Causes of Limp in Children

1. Causes: Common
   1. Acute Limp
      1. Transient Synovitis (most common)
      2. Contusion
      3. Foot foreign body
      4. Fracture
      5. Osteomyelitis
      6. Septic Arthritis
      7. Reactive Arthritis
      8. Lyme Arthritis
      9. Poor shoe wear
   2. Chronic Limp
      1. Rheumatic disease (e.g. Dermatomyositis, Rheumatic Fever, Inflammatory Bowel Disease, SLE, Juvenile RA)
      2. Apophysitis (e.g. Osgood-Schlatter Disease, Sever's Disease) and other overuse syndromes
      3. Slipped Capital Femoral Epiphysis (esp. boys at 14 to 16 years old)
      4. Legg-Calve-Perthes Disease (esp. boys at ages 4 to 9 years old)
   3. References
      1. Fischer (1999) J Bone Joint Surg Br 81(6): 1029-34 [PubMed]
2. Causes: LIMPSS Mnemonic
   1. Legg-Calve-Perthes Disease (Femoral Head Avascular Necrosis)
      1. Especially in males, 4-9 years old with Hip Pain and reduced range of motion (84% unilateral)
   2. Infection or Inflammation
      1. Examples: Cellulitis, Osteomyelitis, Septic Hip, Transient Synovitis
   3. Malignancy
      1. Examples: Ewing's Sarcoma and Osteosarcoma represent 90% of Bone Cancers in children; Also ALL
   4. Pain from Trauma
      1. Consider Toddler's Fracture, Non-accidental Trauma
   5. Slipped Capital Femoral Epiphysis (SCFE)
      1. Especially Overweight, black or hispanic boys (14-16 yo) more than girls (11-13 yo) with Hip Pain (90% unilateral)
   6. Somewhere Else (referred pain)
      1. Examples: Appendicitis or psoas abscess, Discitis
      2. Girls: UTI, Ectopic Pregnancy, Ovarian Torsion, Pelvic Inflammatory Disease
   7. References
      1. Jhun and Raam in Herbert (2016) EM:Rap 16(2):15-6
3. Causes: Age 1-5 years
   1. See Common causes for all ages as above
   2. Acute
      1. Hip and Leg
         1. Toxic or Transient Synovitis (most common)
         2. Toddler's Fracture
         3. Tibial Stress Fracture
         4. Septic Hip
         5. Henoch-Schonlein Purpura (esp. Polyarthritis at ankles and knees)
      2. Foot
         1. Hand Foot and Mouth Disease
      3. Systemic
         1. Non-Accidental Trauma in Children (Child Abuse)
         2. Salter Fracture Type 1
         3. Immunizations (local reaction may cause limp due to affected injected leg)
   3. Chronic
      1. Hip
         1. Congenital Hip Dysplasia (most common, esp girls)
      2. Foot
         1. Clubfoot
         2. Kohler Bone Disease
         3. Vertical talus
      3. Spine
         1. Diskitis
      4. Systemic
         1. Cerebral Palsy
         2. Leg-length discrepancy
         3. Juvenile Rheumatoid Arthritis (or Systemic Juvenile Idiopathic Arthritis)
4. Causes: Age 5-12 years
   1. See Common causes for all ages as above
   2. Acute
      1. Myositis
      2. Salter Fracture Type 1
   3. Chronic
      1. Hip
         1. Legg-Calve-Perthes Disease (most common, esp. boys)
      2. Foot
         1. Kohler Bone Disease
         2. Tarsal Coalition
      3. Spine
         1. Spinal Dysraphism with tethered cord
      4. Systemic
         1. Acute Rheumatic Fever
         2. Muscular Dystrophy
         3. Dermatomyositis
         4. Juvenile Rheumatoid Arthritis (or Systemic Juvenile Idiopathic Arthritis)
         5. Leukemia
5. Causes: Ages 11-19 years
   1. See Common causes for all ages as above
   2. Acute
      1. Soft Tissue Injury (Ligament Sprain, Tendon Strain)
      2. Tendinopathy
      3. Overuse syndrome
   3. Chronic
      1. Hip
         1. Slipped Capital Femoral Epiphysis (most common, esp. boys)
         2. Legg-Calve-Perthes Disease (esp. boys)
      2. Knee
         1. Osgood-Sclatter Disease or Chondromalacia petellae
         2. Osteochondritis Dissecans of the Knee
         3. Discoid meniscus
      3. Foot
         1. Tarsal Coalition
      4. Spine
         1. Spinal Dysraphism with tethered cord
         2. Spondylolisthesis
         3. Lumbar Disc Herniation
         4. Scoliosis
      5. Systemic Arthritis
         1. Juvenile Rheumatoid Arthritis (or Systemic Juvenile Idiopathic Arthritis)
         2. Systemic Lupus Erythematosus
         3. Inflammatory Bowel Disease
      6. Miscellaneous
         1. Tumor
         2. Hypermobility syndrome
6. Causes: Hematology and Oncology
   1. Sickle Cell Anemia (causes osteonecrosis)
   2. Henoch-Schonlein Purpura
   3. Benign Neoplasm
      1. Osteoblastoma
      2. Osteoid Osteoma
      3. Bone cyst
   4. Malignant Neoplasm
      1. Ewing Sarcoma
      2. Leukemia
      3. Osteosarcoma
      4. Spinal cord tumor
      5. Metastatic cancer to bone
7. Causes: Congenital and Developmental Disorders
   1. Congenital deformity
      1. Clubfoot
      2. Short femur or other Limb Length Discrepancy
      3. Congenital Hip Dysplasia
      4. Discoid lateral meniscus
   2. Developmental bone disorder (see age specific causes as above)
      1. Slipped Capital Femoral Epiphysis (SCFE)
      2. Legg-Calve-Perthes Disease
      3. Blount's Disease (Tibia Vara)
      4. Tarsal Coalition
   3. Neuromuscular disorders
      1. Cerebral Palsy
         1. Developmental Delay
         2. Spasticity or hypertonia
         3. Asymmetric motor activity or Deep Tendon Reflexes
      2. Muscular Dystrophy
      3. Spinal Dysraphism (e.g. Myelomeningocele)
8. Causes: Infection
   1. Osteomyelitis
   2. Transient Synovitis (follows Group A Streptococcus or viral infection)
   3. Septic Arthritis
   4. Lyme Disease
   5. Meningitis (especially Meningococcus)
   6. Soft tissue abscess or Cellulitis
   7. Pyomyositis
   8. Discitis or Vertebral Osteomyelitis (esp. Lumbar Spine in young children)
      1. Subtle presentation (focal tenderness and preference for supine position may be only findings)
   9. Spinal Epidural Abscess
   10. Acute appendicitis or other intra-abdominal infection
   11. Infectious Myositis
       1. Viral Myositis
          1. Influenza (esp. affecting calf muscles, with "Charlie-Chaplain shuffle" with Out-toeing)
       2. Bacterial Myositis (pyomyositis), with focal infection (esp. upper thigh or deep Pelvis)
          1. May be associated with underlying Osteomyelitis
9. Causes: Musculoskeletal
   1. Fracture, Trauma or overuse
      1. Osteochondritis Dissecans (overuse injury)
      2. Pediatric Fractures or Stress Fractures (consider Child Abuse)
      3. Intra-articular injury or Hemarthrosis (may also be caused by Hemophilia)
      4. Patellofemoral Syndrome (Chondromalacia Patellae)
      5. Soft tissue foreign body (e.g. foot)
   2. Apophyseal Injury
      1. Osgood-Schlatter Disease (tibial tuberosity Apophysitis)
      2. Sever Disease (Calcaneal Apophysitis)
      3. Sindig-Larsen-Johansson Disease (inferior Patellar Apophysitis)
   3. Rheumatologic Conditions (chronic systemic symptoms and bilateral symmetric or multifocal findings)
      1. Acute Rheumatic Fever
      2. Juvenile Rheumatoid Arthritis
      3. Dermatomyositis or Polymyositis
      4. Reactive Arthritis or Spondyloarthropathy
      5. Systemic Lupus Erythematosus
      6. Transient Synovitis
      7. Henoch-Schonlein Purpura
10. Causes: Miscellaneous
    1. Referred intra-Abdominal Pain
       1. Appendicitis or other psoas abscess
       2. Neuroblastoma
    2. Neurologic causes
       1. Peripheral Neuropathy
       2. Spinal cord lesion or compression
    3. Non-Organic
       1. Growing Pains
       2. School Phobias
       3. Conversion Disorder
11. References
    1. Gardiner (2018) Crit Dec Emerg Med 37(5): 3-14
    2. Fischer (1999) J Bone Joint Surg Br 81(6): 1029-34 [PubMed]
    3. Flynn (2001) J Am Acad Orthop Surg 9(2): 89-98 [PubMed]
    4. Naranje (2015) Am Fam Physician 92(10): 908-16 [PubMed]
    5. Sawyer (2009) Am Fam Physician 79(3): 215-24 [PubMed]