Causes of Limping in Children

Written by Prof. Dr. Levent Altınel

When does normal walking begin in children, and how does it develop?

Walking is the forward movement achieved by lifting the feet off the ground and putting them down again in a certain order and at regular intervals. One of the things parents most want to know is when their baby will walk.

For walking to happen, the brain and nervous system must develop along with the bones and muscles of the legs. Families eager to see their baby walk, or even run, towards them should expect to wait on average 12–18 months, because before this period children usually go through a preparatory stage we call crawling. Crawling varies greatly from baby to baby: some crawl at 6–9 months, while others never crawl. All of this is normal.

The age at which children start walking completely unsupported can extend to 18 months. This varies from baby to baby, and the family's approach can also affect when the baby starts walking. If the child is still not walking after 18 months, or if there is unevenness or limping from the moment the child starts walking, this is a sign of a problem.

Children who have just started walking keep their legs apart to maintain balance. Later, a tiptoe, quick walking pattern is acquired. If a baby walker is used in this period and set too high, the transition from tiptoe walking to flat-foot walking can take a long time. With prolonged tiptoe walking it is advisable to see a doctor so as not to miss other underlying diseases. However, it should not be forgotten that the transitions between these walking stages can differ in every child.

When should I see a doctor if my child is limping?

If a child is limping, a doctor should be seen as soon as possible. However, limping is very often caused by minor injuries or a simple fall or knock and heals by itself. If it lasts longer than a week and does not get better on its own, an orthopaedic specialist must be consulted. The most common causes of limping in children are muscle injuries or fractures after trauma. Apart from these, the child's age group must be taken into account when investigating the cause, because some diseases are more common at certain ages. The causes of limping can be classified by age as follows:Causes of limping by age

To find the cause of the limp, your doctor will ask you about the pregnancy, the birth and any illnesses the child has had since birth. The family's role in finding the cause is also important. The family should report the child's general condition, any weight loss or fever, and whether the child has recently had an infection. The family should observe how the child walks, how they behave in their sleep and which parts of the body are tender, and be able to tell the doctor about this. Having noted when the limp began, how it has progressed, and any trauma or possible causes will help the doctor make the right diagnosis.

Causes of limping in children aged 1–3

When limping is painful, the child changes their gait to relieve the pain. The child uses the painful leg with quick, soft steps and shortens the time it is in contact with the ground. This gait, which keeps the child on the healthy leg for longer, is called an "antalgic gait". In disc and vertebral infections of the lumbar spine, the child walks very slowly and guardedly, or does not want to walk at all.

The most common causes of painful limping in children aged 1–3 are: a foreign body in the foot, ankle sprain, crush injuries, undisplaced fractures of the upper shin bone and ankle, ingrown toenail, transient synovitis of the hip, joint infection (septic arthritis) and bone infection (osteomyelitis).

First, if there are signs of trauma and tenderness is found in a particular area on examination, an X-ray is taken to determine whether there is a fracture or crack.

If there are no signs of trauma, the first thing to do is to determine whether an infection is causing the painful limp. Because these diseases show the same signs at first, they cannot be told apart clinically. For this distinction it is important that the child has not been given antibiotics. Clinical follow-up, additional laboratory tests and imaging can also be used in the differential diagnosis.

Septic arthritis (bacterial joint infection):

Septic arthritis is one of the emergencies of orthopaedics. Bacteria that reach the joint through the bloodstream, or rarely directly through the skin, multiply in the joint and quickly cause joint damage.

The child usually has a high fever, severe joint pain and restlessness. The child usually lies on their back, keeping the affected leg bent and not moving it at all. First the child's history is taken from the parents, asking about any trauma or accompanying infection. Blood tests show markedly raised C-reactive protein (CRP), sedimentation rate and white cell count. However, the onset of septic arthritis can be confused with transient synovitis, so care is needed. When in doubt, joint fluid must be sampled. In septic arthritis the white cell count in the joint fluid is 80,000–200,000, more than 75% of which are polymorphonuclear leukocytes (PMN). Seeing bacteria in the fluid confirms the diagnosis. As soon as the diagnosis is made, urgent surgical opening and washing out of the joint prevents disability. Antibiotic treatment is given in addition to surgical drainage and washout.

Osteomyelitis (bone infection):

Bone infection develops after bacteria enter the bone. Especially in children aged 1–3, it shows itself with local pain, swelling and the child not moving the leg (pseudo-paralysis). In adolescents the course may be quieter. If not diagnosed and treated early, it can leave permanent disability.

Transient synovitis (toxic synovitis, "irritable hip")

Although it can also occur between 1 and 3, it is more common than septic arthritis between the ages of 3 and 8. There is no definite cause; it is often due to viruses. Transient synovitis starts suddenly, and there is often a history of a viral upper respiratory infection in the previous 2 weeks. On examination there is limping and restricted joint movement. Depending on how badly the joint is affected, it may appear as a limp or sometimes as an inability to walk at all. The temperature rarely exceeds 38°C.

Transient synovitis is often confused with septic arthritis. Transient synovitis heals without after-effects, whereas septic arthritis can cause disability, so the two must be distinguished. A low temperature, absence of systemic illness, near-normal laboratory values, normal imaging and gradual settling without flare-ups during follow-up distinguish transient synovitis from septic arthritis. If in doubt, joint fluid is sampled and examined; in transient synovitis the white cell count and the PMN ratio are much lower than in septic arthritis.

Transient synovitis is treated with non-steroidal anti-inflammatory pain-relief syrups. The child's condition is followed daily. Bed rest helps the symptoms improve quickly. The problem usually resolves completely within 7–10 days.

Discitis

It usually affects children between 6 months and 4 years. Discitis is an inflammation of the discs of the spine, most often the L3–L4 discs. It can disturb walking by causing back and low back pain. When asked to bend forward, the child cannot do so and bends the knees while keeping the back straight. The child usually does not look ill, but the sedimentation rate is often raised. It is usually difficult to diagnose with X-rays in the early period, and scintigraphy or MRI may be needed. Antibiotics are used for treatment.

Juvenile rheumatoid arthritis

One of the most important causes of chronic restricted movement in children is juvenile rheumatoid arthritis. Juvenile rheumatoid arthritis (JRA) is one of the most common rheumatological diseases of childhood. It is a long-term disease presenting with joint inflammation and occurs in 15–20 of every 100,000 children. Because it can take very different forms, diagnosis is quite difficult and it is often confused with other diseases. It usually causes a slight limp in children around the age of 2; it is 4 times more common in girls and most often affects the ankle and knee. The joints become swollen and red.

In the early stages the white cell count, sedimentation rate and rheumatoid factor may be normal, but they rise later. The child should be referred to a paediatric rheumatologist for treatment.

Neuromuscular diseases:

If the child's walking is abnormal or the child has not started walking after 18 months, a neurological disease should be considered. Illnesses and accidents during pregnancy, the child's development in the womb, problems at birth and the child's development after birth are asked about. The most common neuromuscular disease is mild cerebral palsy (spastic child).

These children often have a history of prematurity, difficult birth, low birth weight, incubator care, or jaundice or infection after birth. It results from damage to the part of the brain that controls the muscles due to lack of oxygen during birth. Signs vary according to the location and extent of the brain damage and are usually noticed in infancy or by the pre-school years at the latest. On examination there is increased muscle tone (especially in the calf muscles), abnormal reflexes, abnormal posture, involuntary movements, unsteady walking and a limp that increases when running. In a child of walking age, cerebral palsy can usually be diagnosed by clinical observation.

Developmental hip dislocation (congenital hip dislocation)

Developmental hip dislocation is a disturbance, to varying degrees, of the relationship between the femoral head and its socket (acetabulum) in the hip joint. Formerly called "congenital hip dislocation", it can lead to permanent disability if not diagnosed and treated early. It must always be suspected when a child of walking age has a painless limp. There is usually mild pain and an increasing limp after prolonged activity. Diagnosis is made by X-ray. When diagnosed in a walking child, surgery is needed to put the hip back in place or improve the roof of the socket.

Malignancies / acute lymphoblastic leukaemia (ALL)

Acute lymphoblastic leukaemia (ALL) is a malignant disease arising from the body's blood-forming system. It appears in the bone marrow, where blood is made, and usually shows itself by excessive production of immature white blood cells. Acute leukaemia is the most common cancer in children under 16, peaking between the ages of 2 and 5, and is more common in boys. In one study, limping was found in 12% of children with leukaemia. General signs may include pallor, high fever, spots and bleeding. Blood tests show anaemia, a raised or lowered white cell count and a raised sedimentation rate, but these findings are hard to distinguish from infection. If in doubt, the child must be seen by a paediatric haematologist. In a child of this age with long-lasting limping, leukaemia should be kept in mind.

Causes of limping in children aged 4–10

Diagnosis is easier in this age group, because it is possible to communicate with the child and the child has acquired an adult walking pattern.

Transient synovitis

This is the most common cause of limping in children aged 3–8. It must be distinguished from septic arthritis and early Legg-Calvé-Perthes disease.

Legg-Calvé-Perthes disease

Perthes disease develops after the blood flow to the femoral head temporarily stops. Disrupted blood flow causes damage (necrosis: bone death) to part or all of the femoral head. The body removes this dead bone and makes new bone. During this rebuilding the bone softens and weakens, and fractures and collapse occur within the head. While rebuilding, the femoral head may take an abnormal shape and protrude from the socket. Treatment aims to keep the femoral head within the hip socket so that it develops a round shape.

Perthes disease, usually seen between 4 and 10, has a better outcome the earlier it starts. At first the child limps but has no pain; as the condition worsens, pain accompanies the limp and joint movement becomes progressively restricted. At the start of the disease X-rays are normal, so it must be distinguished from transient synovitis. Bone scintigraphy and MRI show changes in the femoral head earlier than plain X-rays. The main goal of early treatment is to preserve joint movement. Rest and anti-inflammatory drugs are recommended, especially in painful periods; later, operations on the femoral head are performed. The course of Perthes disease is 2–2.5 years.

Discoid meniscus

This is a rare congenital condition in which the meniscus is half-moon or disc-shaped rather than C-shaped. It is more prone to injury than a normal meniscus and is usually seen in the outer meniscus. Patients with a discoid meniscus may never have problems, but usually in childhood there is a feeling of discomfort with a clicking sound in the knee, and symptoms increase with activity. Usually between 3 and 12 years of age the discoid meniscus tears, causing pain and locking. The diagnosis is confirmed by MRI. In treatment, the discoid meniscus is reshaped arthroscopically to a normal form.

Leg length differences

Length differences of less than 1 cm are not noticed by the body, but walking may be affected over time as the difference increases. There are many causes of leg length difference: congenital problems (idiopathic hemiatrophy, hemihypertrophy), or trauma, infections, tumours and metabolic bone diseases that damage the growth plates. Congenital deficiencies are noticed immediately after birth, while other developmental disorders usually become apparent between the ages of 4 and 10.

Causes of limping in children aged 11–15

This age group is the easiest to communicate with, but because of issues such as school problems they may exaggerate their complaints or not mention them. A more careful examination is therefore needed.

Overuse syndrome

This is common in sporty children. It presents with pain where tendons attach to bone. In this period, accelerated growth and increased athletic activity can lead to overuse of the lower limbs, causing a limp. The knee is affected most: the tibial tuberosity (Osgood-Schlatter disease) and the patellar tendon (jumper's knee) become inflamed. Short-term rest and non-steroidal anti-inflammatory drugs are used for treatment.

Slipped capital femoral epiphysis

This is common in boys aged 12–15. It is a slipping of the growth cartilage of the femoral head and can be acute or chronic. In the acute form there is severe pain and the patient cannot walk. In the chronic form the pain is milder and increases with activity and loading. Pain is felt in the groin and knee. On examination the hip moves abnormally: when it is bent, it rotates outward, because the femoral head has slipped backward and downward relative to the femoral neck. For the same reason inward rotation of the hip is limited. The acute form needs emergency treatment. If not treated, the limp becomes permanent.

Osteochondritis dissecans

This is a fragment of joint cartilage breaking off into the joint. It usually appears in adolescence and causes pain, limping and occasional locking of the knee. The damage is most often on the outer side of the inner condyle of the knee, followed by the ankle and hip joints. Treatment depends on the size and location of the defect: small defects are treated with closed arthroscopic multiple drilling, while large defects involving the joint surface are treated with cartilage transfers.

Idiopathic chondrolysis of the hip

This is described as dissolution of the joint cartilage. It is a rare disease that can be seen in girls aged 12–14. There is hip pain and restricted movement. Treatment consists of NSAIDs and hip range-of-motion exercises.

Tarsal coalition

Seen in less than 1% of people, tarsal coalition is an abnormal connection between the tarsal bones at the back of the foot. The connection is made of bone, cartilage or fibrous tissue and can cause restricted movement in one or both feet and pain in the mid- and hindfoot. Tarsal coalition is congenital; more rarely it can be caused by infection, arthritis or old injuries in this area.

Although most people with tarsal coalition are born with it, symptoms usually do not appear until the bones mature (between 9 and 16). Initial treatment is non-steroidal anti-inflammatory drugs and immobilisation. In patients who do not respond, the tissue causing the coalition is removed surgically.

Osteoid osteoma

It is usually seen between the ages of 5 and 30. Osteoid osteoma is a benign bone tumour, accounting for 10% of benign bone tumours. It is more common in childhood and 2–3 times more common in boys than girls. It usually affects long bones (shin bone, thigh bone, arm bones), but can occur in other bones too. Clinically it causes local pain; pain at night that responds to painkillers such as aspirin is typical. CT and scintigraphy are important for diagnosis. The pain goes away when the tumour is removed surgically.

The information on this page is for general information only and does not replace an examination and diagnosis.