Aetiology
Classification by cause
Orthopaedic
Orthopaedic trauma (including toddler's fracture [non-displaced spiral fracture of the tibia]) is the most common cause of limping.[2][8] Be aware of injuries that may trigger safeguarding concerns.
Non-traumatic orthopaedic causes primarily affect the hip (developmental dysplasia of the hip, slipped capital femoral epiphysis, transient synovitis of the hip, Legg-Calvé-Perthes disease); the knee (Osgood-Schlatter disease); the foot and ankle (tarsal coalition, Sever's disease); and the spine (spondylolysis/spondylolisthesis, prolapsed disc lesions).
Rheumatological
JIA is a spectrum of disorders with involvement of the knee or ankle being most common at presentation.[9][Figure caption and citation for the preceding image starts]: Ankle involvement in oligoarticular juvenile idiopathic arthritisFrom Dr Foster's personal collection; used with permission [Citation ends].
[Figure caption and citation for the preceding image starts]: Swollen knee in juvenile idiopathic arthritisFrom Dr Foster's personal collection; used with permission [Citation ends].
[Figure caption and citation for the preceding image starts]: Polyarticular juvenile idiopathic arthritis in the handsFrom Dr Foster's personal collection; used with permission [Citation ends].
[Figure caption and citation for the preceding image starts]: Polyarticular juvenile idiopathic arthritis in the knees, feet and anklesFrom Dr Foster's personal collection; used with permission [Citation ends].
[Figure caption and citation for the preceding image starts]: Fever chart in systemic-onset juvenile idiopathic arthritisFrom Dr Foster's personal collection; used with permission [Citation ends].
[Figure caption and citation for the preceding image starts]: Short right leg from hip disease (juvenile idiopathic arthritis)From Dr Foster's personal collection; used with permission [Citation ends].
[Figure caption and citation for the preceding image starts]: Leg length inequality and flexion contracture at left knee in juvenile idiopathic arthritisFrom Dr Foster's personal collection; used with permission [Citation ends].
Juvenile dermatomyositis is a rare inflammatory muscle disease which results in proximal muscle weakness and characteristic rash. Other connective tissue diseases (also rare in childhood), such as systemic lupus erythematosus (SLE) are more likely to present with a multi-system illness (rash, fever, malaise, and arthralgia) rather than gait disturbance.
Neurological
Central nervous system (CNS) disorders include cerebral palsy and cerebellar ataxia.
Conditions affecting the spinal cord and peripheral nervous system include spina bifida[Figure caption and citation for the preceding image starts]: Myelomeningocele in spina bifidaFrom Dr Foster's personal collection; used with permission [Citation ends].
and peripheral neuropathies such as Charcot-Marie-Tooth disease or Guillain-Barre syndrome.Neuromuscular disorders include inherited myopathies.
Infectious
Septic arthritis and osteomyelitis are serious conditions that involve most commonly the hips, lower limbs, and soft tissue. In a child with limp and fever, infectious causes must be considered; late diagnosis may lead to joint or bone sequelae.
Neoplastic
Benign osteoid osteomas and malignant tumours (most common are osteosarcoma and Ewing's sarcoma).
Leukaemia and neuroblastoma are the most common non-bone tumours in children.
Musculoskeletal complaints are common in the presenting symptoms of childhood cancers, such as leukaemia.[10]
Metabolic
Osteomalacia can cause proximal muscle weakness and joint and limb pain, resulting in limp.
Mild forms of lysosomal storage disorders may present primarily with musculoskeletal features including gait abnormalities.
Haematological
Sickle cell disease results in acute painful crises affecting bones and joints, often in the hands and feet, and is more common in children of African descent.
Haemophilia may result in easy bruising, bleeding after dental procedures, haemarthrosis, soft-tissue/muscle haematomas in toddlers, and swollen joints in active toddlers (usually boys).
Idiopathic
Pain syndromes with unknown organic cause and complex regional pain syndromes (sometimes called reflex sympathetic dystrophy) often present with gait disturbance.[11]
Some children with hypermobility will experience significant pain, although not all children with hypermobility are symptomatic.[12]
Referred pain
Abdominal diseases such as appendicitis or a psoas abscess may be associated with non-weight-bearing or referred pain to the thigh/groin.
Spinal lesions (abscess, tumours, nerve root irritation) can cause referred pain to the legs and gait abnormality.
Other
Other possible causes include poorly fitting footwear, verrucae, and foreign body to the sole of the foot.
Classification by age
Toddler/pre-school (1 to 4 years)
Infection (septic arthritis, osteomyelitis in the hip/spine)
Mechanical (trauma and non-accidental injury)
Congenital/developmental problems (developmental dysplasia of the hip, talipes, leg length discrepancy)
Reactive arthritis/transient synovitis (toxic synovitis, irritable hip)
Legg-Calvé-Perthes disease
Neurological disease (cerebral palsy, hereditary syndromes)
Inflammatory arthritis (most commonly JIA)
Metabolic (e.g., osteomalacia)
Haematological (haemophilia)
Malignant disease (e.g., leukaemia, neuroblastoma).
Children (5 to 10 years)
Mechanical (trauma, overuse injuries, sport injuries)
Reactive arthritis/transient synovitis (toxic synovitis, irritable hip)
Legg-Calvé-Perthes disease
Inflammatory arthritis (JIA most common)
Infection (septic arthritis, osteomyelitis)
Metabolic (e.g., osteomalacia)
Tarsal coalition
Complex regional pain syndromes
Malignant disease (e.g., leukaemia, neuroblastoma, lymphoma)
Neurological disease (hereditary syndromes, acquired conditions).
Adolescents (older than 10 years)
Mechanical (trauma, overuse injuries, sport injuries)
Slipped capital femoral epiphysis
Inflammatory arthritis (most commonly JIA)
Infection (septic arthritis, osteomyelitis)
Tarsal coalition
Complex regional pain syndromes
Malignant disease (leukaemia, lymphoma, primary bone tumour) [Figure caption and citation for the preceding image starts]: Malignant bone tumour (x-ray)From Dr Foster's personal collection; used with permission [Citation ends].
Neurological disease (later onset hereditary conditions, acquired conditions).
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