An antalgic gait results from pain in one extremity that causes the patient to shorten the stance phase on that side with a resultant increase in the swing phase. The most common causes of an antalgic gait are trauma or infection.
A Trendelenburg gait is a downward pelvic tilt away from the affected hip during the swing phase as a result of weakness of the contralateral gluteus medius muscle (Barkin, Barkin, & Barkin, 2000). The gait disturbance is commonly observed in children with developmental dysplasia of the hip, Legg-Calvé-Perthes disease, or slipped capital femoral epiphysis. If the involvement is bilateral, a waddling gait results (Barkin et al.).
A steppage (equinus) gait is a result of the inability to actively dorsiflex the foot, with exaggerated hip and knee flexion during the swing phase. A steppage gait is seen in children with neuromuscular diseases (eg, cerebral palsy) that cause impairment of dorsiflexion of the ankle (Kost, 2000).
A vaulting gait occurs when the knee is hyperextended and locked at the end of the stance phase and the child vaults over the extremity (Clark, 1997). A vaulting gait is seen in children with limb length discrepancy or abnormal knee mobility (Kost, 2000).
A stooped gait is characterized by walking with bilaterally
increased hip flexion (Clark, 1997). A stooped gait is common in children
with pelvic or lower abdominal pain (Kost, 2000).
Table 1. Causes of Limping in Children
Fractures Sprains/strains Contusion Child abuse Overuse injuries
Legg-Calvé-Perthes disease Slipped capital femoral epiphysis Benign hypermobility syndrome Chondromalacia patellae Developmental dysplasia of the hip Limb length discrepancy
Toxic synovitis Osteomyelitis Septic arthritis Diskitis
Rheumatic diseases Hematologic disorders Neoplastic diseases Intra-abdominal disorders Conversion disorders
A slipped capital femoral epiphysis is caused by dislocation of the femoral head from its neck and shaft at the level of the upper epiphyseal plate. The condition typically affects obese adolescent boys. Black children are more predisposed to slipped capital femoral epiphysis than are White children (Clark, 1997). The characteristic pain occurs in the affected hip and/or the medial aspect of the ipsilateral knee. Limping is the most common symptom (Connolly & Treves, 1998). Obligatory external rotation of the hip with flexion is characteristic.
The benign hypermobility syndrome is a common cause of evening limb pain, which may result in a limp. The condition can be detected by checking for hyperextension and laxity of the joints.
Chondromalacia patellae is common in adolescents. The condition is a result of misalignment of the patella in the femoral groove, producing abnormal shear forces on the patellar cartilage. The pain is usually retropatellar and aggravated by stair climbing.
Developmental dysplasia of the hip is more common in breech deliveries (Alexander, FitzRandoph, & McConnell, 1987). The female to male ratio is 8:1 (Alexander et al.). Despite careful screening in the neonatal period, some cases remain undetected until the time walking commences. When developmental dysplasia of the hip appears at walking age, the child has a Trendelenburg gait, decreased hip abduction, and thigh pistoning. In bilateral cases the child has a lordotic, swaying, "drunken sailor" (waddling) gait that is pathognomonic (Lawrence, 1998).
Leg length discrepancy of greater than 3% may cause a
limp (Barkin et al., 2000). When the discrepancy is greater than 5.5%,
the compensatory gait is often manifested by toe-walking on the side of
the shorter limb (Song, Halliday, & Little, 1997).
Osteomyelitis is most common in children 3 to 12 years of age and is most often caused by Staphylococcus aureus. The infection usually occurs by hematogenous spread. Osteomyelitis usually involves the metaphysis of the long bone and is associated with tenderness, redness, warmth, and swelling over the lesion, as well as systemic signs, such as fever and toxicity. The organisms causing septic arthritis are basically the same as those causing osteomyelitis. Septic arthritis is the most common cause of severe monoarticular pain (Sherry, 1999), with the hip being the most common site of infection (Wang, Wang, Yang, Tsai, & Liu, 2003). The affected joint is often erythematous, swollen, and tender.
Diskitis is an inflammatory disease of the intervertebral
disk space that occurs almost exclusively in children (Clark, 1997). The
pain often radiates to the legs, causing a limp or refusal to bear weight.
Exquisite tenderness is noted when the involved vertebrae are palpated.
Table 2. Causes of Limping in Children at Different Ages
Birth to 3 years
Septic arthritis Osteomyelitis Fractures Developmental dysplasia of the hip Congenital limb length discrepancy
Ages 4 to 10 years
Septic arthritis Osteomyelitis Toxic synovitis Fractures Legg-Calvé-Perthes disease Juvenile rheumatoid arthritis Leukemia
Ages 11 to 18 years
Sprains/fractures Slipped capital femoral epiphysis Osgood-Schlatter disease Overuse syndromes Tumors Osteomyelitis
Sex. Developmental dysplasia of the hip is more common in girls, whereas Legg-Calvé-Perthes disease and slipped capital femoral epiphysis are more common in boys (Clark, 1997; Sty et al., 1998).
Chronicity of the Limp. An acute onset of a limp suggests trauma or infection. A gradual onset with progression of the limp suggests a neuromuscular disorder, Legg-Calvé-Perthes disease, slipped capital femoral epiphysis, rheumatic disease, or malignancy. A chronic limp is often mechanical or psychogenic in nature.
Recent Trauma or Strenuous Exercise. A history of recent trauma should be sought but may be difficult to obtain in very young children. On the other hand, obvious trauma in the absence of a consistent history raises the question of child abuse. Limping after strenuous activity suggests a musculoskeletal etiology.
Associated Symptoms. If pain is associated with the limp, its exact location and character should be explored. Pain is usually severe and consistently reproducible or localized in fractures, dislocations, osteomyelitis, and septic arthritis (Lawrence, 1998). One must bear in mind that referred pain is not uncommon in children; as a result, hip pathology may present as knee pain and pain from the lower back can be referred to the lateral thigh (Lawrence). A painful limp without localization or with migratory bone pain is seen in patients with sickle cell disease or leukemia (Kost, 2000). Limping with bilateral leg pain localized to the calf muscles suggests myositis (Kost). Muscle pain is more aching in nature, whereas nerve pain is often described as burning or tingling in nature. Increasing pain with joint motion suggests a joint problem. Severe pain out of proportion to the history of injury suggests reflex sympathetic dystrophy. A painless limp may result from limb length discrepancy, developmental dysplasia of the hip, or a neuromuscular disease. Fever suggests an infectious or inflammatory process. Recurrent fever, rash, and joint pain suggest juvenile rheumatoid arthritis. Patients with occult malignancy many have a history of low-grade fever, weight loss, and malaise. Unexplained bruising in the lower extremities, joint pain, and abdominal pain suggest Henoch-Schönlein purpura (Robson & Leung, 1994). A deterioration of gait or loss of acquired motor skills is suggestive of a neuromuscular disease.
Precipitating or Relieving Factors. Morning stiffness and a limp that is worse in the morning suggest juvenile rheumatoid arthritis. A limp that worsens with activity suggests soft tissue strain, stress fracture, benign hypermobility syndrome, or overuse injury. The pain of osteoid osteoma is relieved by aspirin. Pain that worsens throughout the day is typical of muscle fatigue.
Past Health. Significant illnesses such as juvenile rheumatoid arthritis and leukemia should be noted.
Family History. A family history of hemophilia or sickle cell
disease suggests the corresponding disorder.
Musculoskeletal Examination. Observing the gait pattern is important because it often gives clues to the underlying diagnosis. This observation should be done with the child walking barefoot and wearing as little clothing as possible. The musculoskeletal examination should include evaluation for skin color, warmth, tenderness, soft tissue/joint swelling, joint laxity, muscle strength, range of motion, and symmetry. The limb lengths should be measured from the patient's anterior superior iliac spine to the medial malleolus. Point tenderness over a bone may indicate a fracture or osteomyelitis. Tenderness over the anterior aspect of the tibial tubercle points to Osgood-Schlatter disease. Muscle atrophy suggests a neuromuscular disorder. Hyperextensibility of joint is seen in the benign hypermobility syndrome. Stiffness of the joints is characteristic of chronic joint inflammation. A stiff, tender spine suggests diskitis (Leet & Shaggs, 2000). A positive FABER test (hip flexion, abduction, and external rotation), performed by placing the ipsilateral ankle on the contralateral knee and applying gentle downward pressure on the ipsilateral knee, signifies sacroiliac joint pathology (Leet & Shaggs).
Neurologic Examination. Sensation, deep tendon reflexes, and spasticity should be assessed. Hyperreflexia and spasticity raise the suspicion of cerebral palsy. Tightness of the hamstring muscles with a limited straight-leg raise is suggestive of a spinal problem (Lawrence, 1998).
Associated Signs. Ecchymosis and puncture wounds suggest that
trauma is the cause of the limp. A midline defect, mass, dimple, or hairy
patch along the spine should lead the clinician to include spinal dysraphism
in the differential diagnosis. Pallor, fever, an appearance of being ill,
generalized lymphadenopathy, and hepatosplenomegaly might lead to the diagnosis
of malignancy, chronic infection, or rheumatic disease. A photosensitive
rash is suggestive of systemic lupus erythematosus or juvenile dermatomyositis
Radionuclide bone scintigraphy is much more sensitive for detecting occult fracture, osteomyelitis, diskitis, avascular necrosis, bone infarct, and neoplasm (Arsonson, Garvin, Seibert, Glasier, & Tursky, 1992; Connelly & Treves, 1998; Lawrence, 1998; Sherry, 1999). Ultrasound is helpful in detecting joint effusion or abscess (Barkin et al., 2000; Meyers & Thompson, 1997). Computed tomography scan is an excellent imaging modality for cortical bone (Kost, 2000). A CT scan also is useful in defining intrapelvic problems and spinal pathology (Dabney & Lipton, 1995). Magnetic resonance imaging is useful in diagnosing diskitis and spinal cord tumor (Barkin et al., 2000).
A complete blood cell count with differential, erythrocyte sedimentation
rate, and C-reactive protein are indicated when an infection is suspected.
The complete blood cell count also will give clues to the diagnosis of
hemoglobinopathy, chronic infection, and malignancy. Blood cultures should
be performed in children with osteomyelitis or septic arthritis. Children
with an infection associated with a joint effusion may require arthrocentesis
for definitive diagnosis (Sty et al., 1998). Tests of muscle enzymes such
as creatine phosphokinase should be ordered if myositis is suspected.
Limping in children is never normal. Physicians providing care to children
need to be knowledgeable regarding the diagnosis and management of limping.
A systematic approach should include a thorough history and physical examination,
and, if necessary, appropriate imaging studies and laboratory testing.
A timely diagnosis will result in a more optimal outcome.
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