — Although typically associated with major lower extremity trauma with fracture, crush injury, or major burns, compartment syndrome can also complicate minor injuries or repetitive trauma involving the anterior compartment and present as a progressively worsening limp (figure 8). Pain out of proportion to the injury and localized to a tense muscle compartment is an early and common finding. Paresthesias, diminished sensation, pallor, and paralysis are late findings that are variably present. In patients with suggestive clinical features, a difference between the diastolic blood pressure and the compartment pressure (delta pressure) of 30 mmHg or less strongly suggests the diagnosis of ACS. Direct compartment pressure establishes the diagnosis. (See "Acute compartment syndrome of the extremities".)
COMMON CONDITIONS — Most children with limp who present to an emergency department or primary care setting have an acute traumatic injury or transient synovitis (table 1). (See "Evaluation of limp in children", section on 'Epidemiology'.)
Lower extremity trauma — A history of trauma often is present in children who present with limp caused by fracture, hemarthrosis, ligamentous strain, muscle, or superficial foot injury.
Fractures — Children with lower extremity fractures typically have significant swelling with localized pain and cannot bear weight. Some children with distal fibular buckle or Salter-Harris I fractures may present with an antalgic gait and minimal swelling. However, these patients will have tenderness over the fracture site.
Plain radiographs typically identify the site of fracture in children. Several lower extremity fractures may be subtle or not evident on initial plain radiographs and require follow-up with repeat imaging to diagnose:
●Salter-Harris I fractures of the ankle (see "Ankle fractures in children", section on 'Diagnosis')
●Toddler's fractures (nondisplaced spiral fractures of the distal tibia in children nine months to three years of age) (see "Tibial and fibular shaft fractures in children", section on 'Toddler's fractures') – Most unintentional toddler's fractures have a reported mechanism described as a mild twisting or rotational force (eg, catching the foot between the bars of a crib or slipping). However, because the injury results from relatively minor trauma, the caregiver may be unaware of the mechanism or dismiss it as trivial. On physical examination, the clinician may note distal tibial tenderness that may be accentuated by plantarflexion of the foot, although localization of pain can sometimes be challenging in the fussy and frightened toddler. The distal tibial fracture line may be evident on plain radiographs (image 12) but is often absent.
●Fractures of the calcaneus or cuboid (see "Foot fractures (other than metatarsal or phalangeal) in children", section on 'Plain radiographs')
●Avulsion fractures of a pelvic apophysis – Active school-age children and skeletally immature adolescents may occasionally develop avulsion fractures of an apophysis (junction of tendon and bone). Avulsion fractures occur most often in skeletally immature athletes aged 14 to 17 years. Sudden forceful muscular contraction with hip hyperextension (eg, accidental split, foot coming off the bike pedal while racing, or coming out of a crouch at the start of a competitive sprint) is the usual cause. The most common sites and muscles include:
•Anterior superior iliac spine (sartorius)
•Anterior inferior iliac spine (rectus femoris)
•Ischial tuberosity (hamstrings)
•Lesser trochanter (iliopsoas)
On physical examination, the patient has localized pain to the site of avulsion with limp; patients may also be unable to ambulate. The initial evaluation of pelvic fractures, including avulsion fractures, and management are discussed separately. (See "Pelvic trauma: Initial evaluation and management".)
Soft tissue injury — In addition to fractures, injuries to the ligaments, muscles and tendons, skin and soft tissue, and joints may present with a limp:
●Ligamentous injury – Ankle and knee sprains are common causes of limp in children and adolescents that may be solitary injuries or complicated fractures. Patients with complete ligamentous tears or ligamentous injuries with fractures typically cannot ambulate. Patients present with pain, swelling, and tenderness over the involved ligament. Joint effusion and limitation of movement are also present. Ligamentous laxity may be noted on provocative testing.
The clinical examination findings and further evaluation of these injuries are discussed separately. (See "Ankle pain in the active child or skeletally immature adolescent: Overview of causes", section on 'Acute injuries' and "Approach to acute knee pain and injury in children and skeletally immature adolescents".)
●Muscle injury – Muscle injury causes acute limp in children by several mechanisms:
•Intramuscular injections – Local inflammation to vaccinations or other medications is a frequent cause of limp in the toddler and young child. Pain and tenderness are restricted to the injection site. A local reaction may also be present. In most children, the limp improves markedly with oral pain medication (eg, ibuprofen) and resolves rapidly within 48 hours after the injection.
•Quadriceps contusion – Direct blows to the thigh may cause quadriceps contusion. Common etiologies include being struck by a baseball or being hit during contact sports such as hockey, rugby, soccer, lacrosse, or American football. The patient presents with pain and swelling of the anterior thigh, pain on knee flexion, and a palpable mass in the thigh. Weakness on active knee extension may also be present. (See "Quadriceps muscle and tendon injuries", section on 'Quadriceps contusion'.)
•Muscle strain – In adolescents approaching skeletal maturity, muscle strains (tears near the musculotendinous junction) may occur during excessive eccentric muscle contraction.
Examples include:
-Hamstring strain from sprinting (see "Hamstring muscle and tendon injuries")
-Quadriceps strain from repeated jumping, sprinting, or kicking (see "Quadriceps muscle and tendon injuries", section on 'Quadriceps strain')
-Adductor muscle strain caused by rapid change of direction while running or skating (see "Adductor muscle and tendon injury")
The symptoms of muscle injury include local pain, which can be severe and limit range of motion. Significant swelling, tenderness to palpation, and ecchymosis may be present. The diagnosis of a muscle strain or tear is based upon clinical findings. Clinical features and management of muscle strains and tears, by muscle group are provided separately. (See "Quadriceps muscle and tendon injuries" and "Calf injuries not involving the Achilles tendon" and "Hamstring muscle and tendon injuries" and "Adductor muscle and tendon injury".)
In younger children and skeletally immature adolescents, muscle strains are less common than in older patients. Avulsion fractures at the apophysis (junction of tendon and bone) are more likely. (See 'Fractures' above.)
●Tendon injury – Tendon injuries are uncommon in children and skeletally immature adolescents. Patients with these injuries may have a secondary cause of tendon weakness such as anabolic steroid abuse, renal disease, metabolic bone disease, or medications associated with tendon rupture (eg, quinolone antibiotics). Tendon tears and complete rupture occur following a sudden, strong contraction of the muscle. After complete tears, the patient may report a "pop" or tearing sensation in the muscle and have difficulty walking. Active motion in the affected muscle will be absent. Partial tears limit range of motion and are associated with tenderness over the tendon. Diagnosis is made based upon clinical findings and may be confirmed with bedside ultrasound. Plain radiographs are indicated to evaluate for an associated avulsion fracture.
●Cutaneous and soft tissue foot injury – Local injury to the foot is frequently the cause of a limp and includes superficial trauma or friction blisters caused by poorly fitting shoes, lacerations or large abrasions, superficial contusions, foreign bodies (eg, wood splinters), or puncture wound to the sole of the foot. These abnormalities are evident upon inspection of the feet. (See "Forefoot and midfoot pain in the active child or skeletally immature adolescent: Overview of causes", section on 'Acute injuries'.)
●Insect bite or stings – Painful insect bites or stings such as those inflicted by fire ants, bees, wasps, or other insects can cause painful lesions on the feet and lower extremities and result in a limp. The bite or sting typically has a round area of swelling, redness, and tenderness with a central puncta. (See "Stings of imported fire ants: Clinical manifestations, diagnosis, and treatment" and "Bee, yellow jacket, wasp, and other Hymenoptera stings: Reaction types and acute management".)
●Hemarthrosis – An acute hemarthrosis is usually diagnosed by the presence of an effusion and joint aspiration that reveals bloody joint fluid. In children, fractures are the most common cause, although ligamentous injuries either solitary or present with a fracture are another potential source, especially in older children and adolescents. If hemarthrosis is found after minimal trauma, then hemophilia or other disorder of blood clotting should be suspected. (See "Overview of hemarthrosis", section on 'Causes of hemarthrosis'.)
Transient synovitis — Transient synovitis typically presents in patients between the ages of three and eight years and is more common in boys than girls. At clinical presentation, most children have acute symptoms for one to three days, although chronic presentations with limp up to 30 days have been described. Fever typically is absent, and children are nontoxic in appearance. They demonstrate an antalgic gait and prefer to keep the hip abducted and externally rotated at rest. Patients will have exacerbation of pain with internal hip rotation on examination. However, they typically lack exquisite tenderness with motion as seen in patients with bacterial arthritis of the hip. The diagnostic approach to transient synovitis and studies that help differentiate it from a septic hip are discussed separately. (See "Approach to hip pain in childhood", section on 'Transient synovitis'.)
Cellulitis or cutaneous abscess — Limp is often present in patients with lower extremity cellulitis or cutaneous abscess, especially when underlying muscle is affected. Typical findings include warmth, redness, swelling, tenderness, and, in patients with abscess, fluctuance or spontaneous drainage. Fever suggests systemic infection or possible involvement of adjacent deeper structures such as muscle, joint, or bone.
Patients with cellulitis or abscess involving a puncture wound on the sole of the foot or complicating an open wound in other regions may warrant imaging (ultrasonography and/or plain radiographs) to assess for a foreign body. (See "Minor wound evaluation and preparation for closure", section on 'Foreign body' and "Infectious complications of puncture wounds", section on 'Imaging'.)
Additional evaluation and management of cellulitis or cutaneous abscess is discussed separately. (See "Cellulitis and skin abscess: Epidemiology, microbiology, clinical manifestations, and diagnosis" and "Skin and soft tissue infections in children >28 days: Evaluation and management" and "Infectious complications of puncture wounds", section on 'Management'.)
Osteochondrosis — Osteochondrosis refers to idiopathic avascular necrosis in children. The tarsal navicular (Köhler disease (image 13)) in children younger than 10 years of age and the second, third, or fourth metatarsal (Freiberg disease or Freiberg infraction (image 14)) in adolescents females represent the most common sites. Osteochondrosis commonly presents with foot pain, limp, and tenderness over the affected bones. The diagnosis is made by characteristic findings on plain radiographs. (See "Forefoot and midfoot pain in the active child or skeletally immature adolescent: Overview of causes", section on 'Köhler disease (navicular osteochondrosis)' and "Forefoot and midfoot pain in the active child or skeletally immature adolescent: Overview of causes", section on 'Freiberg disease (metatarsal avascular necrosis)'.)
Traction apophysitis — Traction apophysitis refers to an overuse injury that is caused by inflammation at the site where the tendon connects to the bone (apophysis).
Typical sites in children include:
●Tibial tuberosity (Osgood Schlatter disease (picture 2)) (see "Osgood-Schlatter disease (tibial tuberosity avulsion)")
●Calcaneus (Sever disease) (see "Heel pain in the active child or skeletally immature adolescent: Overview of causes", section on 'Calcaneal apophysitis (Sever disease)')
●Lower pole of the patella (Sinding-Larsen-Johansson disease) (see "Approach to chronic knee pain or injury in children or skeletally immature adolescents", section on 'Sinding-Larsen-Johansson disease (patellar apophysitis)')
●Base of the fifth metatarsal (Iselin disease (image 15)) (see "Forefoot and midfoot pain in the active child or skeletally immature adolescent: Overview of causes", section on 'Iselin disease (fifth metatarsal traction apophysitis)')
Findings consist of pain worsened by activity, swelling, and tenderness over the apophysis. The diagnosis is made clinically.
Acute myositis — Benign acute myositis in children is a self-limited illness that typically occurs during epidemics of influenza A and B. Epidemiology varies by the causative organism. Bilateral muscle pain, tenderness, and sometimes swelling develop during the first week of influenza illness. The calf muscles typically are the most severely affected. The child may refuse to walk or toe walk and refuse to dorsiflex the feet. On examination, the calves are exquisitely tender. Serum creatine phosphokinase levels may be markedly elevated. Myoglobinuria with acute kidney injury is a rare but reported complication. Although influenza is the most common viral etiology, a variety of other viruses can cause acute myositis as well. Nearly all children do not develop rhabdomyolysis and can be discharged home with supportive care. (See "Overview of viral myositis", section on 'Benign acute childhood myositis' and "Overview of viral myositis", section on 'Etiology'.)
Lyme arthritis (endemic regions) — Lyme arthritis is a late form of Lyme disease that can present with an acute limp and arthritis, typically monoarticular and involving the knee most frequently and occasionally the hip. Patients will have a history of residing in or traveling to an endemic region (see "Microbiology of Lyme disease", section on 'Geographic distribution'). There is a wide spectrum in the acuity of the presentation of Lyme arthritis, and in some instances, it may be confused with acute bacterial arthritis. Unlike patients with bacterial arthritis, children with Lyme arthritis are typically afebrile, have less intense joint pain, and can ambulate. The diagnosis is confirmed by positive serum tests (+ELISA and presence of 5 of 10 specific bands on Western blot). (See "Musculoskeletal manifestations of Lyme disease", section on 'Diagnosis of Lyme arthritis'.)
Plantar wart — Plantar warts are caused by human papilloma virus (HPV) and appear as multiple hyperkeratotic papules with thrombosed capillaries and interruption of dermatoglyphics (skin lines) (picture 3). These lesions can be painful and cause a limp. The diagnosis is made based upon clinical appearance. (See "Cutaneous warts (common, plantar, and flat warts)".)
OTHER CONDITIONS
Hand, foot, and mouth disease — Children with enterovirus or coxsackievirus infections may develop painful plantar vesicular lesions of the foot and limp, especially after infection with coxsackievirus A6 or A16 (picture 4 and picture 5) and enterovirus 71. The diagnosis is typically made based upon physical examination findings. (See "Hand, foot, and mouth disease and herpangina".)
Legg-Calvé-Perthes disease — Legg-Calvé-Perthes (LCP) disease is a syndrome of idiopathic avascular necrosis of the hip that occurs in children between the ages of 3 and 12 years with a peak incidence between 5 and 7 years of age. It is bilateral in 10 to 20 percent of patients. The male-to-female ratio is 4:1. Children with LCP disease present with limp of insidious onset and a Trendelenburg gait. Pain, if present, is mild and often referred to the anteromedial thigh or knee. On examination, patients may have limited internal rotation and abduction of the hip. Pain may lead to disuse, which may result in atrophy of the thighs and buttocks. The diagnosis of LCP disease demands a high index of suspicion because initial radiographs often are normal. (See "Approach to hip pain in childhood", section on 'Legg-Calvé-Perthes and secondary avascular necrosis'.)
Osteochondritis dissecans — In osteochondritis dissecans (OCD), a segment of subchondral bone and articular cartilage separates from the underlying bone, leaving either a stable or unstable fragment. OCD most commonly affects the knee (medial condyle), but can also affect the ankle (superior surface of the talus) with a resultant limp (image 16).
Affected children complain of vague pain, stiffness, swelling, clicking, and/or occasional locking of the involved joint. Locking and acute symptoms are caused by complete detachment of the fragment. The pain is intermittent, worsened by activity, and may cause an antalgic gait. Physical examination may reveal bony tenderness over the lesion. When the knee is affected, tenderness can be elicited by palpating the lateral aspect of the medial condyle with the knee flexed. When the ankle is affected, tenderness can be elicited by palpating the dome of the talus with the ankle maximally plantar flexed. Plain radiographs are often diagnostic (image 17 and image 18). The diagnosis and management of OCD are discussed in greater detail separately. (See "Osteochondritis dissecans (OCD): Clinical manifestations, evaluation, and diagnosis", section on 'Clinical presentation' and "Management of osteochondritis dissecans (OCD)".)
Stress fractures — A stress fracture occurs when a bone breaks after being subjected to repeated tensile or compressive stresses, none of which would be large enough individually to cause the bone to fail, in a person who is not known to have an underlying disease that would be expected to cause abnormal bone fragility. Stress fractures are uncommon in children younger than 10 years of age but can occur in adolescents, especially those engaged in certain high-risk activities (table 6).
Patients with stress fractures often describe a recent marked increase in activity level and insidious onset of localized pain that initially is worsened by continued activity, then present during less strenuous activity and ultimately during rest. Tenderness of the affected bone is the most sensitive physical finding for diagnosing a stress fracture. Tenderness is usually limited to the site of injury, unless a complete fracture is present, in which case the area of tenderness may be wider due to bleeding and inflammation. Radiographic imaging is needed when high-risk stress fractures are suspected, or a definitive diagnosis is necessary. Plain radiographs should be obtained initially with magnetic resonance imaging (MRI) reserved for patients in whom plain radiographs are negative, but suspicion remains high. (See "Overview of stress fractures".)
Oligoarticular juvenile idiopathic arthritis and other rheumatic conditions — Oligoarticular juvenile idiopathic arthritis (JIA) most commonly occurs in toddlers and young children and affects girls more often than boys. The typical child is noticed to be limping without complaint. Often, the parent/primary caregiver reports that the child "walks funny" in the morning, but after a little while seems fine ("morning stiffness" or "gel phenomenon"). In many cases, the child has never complained of pain; the parent/primary caregiver seeks medical advice only because the knee is swollen and typically cannot specify exactly when the illness started. Physical examination typically shows joint warmth, swelling, and tenderness without erythema, typically of the knee or ankle. On careful examination, other joints, such as the wrist or elbow may be affected but the hip is rarely involved. Fever, rash, or constitutional symptoms are not usually present. (See "Oligoarticular juvenile idiopathic arthritis", section on 'Clinical presentation'.)
The diagnosis of oligoarticular JIA is made in the presence of arthritis in four or fewer joints during the first six months of disease after ruling out other causes. There are no diagnostic laboratory tests specific for oligoarticular JIA. The erythrocyte sedimentation rate (ESR) is generally normal or mildly elevated. Antinuclear antibodies (ANAs) are frequently present and are associated with an increased risk of iridocyclitis/uveitis. Laboratory abnormalities other than elevated ANAs are typically absent and should only be obtained if features of other rheumatic disease are present. Because diagnosis of oligoarticular JIA, requires a long period of follow-up and can mimic other conditions, referral to a rheumatologist with pediatric expertise is warranted when clinical suspicion is high. (See "Oligoarticular juvenile idiopathic arthritis", section on 'Diagnosis'.)
Other rheumatic diseases to be considered in the child who presents with a limp include systemic lupus erythematosus (table 7), systemic or polyarticular JIA (table 8), and juvenile dermatomyositis (picture 6). These are frequently differentiated in consultation with a pediatric rheumatologist based upon clinical presentation, associated features, and laboratory abnormalities.
Ascorbic acid deficiency (scurvy) — Acute limp is a presenting sign of scurvy in children with severe malnutrition caused by food insecurity, neglect, or eating disorders (eg, avoidant/restrictive food intake disorder or anorexia nervosa). Hypertrophic or bleeding gums (picture 7) and cutaneous petechiae are frequently present in these patients as well; perifollicular hemorrhage (picture 8 and picture 9) and corkscrew hairs are more specific to scurvy but less common findings. The diagnosis of scurvy requires recognition of characteristic clinical findings and documentation of improvement with ascorbic acid supplementation; confirmatory testing (measurement of ascorbic acid in leukocytes) is not widely available. (See "Overview of water-soluble vitamins", section on 'Deficiency'.)
Other inflammatory arthritis — Conditions that cause a painful inflammatory arthritis frequently cause a limp or refusal to walk. These are typically diagnosed by a history of an exposure or associate signs and symptoms:
●Serum sickness and serum sickness-like reactions – Serum sickness and serum sickness-like reactions (SSLRs) are most commonly caused by antibiotics, such as penicillin, cefaclor, amoxicillin, and trimethoprim-sulfamethoxazole, although vaccines, monoclonal antibody therapy, infection with hepatitis B, and a variety of medications have been associated with these reactions (table 9). The most common symptoms are rash, fever, malaise, and polyarthralgia or polyarthritis with limp occurring one to two weeks after first exposure to the responsible agent. The rash is a pruritic urticarial and/or morbilliform eruption. The mucosal membranes are not involved. Laboratory findings are variable but may demonstrate neutropenia with reactive, plasmacytoid lymphocytes, and mild thrombocytopenia; elevated acute phase reactants; and mild proteinuria and/or hematuria. The diagnosis of serum sickness and SSLRs is made clinically, based upon the characteristic pattern of physical and laboratory findings occurring after exposure to a potential offending agent. (See "Serum sickness and serum sickness-like reactions", section on 'Clinical manifestations' and "Serum sickness and serum sickness-like reactions", section on 'Evaluation'.)
●Reactive arthritis – Reactive arthritis refers to a typically mono- or oligoarticular pattern of sterile arthritis that occurs several days to weeks after an antecedent infection, commonly with a urogenital or gastrointestinal organism, such as Chlamydia trachomatis; Yersinia, Salmonella, Shigella, and Campylobacter species; Escherichia coli or Clostridioides difficile. The onset of reactive arthritis is usually acute, and the knee joint is commonly affected. Associated findings include pain and swelling at the site of insertion of ligaments, tendons, joint capsule, or fascia to bone (enthesitis), most commonly in the heels; dactylitis; and low back pain. The diagnosis of reactive arthritis is made clinically based upon the pattern of findings and exclusion of other diseases. (See "Reactive arthritis", section on 'Diagnosis'.)
●Immunoglobulin A vasculitis (Henoch-Schönlein purpura) – Immunoglobulin A vasculitis (IgAV); formerly called Henoch-Schönlein purpura [HSP]), is characterized by a tetrad of clinical manifestations:
•Palpable purpura (picture 10 and picture 11) in patients with neither thrombocytopenia nor coagulopathy
•Arthritis/arthralgia
•Abdominal pain
•Renal disease
Up to three-quarters of patients with immunoglobulin A vasculitis (IgAV) have arthritis or arthralgia. The arthritis is usually transient or migratory, typically oligoarticular (one to four joints), and nondeforming. It usually affects the lower extremity large joints (hips, knees, and ankles) or less commonly the upper extremities (elbows, wrists, and hands). There is often prominent periarticular swelling and tenderness but usually without joint effusion, erythema, or warmth. Patients may have considerable pain and limitation of motion. Younger children with lower extremity involvement may refuse to ambulate. The arthritis may precede the appearance of purpura, though usually by no more than one or two days. The diagnosis of IgAV requires the characteristic rash, which most typically involves the buttocks and legs, and at least one additional clinical manifestation. (See "IgA vasculitis (Henoch-Schönlein purpura): Clinical manifestations and diagnosis".)
●Acute rheumatic fever (ARF) – ARF can present with several different clinical findings within weeks of a group A streptococcal (GAS) tonsillopharyngitis. The most common presentation is an acute febrile illness with joint manifestations (arthritis or migratory arthralgia), and often carditis (table 10). (See "Acute rheumatic fever: Clinical manifestations and diagnosis".)
Nonmalignant tumors — Nonmalignant bone tumors often are asymptomatic and discovered incidentally during evaluation for trauma or another condition. When they are symptomatic, they may present with a subacute or chronic limp due to localized pain, swelling, or deformity. The pain is usually responsive to oral analgesics such as ibuprofen. In most cases, the differential diagnosis of these lesions can be narrowed based upon the age of the child, the involved bone, the location of the lesion within the bone, and other general radiographic characteristics (table 11). (See "Nonmalignant bone lesions in children and adolescents".)
Hypermobile Ehlers-Danlos and hypermobility spectrum disorder — Patients with hypermobile Ehlers-Danlos and hypermobile spectrum disorder may have a combination of recurrent sprains and tendinopathy, joint subluxation (hip and ankle), and patellar subluxation, all of which may manifest as a limp. The diagnosis of hypermobile Ehlers-Danlos or hypermobile spectrum disorder is made clinically, based upon the medical history and physical examination as discussed separately. (See "Clinical manifestations and diagnosis of hypermobile Ehlers-Danlos syndrome and hypermobility spectrum disorder".)
Spinal column conditions — Spinal column conditions that cause limp include:
●Spondylolysis and spondylolisthesis – Spondylolysis is a unilateral or bilateral defect (fracture or separation) in the vertebral pars interarticularis, usually in the lower lumbar vertebrae (figure 9 and figure 10). Adolescent athletes with an acute or subacute spondylolysis often develop symptoms insidiously. The primary symptom is low back pain during activities, particularly those involving lumbar extension. Severe pain from spondylolysis may cause an antalgic gait with kyphotic posture and reduced hip extension.
Spondylolisthesis (picture 12) involves anterior displacement of a vertebral body due to bilateral defects of the posterior arch and is less common than spondylolysis. Spondylolisthesis patients often develop pain that spreads across their lumbar region and radiates into their buttocks or posterior legs. The pain can be associated with radicular symptoms, including paresthesias, numbness, or a feeling of weakness in the extremities. Pain on lumbar extension is characteristic. With high-grade spondylolisthesis, the athlete may demonstrate an exaggerated posterior pelvic tilt with the buttocks appearing "tucked in" (ie, loss of normal gluteal contour) (figure 11).
The diagnostic approach to spondylolysis and spondylolisthesis is provided separately. (See "Spondylolysis and spondylolisthesis in child and adolescent athletes: Clinical presentation, imaging, and diagnosis", section on 'Diagnosis'.)
●Closed spinal dysraphism with tethered cord – In toddlers and children, tethered cord syndrome typically presents with progressive motor and sensory dysfunction, which may include gait abnormalities such as toe-walking, and loss of bladder control. Older children and adolescents are more likely to complain of pain in the lumbosacral region, perineum, and legs. In the classic progression of symptoms with tethered cord syndrome, children begin to stumble after they have learned to walk normally. Then they start dribbling urine after having achieved successful toilet training. Later, they develop musculoskeletal signs and symptoms; common findings include foot drop, painless sores, and scoliosis. The diagnosis is confirmed by radiologic demonstration of a spinal dysraphic lesion on MRI. (See "Closed spinal dysraphism: Clinical manifestations, diagnosis, and management", section on 'Tethered cord syndrome'.)
●Disc herniation – Herniation of the nucleus pulposus is much less common in children and adolescents than in adults and typically occurs in patients older than 10 years of age. With significant compression of the nerve root, patients may develop lumbar pain with sciatica and present with a limp. Disc herniation is usually confirmed with MRI. (See "Back pain in children and adolescents: Causes", section on 'Intervertebral disc herniation'.)
Other bone conditions — Several other bone conditions can impact gait:
●Tarsal coalition – Tarsal coalition is an abnormal connection (fibrous, cartilaginous, or osseous) between two or more bones in the mid/rear foot (figure 12). Ninety percent of coalitions are calcaneonavicular or talocalcaneal and will present between ages 8 to 12 years, typically the time of ossification of the coalition. While many are asymptomatic, the lack of mid/rear foot motion often manifests with generalized mid or rear foot pain and limp that is worsened with activity, especially on uneven ground. Physical examination findings include rigid flat foot, hindfoot valgus, loss of subtalar motion, and limited painful passive ankle inversion. The diagnosis of tarsal coalition requires appropriate imaging. (See "Forefoot and midfoot pain in the active child or skeletally immature adolescent: Overview of causes", section on 'Tarsal coalition'.)
●Pathologic varus (bow legs) – Pathologic varus refers to varus occurring outside the normal progression of lower-extremity alignment (figure 13). Pathologic varus may be caused by Blount disease, systemic disorders (eg, nutritional rickets and other metabolic bone diseases), skeletal dysplasia, or asymmetric growth (eg, following unilateral trauma, infection, or neoplasia) (table 12) and commonly presents with concerns about gait and in-toeing. Clues to pathologic varus include short stature, lateral thrust at the knee during the stance phase of gait (figure 14), asymmetry, and progression rather than improvement between birth and two years (table 13). Diagnostic evaluation for pathologic varus includes plain radiographs and, depending on the underlying condition, special testing as discussed separately. (See "Approach to the child with bow-legs" and "Overview of rickets in children".)
●Pathologic valgus (knock knees) – Pathologic valgus describes valgus occurring outside the normal progression of lower-extremity alignment (figure 13). Pathologic valgus may occur after trauma, in association with a number of systemic/metabolic conditions, skeletal dysplasia, or neoplasms (table 14). Patients may present with caregiver concern about frequent falling and an abnormal gait. Clues to pathologic valgus include age <2 years or >7 years, unilateral valgus, short stature, medial thrust (brief medial knee-joint protrusion during the stance phase of gait that suggests incompetence of the knee ligaments), asymmetry, and progression rather than improvement after four to five years of age (table 15). Clinical and radiographic features help to distinguish physiologic from pathologic valgus. Further evaluation of pathologic valgus depends upon the underlying cause. (See "Approach to the child with knock-knees".)
Neuromuscular disease — Limp can be caused by neuromuscular problems such as peripheral neuropathy, spastic paralysis (eg, cerebral palsy), ataxia, and muscular dystrophy.
Acute limp may be caused by central nervous system hemorrhage or Guillain-Barré syndrome. Further, cerebellar ataxia may be confused with limp and indicate a posterior fossa central nervous system lesion.
●Peripheral neuropathy – Peripheral neuropathy can have many infectious, hereditary, inflammatory, rheumatologic, metabolic, and toxic causes. These disorders are discussed in detail separately. (See "Overview of acquired peripheral neuropathies in children" and "Neuropathies associated with hereditary disorders" and "Charcot-Marie-Tooth disease: Genetics, clinical features, and diagnosis".)
Most peripheral neuropathies have both a motor and sensory component and a gradual and slowly progressive course. Inflammatory and toxic conditions can present acutely. The lower extremities usually are affected first, and the involvement typically is bilateral, symmetric, and predominantly distal. The important clinical findings are weakness and delayed or absent deep tendon reflexes. Weakness may present as clumsiness or difficulty with running or climbing stairs. Sensory symptoms include numbness, dysesthesias such as burning pain, or ataxia. Autonomic symptoms such as abnormal sweating, cardiac arrhythmias, hypotension, or bowel and bladder dysfunction may accompany peripheral neuropathy.
●Neuromuscular junction – Tick paralysis caused by Dermacentor ticks usually begins with paresthesias and a sense of fatigue and weakness, although individual patients may sometimes appear irritable or restless and complain of muscular pain. Fever is characteristically absent, and there is no change in the sensorium or headache unless severe hypoxia or hypercarbia are present. Most patients eventually develop an unsteady gait that progresses to an ascending complete paralysis. Deep tendon reflexes are characteristically absent. Respiratory paralysis and death can occur in severe cases. (See "Tick paralysis".)
Myasthenia gravis, an acquired autoimmune disorder of the neuromuscular junction characterized by weakness and fatigability of skeletal muscles, is a rare cause of proximal limb weakness and limp in children but may accompany the much more common ocular symptoms of diplopia and ptosis. Diagnostic testing is discussed separately. (See "Clinical manifestations of myasthenia gravis" and "Diagnosis of myasthenia gravis".)
●Muscular dystrophy – The muscular dystrophies are an inherited group of progressive myopathic disorders resulting from defects in numerous genes required for normal muscle function. They are inherited in an X-linked recessive fashion. Weakness is the principal symptom, with typical onset occurring in children between two and three years of age.
In contrast to peripheral neuropathy, the weakness selectively affects the proximal limb muscles before the distal limb muscles. Affected children have difficulty running, jumping, and walking up steps. When arising from the floor, affected boys also may use hand support to push themselves to an upright position, an action termed Gower sign. An unusual waddling gait, lumbar lordosis, and calf enlargement usually are observed. Complaints of leg pain may also be found with early disease. (See "Duchenne and Becker muscular dystrophy: Clinical features and diagnosis".)
●Complex regional pain syndrome – Complex regional pain syndrome (CRPS) is an amplified musculoskeletal pain syndrome that is characterized by extreme pain in a limb out of proportion to the history and physical findings accompanied by one or more signs of autonomic dysfunction (eg, decreased skin temperature, cyanosis, edema, or increased regional sweating). Pain typically occurs in a lower extremity and cause an antalgic gait but may occur in an upper extremity or at multiple sites. Most patients will experience allodynia and are unable to tolerate light touch or clothing on the limb. The borders of allodynia vary by 4 to 6 cm with retesting. Children with CRPS frequently hold the involved extremity in an unusual position, and the limb is cool and cyanotic (picture 13 and picture 14). A history of minor trauma to the affected extremity may be elicited. CRPS is a clinical diagnosis. (See "Complex regional pain syndrome in children".)
Somatic symptom disorder (conversion disorder) — Somatic symptom disorder is a rare cause of limp that occurs in older children and adolescents and requires heightened clinical suspicion to diagnose. Supportive history includes abrupt and paroxysmal onset with maximal symptoms, nonprogressive course, and spontaneous remission. Past medical and social history may be notable for psychologic stressors, psychiatric comorbidities, multiple somatic symptoms (eg, pseudoseizures) or undiagnosed conditions, and potential secondary gain [8]. On physical examination, the child may have movement inconsistencies (intermittent or varying limp), a limp not consistent with organic cause, a distractible limp, a paroxysmal or suggestible limp, and/or false weakness (giving away). Associated findings may include sensory loss that does not correspond to normal dermatomes (eg, crosses the midline) or functional disability out of proportion to examination findings.
The approach to somatic symptom disorder including diagnosis and treatment is provided separately. (See "Somatic symptom disorder: Assessment and diagnosis" and "Somatic symptom disorder: Treatment".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics (see "Patient education: Transient synovitis (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Definition – For the purposes of this discussion, limp is defined as an abnormality in gait that is caused by pain, weakness, or deformity. In toddlers and young children, limp also refers to refusal to walk or stand. (See 'Definition' above.)
●Etiology and classification – The many causes of limp can be divided according to life-threatening/emergency, common, or other important conditions (table 1). In addition, to assist clinicians with narrowing the differential diagnosis in individual patients, a table that identifies etiology by location of abnormality is provided (table 2). (See 'Classification of limp' above.)
●Evaluation – The cause of limp in children usually can be determined through a careful history and physical examination. Ancillary studies are often necessary to confirm clinical suspicions, but operative procedures are rarely required. Acute trauma or benign self-limiting conditions are the most frequent etiologies. (See "Evaluation of limp in children".)
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