Limping in Children: Clinical Evaluation Learning Tool

Clinical History Assessment

Systematic approach to history taking for a child presenting with limping

Physical Examination Guide

Systematic approach to examining a child with limping

Diagnostic Approach

Initial Assessment

For a child presenting with limping, the initial assessment should include:

• Detailed history focusing on onset, duration, pattern, and associated symptoms
• Complete physical examination with special attention to the musculoskeletal system
• Assessment of developmental milestones and prior medical history
• Pain assessment using age-appropriate pain scales

Clinical Classification of Limping

Different patterns of limping provide diagnostic clues:

Pattern	Description	Key Features
Antalgic Gait	Shortened stance phase on affected side due to pain	Acute onset, asymmetric, suggests painful condition
Trendelenburg Gait	Pelvic drop on unaffected side during stance phase	Hip abductor weakness, may see compensatory trunk lean
Circumduction Gait	Leg swings outward in a semicircle during swing phase	Associated with leg length discrepancy or hip/knee contracture
Stiff Gait	Decreased joint motion, particularly in hip or knee	Often due to arthritis, infection, or protective muscle spasm
Steppage Gait	Exaggerated hip and knee flexion to clear foot	Suggests foot drop, peroneal nerve injury, or muscular dystrophy

Differential Diagnosis by Age

Age Group	Common Causes	Key Considerations
Toddler (1-3 years)	- Developmental dysplasia of the hip - Toddler's fracture - Septic arthritis - Transient synovitis - Foreign body in foot	- Consider non-accidental trauma - Limited verbal expression of pain - Consider reactive arthritis - Developmental considerations
Young Child (4-10 years)	- Transient synovitis - Legg-Calvé-Perthes disease - Juvenile idiopathic arthritis - Osteomyelitis - Septic arthritis - Stress fractures	- Fever suggests infection - Morning stiffness suggests JIA - Night pain suggests malignancy - Recent trauma history important
Adolescent (11-18 years)	- Slipped capital femoral epiphysis - Osgood-Schlatter disease - Apophysitis (various locations) - ACL/meniscal injuries - Osteochondritis dissecans - Spondylolysis	- Sports-related injuries common - Growth-related conditions - Obesity increases SCFE risk - Consider referred pain

Red Flags Requiring Urgent Evaluation

Red Flag	Concerning For	Immediate Action
Fever	Septic arthritis, osteomyelitis	Urgent laboratory workup, joint aspiration if indicated
Non-weight bearing	Fracture, severe infection, SCFE	Immediate imaging, orthopedic consultation
Night pain/awakening	Malignancy, osteoid osteoma	Advanced imaging, oncology referral if indicated
Systemic symptoms	Malignancy, systemic inflammatory disease	Complete blood count, inflammatory markers, imaging
Neurological symptoms	Spinal cord or nerve compression	Neurological evaluation, spinal imaging

Laboratory Studies

Consider these studies based on clinical presentation:

Investigation	Clinical Utility	When to Consider
Complete Blood Count	Assess for infection, inflammation, or malignancy	Fever, night pain, systemic symptoms
Inflammatory Markers (ESR, CRP)	Evaluate for infection or inflammatory conditions	Suspected infection, JIA, inflammatory conditions
Blood Culture	Identify causative organism in infection	Fever with suspected osteomyelitis or septic arthritis
Joint Aspiration	Definitive diagnosis of septic arthritis	Joint effusion with fever or high clinical suspicion
Lyme Serology	Diagnose Lyme arthritis	Endemic areas, monoarticular arthritis, potential tick exposure

Imaging Studies

Investigation	Clinical Utility	When to Consider
Plain Radiographs	First-line imaging for bone pathology	All patients with significant limp or pain, trauma
Ultrasound	Detect joint effusions, soft tissue abnormalities	Suspected hip effusion, guided aspiration
MRI	Detailed evaluation of bone, cartilage, and soft tissues	Negative radiographs with persistent symptoms, suspected malignancy, osteomyelitis
Bone Scan	Identify areas of increased bone turnover	Suspected occult fracture, osteomyelitis, malignancy
CT Scan	Detailed bone evaluation	Complex fractures, tarsal coalition, osteoid osteoma

Diagnostic Algorithm

A stepwise approach to evaluating limping in children:

1. Initial Assessment
   • History and physical examination
   • Determine acuity and severity
   • Identify pattern of limp (antalgic, Trendelenburg, etc.)
2. Screen for Red Flags
   • Fever, night pain, systemic symptoms
   • Non-weight bearing status
   • Neurological symptoms
3. Initial Imaging
   • Plain radiographs of affected area (and contralateral for comparison)
   • Hip ultrasound if hip pathology suspected in young child
4. Laboratory Testing (if indicated)
   • CBC, ESR, CRP for suspected infection or inflammation
   • Joint aspiration for suspected septic arthritis
5. Advanced Imaging (if indicated)
   • MRI for persistent symptoms with negative initial workup
   • Bone scan for occult fracture or multifocal pathology
6. Specialist Referral as appropriate:
   • Orthopedic surgeon for surgical conditions
   • Rheumatologist for inflammatory conditions
   • Infectious disease for complex infections
   • Oncologist for suspected malignancy

Management Strategies

General Approach to Management

Key principles in managing limping in children:

• Establish diagnosis: Accurate diagnosis guides appropriate management
• Pain control: Appropriate analgesia improves comfort and function
• Activity modification: Balance between rest and activity based on condition
• Follow-up: Monitor response to treatment and disease progression
• Involve specialists: Timely referral to appropriate specialists

Management of Common Conditions

Condition	Management Approach	Expected Course and Follow-up
Transient Synovitis	- Rest - NSAIDs for pain and inflammation - Limited weight-bearing as tolerated - Hydration	- Self-limiting (3-10 days) - Follow-up in 1-2 weeks - Consider re-imaging if symptoms persist >2 weeks - 1-2% risk of recurrence
Septic Arthritis	- Urgent orthopedic consultation - Joint aspiration and drainage - IV antibiotics (initially empiric) - Pain management	- Hospitalization typically required - IV antibiotics 1-2 weeks followed by oral - Close monitoring for complications - Long-term follow-up for growth plate damage
Legg-Calvé-Perthes Disease	- Activity modification - Physical therapy for ROM and strengthening - Possible bracing or containment surgery - Pain management	- Long-term orthopedic follow-up (2-4 years) - Regular radiographic monitoring - Better prognosis in younger patients - Monitor for limb length discrepancy
Slipped Capital Femoral Epiphysis	- Urgent orthopedic referral - Non-weight bearing - Surgical fixation (in situ pinning) - Monitor contralateral hip	- Long-term orthopedic follow-up - Monitor for AVN and chondrolysis - 20-40% risk of contralateral involvement - Weight management for obese patients
Toddler's Fracture	- Cast immobilization (3-4 weeks) - Pain management - Follow-up radiographs to confirm healing - Gradual return to activities	- Excellent prognosis - Follow-up in 2-3 weeks - Full recovery expected - No long-term complications
Juvenile Idiopathic Arthritis	- NSAIDs for pain and inflammation - DMARDs for disease control - Physical therapy for ROM and strength - Rheumatology follow-up	- Chronic disease requiring ongoing management - Regular monitoring of disease activity - Growth monitoring - Monitor for medication side effects
Osteomyelitis	- IV antibiotics (2-6 weeks) - Possible surgical debridement - Pain management - Protected weight bearing	- Initial hospitalization - Follow-up imaging to assess resolution - Monitor for chronic osteomyelitis - Growth disturbance possible
Osgood-Schlatter Disease	- Activity modification - Ice after activity - NSAIDs for pain - Physical therapy for flexibility/strengthening	- Self-limiting with skeletal maturity - Symptom-based follow-up - May have persistent tibial tuberosity prominence - Usually resolves with growth plate closure

Pain Management Approaches

Intervention	Indications and Dosing	Considerations
NSAIDs	- Ibuprofen: 10 mg/kg/dose q6-8h - Naproxen: 5-7 mg/kg/dose q12h (>2 years) - First-line for inflammatory conditions	- Monitor for GI effects - Use caution with renal/hepatic impairment - Avoid in dehydration - Consider with food
Acetaminophen	- 10-15 mg/kg/dose q4-6h - Alternative to NSAIDs - Can be used in combination with NSAIDs	- Less anti-inflammatory effect - Better tolerated than NSAIDs - Monitor total daily dose - Avoid in liver disease
Opioids	- Reserved for severe pain - Short-term use - Codeine not recommended in children	- Monitor for respiratory depression - Risk of constipation - Use lowest effective dose - Taper for longer courses
Non-Pharmacologic	- RICE protocol (Rest, Ice, Compression, Elevation) - Physical therapy - Activity modification	- Essential complement to medication - Improves function and healing - No significant side effects - Empowers patient/family

Activity Recommendations by Condition

Condition	Activity Guidelines	Return to Sports Criteria
Transient Synovitis	- Rest until pain-free - Gradual return to activities - No formal restrictions once resolved	- Pain-free ambulation - Full range of motion - Normal strength - Typically 1-2 weeks
Fractures	- Initial immobilization - Protected weight-bearing as directed - Progressive activity as healing occurs	- Radiographic healing - Pain-free with stress - Adequate rehabilitation - May require 6-12 weeks
SCFE	- Post-surgical protocol from orthopedist - Initially limited weight-bearing - Gradual increase in activities	- Physician clearance required - Radiographic evidence of healing - Functional assessment - May require 3-6 months
Legg-Calvé-Perthes	- Activity limitations based on disease stage - Low-impact activities encouraged - Avoid running and jumping in fragmentation phase	- Based on healing stage - Physician clearance required - May have long-term restrictions - Individual assessment essential

Physical Therapy Interventions

Goal	Interventions	Appropriate Conditions
Improve Range of Motion	- Gentle stretching - Joint mobilization techniques - Active-assisted exercises	- Post-immobilization stiffness - JIA - Legg-Calvé-Perthes - Post-surgical rehabilitation
Strengthen Supporting Muscles	- Progressive resistance exercises - Closed-chain activities - Core strengthening	- Lower extremity injuries - Post-fracture rehabilitation - Patellofemoral pain syndrome - Trendelenburg gait
Improve Balance and Proprioception	- Balance boards - Single-leg stance activities - Proprioceptive training	- Ankle sprains - Post-injury return to sports - Joint instability - Developmental coordination issues
Gait Training	- Gait analysis - Corrective exercises - Assistive device training if needed	- Limb length discrepancy - Post-surgical rehabilitation - Neuromuscular conditions - Abnormal gait patterns

When to Refer

Guidelines for appropriate specialty referral:

Specialist	When to Refer	Urgency
Orthopedic Surgeon	- Suspected or confirmed fractures - Joint effusions - Slipped capital femoral epiphysis - Legg-Calvé-Perthes disease - Persistent limping >2 weeks	- Urgent: SCFE, septic arthritis, displaced fractures - Semi-urgent (days): Non-displaced fractures, persistent pain - Routine: Mild trauma, mechanical symptoms
Rheumatologist	- Suspected juvenile idiopathic arthritis - Multi-joint involvement - Morning stiffness - Family history of rheumatic disease	- Semi-urgent: Multiple joint involvement, systemic symptoms - Routine: Single joint arthritis without systemic symptoms
Infectious Disease	- Osteomyelitis - Complex or atypical infections - Septic arthritis - Immunocompromised patients	- Urgent: Acute infections with systemic symptoms - Semi-urgent: Subacute infections - Concurrent with antibiotic initiation
Neurology	- Neurological symptoms accompanying limp - Muscle weakness patterns - Suspected neuromuscular disease	- Urgent: Progressive neurological deficits - Semi-urgent: Stable neurological findings - Routine: Mild or intermittent symptoms
Oncology	- Bone pain with night awakening - Constitutional symptoms (fever, weight loss) - Abnormal mass on imaging - Persistent unexplained pain	- Urgent: Suspected malignancy with imaging findings - Semi-urgent: Bone pain with normal initial imaging

Parent Education

• Expected course of recovery: Provide timeline and milestones for specific conditions
• Warning signs: Educate about symptoms requiring prompt reassessment
• Medication administration: Proper dosing and potential side effects
• Activity restrictions: Clear guidelines for school, sports, and recreational activities
• Home exercises: Demonstrations and written instructions for prescribed exercises
• Follow-up plan: Importance of scheduled follow-up appointments

Long-term Considerations

• Growth monitoring: Regular assessment for certain conditions affecting growth plates
• School accommodations: Temporary modifications for limited mobility
• Psychological impact: Support for chronic conditions affecting activities
• Athletic performance: Gradual return to sports with appropriate rehabilitation
• Prevention strategies: Injury prevention education for recurrent conditions