A limp is defined as an uneven, jerky, or laborious gait, usually caused by pain, weakness, or deformity. Although limps are often caused by benign conditions or trauma, there are life or limb threatening conditions that must be diagnosed promptly. The goal of this review is to understand the process to evaluate a limp and important must not miss diagnoses.
There are many causes of limps and unfortunately this review will not cover all of them. Typically, minor trauma predominates as the typical etiology for a limp, but rheumatologic, infectious, and neoplastic processes exist. We will cover how to diagnose the common life and limb threatening causes quickly and accurately.
One study performed evaluated children under the age of 14 presenting with limp but no history of trauma. They discovered the following:
- Boys outnumbered girls by almost two to one
- The median age was four years
- The limps was antalgic, or painful, in 80% of patients
- 77% of patients had a bening cause that could be managed without subspecialty follow up or hospital admission.
- Duration of the limp
- Recent onset indicates trauma or acute infection
- Chronic limps arise from overuse syndroms, Legg-Calve-Perthes disease, SCFE, or systemic illness such as rheumatic disease, tumor.
- Soft tissue injury and fractures often have trauma as part of their history
- Must be careful one study showed 163 infants with osteomyelitis a history of preceding blunt trauma was present in one third of cases.
- Osteomyelitis and septic arthiritis are suggested with a fever
- Toxic synovitis is also present with viral illness and fever
- Leukemia and rheumatic disease are rare causes
- Difficult for children to describe and localize pain
- Intermittent, less severe pain think about JIA, Legg-Calve-Perthes disease, SCFE, Osgood Schlatter
- Night awakening from pain is common in neoplastic conditions like leukemia, osteogenic sarcoma, Ewing Sarcoma
- Worsening pain with activity is indicative of a stress fracture, overuse injury, or hypermobility syndrome.
- Improving pain with activity is indicative of rheumatologic conditions and complex regional pain syndrome.
- Ill appearance or significant pain indicates a serious cause. Infections associated with fever
- Gait Evaluation
- Most children can walk independently by 15 months and run by 18 months
- Legs and feet exposed, have the child walk up and down the hall several times
- Look and listen for irregular cadences
- Circumduction (circular movement of limb during gait) suggests ankle and/or foot problems
- Downward pelvic tilt (Trendelenberg Gait) suggests a hip pathology
- Toe-to-Heel sequence, where the normal is heel to toe, suggests a neurologic problem or cerebral palsy.
- Inspection of the knees may show knock knees (genu valgum) or bowing of the tibias (genu varum). These can be normal up to 4 years of age
- Soles of the feet can show warts, foreign bodies, or calluses form poorly fitting shoes
- Joint swelling
- In a single joint with fever suggests a septic arthritis
- Minor trauma or no history in a single joint may be hemarthrosis, an initial way for a bleeding disorder to present. Check the ankle if under 5, if over 5 check the knees and elbow
- Painful palpation of tendon or fascia without fever or trauma, think about Osgood-Schlatter disease, Sever Disease, and Köhler disease
- Limb length discrepancy, measure from Anterior Superior Iliac Spine to Medial Malleolus of the ankle. Common in Developmental Dysplasia of the Hip
- Severe soft tissue pain and swelling could be compartment syndrome. Check passive extension of the affected area.
- Hip Rotation
- Roll thigh in supine position
- Causes pain in all traumatic, infections, or inflammatory conditions of the hip
- Decreased hip rotation helpful in SCFE, Legg-Calve-Perthes disease, and septic arthritis
- Roll thigh in supine position
- Galeazzi Test
- Helpful with DDH or Leg Length Discrepancy
- Supine, flex hips and knees with feet side by side and heels touch buttocks
- Positive if the knees are at different heights
- Think of clubfoot, disuse or paralysis, ischemia, physeal injury with a leg length discrepancy
- Tendelenburg Test
- Stand on the affected leg
- Get a pelvic tilt with SCFE, Legg-Calve-Perthes or DDH
- Caused by gluteal weakness
- Stand on the affected leg
- FABERE Test
- Sacroiliac Joint examined with “figure of four”
- Flexion of the hip and knee, Abduction, External Rotation at the hip, Extension of sacroiliac joint.
- Pain from this maneuver without pain from passive hip motion suggests sacroiliac origin
- Skin Examination
- Serum sickness rash, Henoch-Schönlein purpura, acute rheumatic fever, or Lyme Disease
- Ask about related symptoms like GI infections, camping trips
- Abdominal Examination
- Tenderness, rebound, guarding, positive psoas sign, think appendicitis
- Can be mistaken for hip pain
- Genital Examination
- Testicular torsion can result in a wide shuffling gait
- Vaginal or Penile discharge can be associated with gonococcal infection
- Neurologic and Spine Exam
- Check for abnormal curvature, kyphosis or scoliosis, and limited range of motion
- Spinal cord tumors, discitis
- Abnormal deep tendon reflexes can indicate peripheral neuropathy
Common Etiologies by Age
One to Three Year Olds
The most difficult age to evaluate because the child will often not tell you what hurts and the exam may be unrevealing.
- Trauma - most commonly involving metatarsals and tibia. Must always think of child abuse
- Toxic synovitis
- Spastic hemiplegias
- Infections - osteomyelitis and septic joint. Evaluation of a possible septic hip is an emergency and needs immediate attention
- Developmental dysplasia of the hip causing leg length discrepancy
Three to Ten year olds
- Toxic synovitis - not ill and pain localized to the hip. Must differentiate from septic joint. May have slight elevation of ESR and radiograph may show joint fluid.
- Legg-Calve-Perthes Disease - avascular necrosis of the capital femoral epiphysis. five times more common in males and 15% bilateral but usually not concomitantly
- Kohlers disease-avascular necrosis of the tarsal navicular bone
Older than Ten years old
- Slipped Capital Femoral Epiphysis (SCFE) - very tall and/or obese. Limp and pain in the hip. Leg is held in an extermal rotation position. Often painful on internal rotation of the hip. Asociation with hypothyroidism.
- Overuse syndromes - Shin splints, stress fractures.
- Osgood Schlatter's Disease, Sever's Disease
- Back pain- Discitis, Spondylolysis and Spondylolisthesis
- Osteochonditis dissicans
- Chondromalacia of the patellar
Other causes of limp and lower extremity pain
- Appendicitis with psoas muscle irritation
- Neoplasms- either cause pain or pathological fractures
- Retroperitoneal neoplasms or infection
- Neuromusculature disorders
- Blood studies
- CBC, ESR, CRP, blood culture if infection is suspected
- Fever and ESR is 93% sensitive for infectious and autoimmune joint disease
- ESR greater than 20 mm per hour and/or temperature greather than 37.5 C is 97% sensitive for septic arthritis
- CRP elevated and temperature above 38.5 C is 100% sensitive and 87% specific for septic arthritis
- ANA can assist in suspected Juvenile Idiopathic Arthritis or other rheumatic disease
- Synovial Fluid Analysis
- Joint aspiration with swollen, inflamed joint in a febrile child that is painful.
- WBC count, Gram stain, anaerobic and aerobic cultures, and measurement of protein and glucose
- Teenagers with bacterial arthritis should be tested for genital gonococcoal infection
- Plain Radiograph
- Radiographic studies are often required to confirm a clinical suspicion.
- Specific for fractures, destructive lesions, and avascular necrosis
- Obtain both anteroposterior and lateral views, hips obtains AP and frog leg views
- Do Not Order Unilateral Hip Series, small SCFE could be missed without opposite for contrast
- Helpful in fracture, osteomyelitis, Legg-Calve-Perthes disease, SCFE, bone tumors (both benign and malignant), apophysitis, and congenital abnormalities.
- Obtain a plain radiographs in children with limp on exam even if lacking trauma
- Favored in suspected osteomyelitis, stress fracture, and early avascular necrosis since it can differentiate between these diseases
- Spine pathology suggested from physical exam, such as discitis, herniated disc, spinal tumors
- Radionuclide Scan
- Can detect alterations in metabolic rate of bone
- Poor specificity, used if MRI is unavailable, especially children with a prolonged limp, localized back pain, elevated acute phase reactants.
- Excellent for joint effusions of hips
- Use when plain radiograph is normal but suspicion is high for septic hip
- Can be used to guide aspiration of the hip as well
- Excellent for joint effusions of hips
- Computed Tomography (CT)
- Rarely used with limp but may consider if appendicitis suspected
- Bone or joint infection requires orthopedic consultation, bone/joint aspiration, and antibiotic therapy
- Surgical drainage should occur as soon as possible
- SCFE requires emergent operative reduction, along with pinning.
- Oncologic process requires workup, staging, and intiation of treatment.
- Afebrile with normal radiographs can be treated with NSAIDs
- Fracture suspected but not apparent, splint and attain outpatient orthopedic surgeon appointment.
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