Limp in children

Last updated: November 27, 2025

Summary

Limp is a deviation from the normal age-appropriate gait pattern. Causes range from benign conditions (e.g., soft tissue trauma, transient synovitis) to orthopedic emergencies and serious medical conditions (e.g., septic arthritis, unstable slipped capital femoral epiphysis, malignancy, physical child abuse). Clinical features vary. The patient's age and symptom duration can help determine the most likely cause. The presence of red flag features (e.g., inability to bear weight, constitutional symptoms, nocturnal pain) suggests a serious and/or emergent underlying cause. Evaluation begins with a thorough history and physical examination. Further workup may include laboratory studies (e.g., inflammatory markers, synovial fluid analysis) and/or imaging. Management is based on the underlying cause.

Etiology

Causes of limp vary. The patient's age can help determine the most likely cause.

All ages ^[1]^[2]

Postinfectious inflammatory arthritis, e.g.:
- Transient synovitis
- Reactive arthritis
Trauma, e.g.:
- Muscular contusion
- Fracture (including toddler fracture and stress fracture)
- Foreign body in foot
Infection
Leg length discrepancy
Juvenile idiopathic arthritis (JIA)
Hemophilia or other coagulopathies ^[3]
Vasoocclusive crises ^[4]
Charcot-Marie-Tooth disease ^[2]
Abdominal causes (e.g., psoas abscess, appendicitis) ^[5]

Transient synovitis is the most common nontraumatic cause of limp in children. ^[1]

Children < 3 years of age ^[1]^[5]

Hand, foot, and mouth disease
Side effect of immunization
Toddler fracture
Physical child abuse
Cerebral palsy
Congenital conditions
- Developmental dysplasia of the hip (DDH)
- Clubfoot
- Congenital Achilles contracture
- Vertical talus
Inherited myopathies
- Progressive muscular dystrophies
- Mitochondrial myopathies

Children 3–10 years of age ^[1]

Muscle disorders
- Post-infectious myositis
- Dermatomyositis
Acute lymphoblastic leukemia
Popliteal (Baker) cyst
Legg-Calvé-Perthes disease (LCPD)
Kohler disease

Children > 10 years of age ^[1]^[2]^[5]

Slipped capital femoral epiphysis (SCFE)
Gonococcal arthritis
Joint hypermobility
- Hypermobile Ehlers-Danlos syndrome
- Hypermobility spectrum disorder
Sport injuries and overuse syndromes, e.g.:
Tarsal coalition
Subchondral bone necrosis: osteochondritis dissecans
Bone tumors, e.g.:

Clinical evaluation

Focused history ^[1]

Onset, duration, and progression of limp
Exacerbating or relieving factors
Associated symptoms
- Pain
- Any red flag features of limp in children
Relevant past history, e.g.:
- Trauma or repetitive activity
- Recent viral infection
- Risk factors for STIs
- Tick exposure
- History of breech position at delivery
Relevant family history

Focused physical examination ^[1]^[2]^[5]

Vital signs, general appearance
Height and weight
Developmental milestones
Pediatric gait assessment
Hip, knee, ankle, foot, and spine examination (See "Orthopedic examination" for details.)
- Assess for:
  - Deformity
  - Point tenderness, signs of inflammation and/or injury, mass
  - Leg length discrepancy
  - Restricted and/or painful range of motion
- Perform relevant maneuvers and tests, including:
Neurological assessment of the lower limbs, including assessment for Gowers sign
Abdominal examination

Pediatric hip pathologies often manifest as referred pain in the knee. Prompt assessment of the hip is indicated in children and adolescents presenting with nonspecific knee pain and no findings that suggest knee pathology.

Red flag features of limp in children ^[6]

The following features suggest an urgent and/or serious underlying cause:

Constitutional symptoms
Neurological symptoms
Inconsolability or severe pain
Inability to bear weight
Clinical features of compartment syndrome after trauma ^[2]
Injury inconsistent with reported mechanism
Nocturnal pain or diurnal symptoms
Palpable mass

A hip held in flexion, abduction, and external rotation may be a sign of septic arthritis of the hip. ^[1]

Diagnostics

Diagnosis may be clinical (e.g., reactive arthritis, soft tissue injury).
Obtain laboratory studies and/or imaging based on suspected underlying cause.
Consult or refer to a pediatric specialist (e.g., orthopedics) early if there is concern for septic arthritis or SCFE.

In children with symptoms localized to the hip, consider prediction rules (e.g., Kocher criteria for septic arthritis) to distinguish between transient synovitis and septic arthritis. ^[1]^[7]^[8]

Kocher criteria for septic arthritis

Laboratory studies ^[1]^[5]

Order targeted diagnostics based on the suspected etiology, e.g.:

Infection, inflammation, or malignancy
- CBC
- Inflammatory markers
Bacterial infection
- Blood culture
- Joint aspiration for synovial fluid analysis
Asymmetric arthritis, morning stiffness: diagnostics for JIA
Features suggesting Lyme arthritis: Lyme serology
Sexually active patients: gonorrhea testing

Imaging ^[5]^[9]^[10]

Initial imaging

No concern for infection ^[9]

Localized symptoms: x-ray area of interest
Nonlocalized symptoms: x-ray bilateral tibia and fibula (AP and lateral views)
Hip pathology suspected: x-ray bilateral hip joints (AP and frog-leg lateral view) ^[1]^[2]

Concern for infection ^[8]^[9]

Localized symptoms: ultrasound, x-ray, or MRI area of interest
- Hip: Ultrasound is preferred.
- Lower limbs (excluding hip): MRI is preferred.
Nonlocalized symptoms: MRI lower extremity

Additional imaging ^[9]

Consider the following if initial imaging is negative but clinical suspicion for infection persists or in the case of diagnostic uncertainty.

X-ray findings are often normal in early stages of septic arthritis, osteomyelitis, nondisplaced fracture (e.g., toddler fracture), and LCPD. ^[1]^[9]^[11]

CT is usually not recommended to evaluate limp in children because of radiation exposure and inferior soft tissue contrast compared with MRI. ^[9]

Common causes

Common causes of acute limp in children

Acute limp is defined as limp lasting < 6 weeks. ^[1]

Common causes of acute limp in children ^[6]^[7]^[12]
Disease	Clinical features	Diagnostic findings	Management
Transient synovitis ^[2]^[13]	3–8 years of age Sex: ♂ > ♀ (2:1) Preceding URI or pediatric gastroenteritis Typically afebrile Transient hip pain Limited ROM ^[1] Pain at end of ROM ^[1]^[13]	Normal x-ray ^[7] Effusion on ultrasound that typically improves over several days ^[6]	Conservative therapy Pain management in children Rest See “Transient synovitis.”
Septic arthritis ^[1]^[14]	Any age Fever > 38.5°C; ill appearing Refusal to bear weight Hip may be held in flexion, abduction, and external rotation if affected. Limited ROM ^[1] Severe pain throughout ROM ^[1]^[13]	↑ Inflammatory markers SFA: WBC > 50,000/mm³ ^[15] X-ray ^[13] May be unremarkable in early septic arthritis Possible soft tissue swelling, gas within periarticular soft tissue, and synovial effusion	Empiric antibiotics for children with septic arthritis Therapeutic arthrocentesis Urgent orthopedics consult
SCFE ^[1]^[16]	10–16 years of age ^[17] May be acute or chronic Dull hip and/or knee pain Antalgic gait Limited internal hip rotation ^[16]	X-ray ^[6] Displacement of the femoral head Widening and irregularity of physis	Non-weight-bearing ^[2] Pain management in children Urgent orthopedics referral for surgical stabilization ^[7] See “Treatment of SCFE.”
Skin or soft tissue injury ^[1]^[10]	Variable findings, e.g.: Ecchymosis and/or swelling Puncture wound Foreign body Ligament instability (e.g., in ankle sprain or knee ligament injuries)	Typically diagnosed clinically MRI: abnormality consistent with etiology	See "Sports injuries." See "Knee ligament injuries." See "Acute wound treatment." Severe injury: Refer to pediatric orthopedics.
Fracture ^[1]^[2]	Localized pain, bruising, swelling Refusal to bear weight Possible clinical features of compartment syndrome ^[2]	X-ray: fracture ^[2] See “Radiographic fracture signs.”	Initiate initial fracture management. Refer to pediatric orthopedics.
Physical child abuse ^[18]^[19]	Reported mechanism inconsistent with clinical findings Patterns suspicious for nonaccidental injuries in children See "Features and mimics of physical child abuse."	X-ray: unexpected findings (e.g., multiple fractures in different stages of healing) ^[10]	Notify child protective services. See “Management of physical child abuse.”
Osteomyelitis in children ^[1]^[8]	Fever Localized tenderness, warmth, swelling, redness Limited ROM Possible recent history of infection or injury	Blood culture: often positive X-ray: Normal in early stages Periosteal reaction, bone lucency, bone destruction MRI: bone marrow edema, cortical destruction, subperiosteal fluid collection	Antibiotic therapy Refer to orthopedics. See "Management of osteomyelitis in children."

Slipped capital femoral epiphysis Bony sequestrum

Common causes of chronic limp in children

Chronic limp is defined as limp lasting ≥ 6 weeks. ^[1]

Common causes of chronic limp in children ^[6]^[7]
Disease	Clinical features	Diagnostic findings	Management
LCPD ^[20]^[21]	4–10 years of age ^[7] Insidious onset Antalgic gait Afebrile Vague hip and/or knee pain ^[1]	X-ray ^[6]^[10] Often normal in early disease Femoral head flattening and lucency Joint space widening MRI ^[22] Bone marrow edema and epiphyseal abnormalities of the femoral head (early finding) Joint effusion	Conservative therapy: limited weight-bearing, physical therapy, bracing Surgery (e.g., femoral osteotomy) See “Treatment of LCPD.”
DDH (if untreated during early infancy) ^[2]^[23]^[24]^[25]	Hip pain, limp Limited hip abduction Asymmetrical gluteal folds Galeazzi test may be positive. ^[23]	X-ray: increased acetabular index ^[26]	Refer to pediatric orthopedics. Nonoperative management for mild symptomatic DDH ^[24]^[25] Surgical repair See “Treatment of DDH.”
Juvenile idiopathic arthritis ^[2]^[27]^[28]	Arthritis ^[29] Morning stiffness Constitutional symptoms Extra-articular manifestations	Diagnosis of exclusion ^[27] ↑ Inflammatory markers Ultrasound: effusion, synovial changes, cartilage erosion ^[30] MRI: synovitis, tenosynovitis, cartilage injury, marrow edema ^[30]	Refer to pediatric rheumatology. Treatment may include NSAIDs, intra-articular glucocorticoids, DMARDs, or biologics. See "Treatment of JIA."
Osgood-Schlatter disease ^[31]^[32]^[33]	Most commonly affects adolescents Anterior knee pain, usually unilateral Exacerbated by activity Tenderness of the tibial tuberosity	Clinical diagnosis X-ray: fragmentation of tibial tubercle ^[31]^[32] MRI: tibial tuberosity edema, apophyseal tears, bursitis ^[34]	Activity modification Oral analgesics for children Physical therapy Surgery for refractory symptoms
Calcaneal apophysitis ^[31]^[35]	Most commonly affects children 8–12 years of age Insidious onset Heel pain with running and jumping Tenderness on palpating the Achilles insertion site	Clinical diagnosis X-ray: typically normal	Rest Ice Physical therapy Oral analgesics for children Shoe modifications
Leg length discrepancy ^[1]^[36]^[37]	Often asymptomatic Hip and/or back pain Variable gait pattern (e.g., circumduction, toe-walking) ^[2] Galeazzi sign: positive	Teleoroentgenogram: length discrepancy ^[38]^[39]	Anatomical leg length discrepancy: Manage according to degree of discrepancy. ^[36] Functional limb length discrepancy: Treat the underlying cause. ^[37] See “Treatment of leg length discrepancy.”
Duchenne muscular dystrophy ^[40]	Progressive weakness Waddling gait (Duchenne limp) with bilateral Trendelenburg sign Gowers sign Calf pseudohypertrophy	↑↑ Creatinine kinase ↑ Serum aldolase Genetic analysis: dystrophin gene mutation	Pediatric specialist referral (e.g., neurology, genetics) Glucocorticoids Physiotherapy Gene-targeted treatments
Malignant bone tumors ^[41]^[42]^[43]	Localized pain Initially intermittent; progresses to pain at rest Nocturnal pain May manifest after minor trauma Constitutional symptoms Localized swelling Pathological fracture	X-ray: osteolytic and/or osteosclerotic lesions, aggressive periosteal reaction	Refer to a pediatric cancer center for multidisciplinary care.

Legg-Calvé-Perthes disease Left hip dysplasia Osgood-Schlatter disease Osteosarcoma Permeative bone lesion

Mimics

The following can cause normal variations of gait in toddlers and young children. Persistence of these beyond the period of usual resolution should prompt appropriate evaluation. ^[2]

Flexible pes planus ^[44]^[45]
Physiological genu varum or genu valgum ^[44]^[46]
Benign intoeing ^[46]

Start your trial, and get 5 days of unlimited access to over 1,100 medical articles and 5,000 USMLE and NBME exam-style questions.

Start free trial

Evidence-based content, created and peer-reviewed by physicians. Read the disclaimer

Limp in children

Summary

Etiology

All ages [1][2]

Children < 3 years of age [1][5]

Children 3–10 years of age [1]

Children > 10 years of age [1][2][5]