Post trauma/intense exercise causing strain syndromes Ill-fitting shoes
Hip disorders, esp. transient synovitis
Heel disorders (12–14 years)
Serious disorders not to be missed
Developmental dysplasia hip (DDH)
Foreign body (e.g. needle in foot)
Slipped capital femoral epiphysis (SCFE)
Avulsion injuries (e.g. ischial tuberosity)
Osteochondritis dissecans of knee
Duchenne muscular dystrophy
Acute viral infections
Tumour (e.g. osteosarcoma)
Juvenile idiopathic arthritis (oligo articular)
Juvenile rheumatoid arthritis
Foreign body (e.g. in foot)
Osteochondritis (aseptic necrosis):
femoral head: Perthes’ disorder
knee: Osgood–Schlatter disorder
calcaneum: Sever disorder
navicular: Köhler disorder
Myalgia = ‘growing pains’
Overuse syndrome (esp. adolescent):
Stress fractures (e.g. tibia, femoral neck, navicular)
Ask about a history of trauma, foci of infection including the skin and any unusual developmental problems. Trauma, sepsis, synovitis and DDH are perhaps the most common reasons for a child to limp and refuse to walk. A painless waddling gait suggests DDH or Perthes’ disorder.
The limp must be considered to be due to a definite organic cause. It is appropriate to focus initially on the hip. Ask about the relationship of the limp to exercise and footwear.
The hip and the knee joints should be examined carefully if the source of the limp has no specific localisation
Get the child to walk and run on the toes and heels. Note the gait and check whether it is antalgic (painful), hemiplegic (arm held out in a balancing action) or Trendelenburg (classic for DDH). Look for evidence of muscle dystrophy
Never forget to examine the soles of the feet and between the toes
FBE and ESR/CRP
needle aspiration of joint
radiological: plain X-ray, ultrasound, bone scan, CT or MRI scan.
Multiple fractures and epiphyseal separations in toddlers are highly suggestive of child battering—order a skeletal survey if suspected.
An acute limp may be due to injury, infection (osteomyelitis, septic arthritis), spinal injuries, a fracture or an irritable hip (synovitis).
Chronic cases include cerebral palsy, DDH, Perthes’ disorder and chronic SCFE.
Infections of and around the hip joint are most common in infancy. Classically, the hip is held immobile in about 30% of flexion with slight abduction and external rotation.
Hip pathology can cause pain in the ...