Paediatric Limping Gait

Original Editor - Stacy Schiurring based on the course by Krista Eskay
Top Contributors - Stacy Schiurring, Jess Bell and Naomi O'Reilly

Introduction

"A limp is defined as any deviation from a normal gait pattern for the child’s age ... The causes of limping are numerous, ranging from trivial to life-threatening conditions. The limping child is often a diagnostic enigma. The challenge is to make an appropriate diagnosis in a timely fashion without exposing the child to unnecessary diagnostic studies." - Leung and Lemay, 2004

A limping gait is not typical in the paediatric population. Trauma (e.g. contusions, sprains and strains) is the most common cause of limping in children. While paediatric limping is often self-limiting, a limping gait can be a sign of certain life-threatening medical conditions. Therefore, it is crucial that rehabilitation professionals can differentiate between different causes of limping in children and know when to refer to medical colleagues.

Limping Gait Differential Diagnosis

Clinical Spotlight: "Growing Pains"

"Growing pains in children are characterised by intermittent poorly localised nocturnal pains in children, usually affecting the legs without any obvious cause. This condition is fairly common presentation in primary care set-ups and the parents often seek consultation of the primary care physicians or family doctors. As per Nelson’s text book of paediatrics, [growing pain] affects about 10–20% of children."

According to the literature, there is no clear definition of growing pains, and many different causes have been proposed. However, these causes are either poorly supported by research, or there is inconsistent evidence. These include:

1. anatomic causes (e.g. hypermobility, genu valgum, low bone mineral density)
2. psychological causes
3. vascular causes
4. metabolic causes (e.g. low vitamin D levels)

Gait Observation

There are three major features of limping in children: (1) pain, (2) weakness, and (3) structural or mechanical abnormalities of the spine, pelvis, and lower extremities. It is important that rehabilitation professionals understand a typical gait pattern and childhood development in order to identify abnormal movement patterns for gait differential diagnosis. Please review the following articles as needed:

• Gait
• Gait deviations
• Gait development

Identifying an abnormal gait pattern may help clinicians determine the aetiology of the limping gait. Table 2 describes different gait patterns and common causes of these patterns.

Table 2. Observational gait analysis for differential diagnosis of limping in children

Gait Pattern	Description/Clinical Observations	Common Causes
Antalgic gait	Shortened stance phase on the painful limb resulting in an increased swing phase on the other limb tenderness decreased range of motion	Trauma Infection
Trendelenburg gait	Downward pelvic tilt during the swing phase away from the involved hip	Weakness of the contralateral gluteus medius muscle developmental dysplasia of the hip Legg-Calvé-Perthes disease slipped capital femoral epiphysis Bilateral involvement results in a waddling gait
Lurching gait (posterior lurching gait, abductor lurch)	Posterior trunk lean with a hyperextended hip seen at loading response during the stance phase of gait	Weakness of gluteus maximus muscle developmental dysplasia of the hip Cerebral palsy
Steppage (equinus) gait	Exaggerated hip and knee flexion during the swing phase of gait secondary to a lack of active dorsiflexion of the foot	Heel-cord contracture Neuromuscular diseases, such as cerebral palsy Idiopathic toe walker Clubfoot *** a neurological examination is indicated ***
Vaulting gait	Weight-bearing knee locked in hyperextension at the end of stance phase, requiring the child to "vault" over the stance extremity	Leg length discrepancy (inequality) Abnormal knee mobility
Circumduction gait	The involved limb is moved in a semi-circular movement utilising a combination of hip hiking, forward rotation of the pelvis, and abduction of the hip in order to clear the swinging limb over the ground	Painful foot Leg length discrepancy (inequality) *** a neurological examination is indicated ***
Stooped gait	Bilateral hip flexion throughout the gait cycle	Pelvic or lower abdominal pain

Infection

Key clinical indication: fever

Transient Synovitis

"Transient synovitis is an acute, non-specific, inflammatory process affecting the joint synovium."

• Common cause of hip and leg pain in children
• A benign and self-limiting condition
• Inflammation and pain tend to be short-lived
• Most common in children under the age of 10 years

Clinical signs: fever without elevated leukocytes in the white blood cell count (WBC).

Potential rehabilitation examination findings

• Mild range of motion limitations of hip abduction and internal rotation
• Position of comfort = hip in a flexed, abducted, and externally rotated position
• Provocative testing includes performing a basic log roll or the Patrick (FABER) test

Aetiology

• Exact aetiology is unknown
• In the paediatric population, it is common to have a history of recent upper respiratory tract infection, pharyngitis, bronchitis, or otitis media
• Other potential aetiologies include recent traumatic injury or viral symptoms, including vomiting, diarrhoea, or common cold symptoms

Interventions

• Inflammation typically resolves on its own within seven days to two weeks

Role of rehabilitation:

• Energy conservation and activity limitation/modification
• stretching
• Pain management (however, pain typically self-resolves within 24-48 hours)

Septic Arthritis

"Septic arthritis is joint inflammation secondary to an infectious etiology, usually bacterial, but occasionally fungal, mycobacterial, viral, or other uncommon pathogens."

• The knee and hip are joints commonly affected in children
• Usually monoarticular (involving one large joint such as the hip or knee) but can be polyarticular (involving multiple or smaller joints)
• While uncommon, septic arthritis can pose an orthopaedic medical emergency, potentially resulting in significant joint damage. In these cases, early diagnosis and treatment are critical for preserving joint function
• Most common in children under the age of 5 years

Clinical signs: fever with elevated leukocytes in WBC, resistance to move the affected joint, joint pain, joint warmth, and significant swelling of the involved joint.

Potential rehabilitation examination findings

• Limited joint range of motion
• Painful joint palpation

Aetiology

• Most often caused by a bacterial organism in children
• Can occur after a foreign object penetrates a joint

Interventions

• Joint aspiration (draining)
• Management with antibiotics
• Severe cases may require joint immobilisation for up to three days
• Proper medical treatment resolves symptoms within a week. However, the patient should return for medical reassessment if no improvement is seen within five to six days

Role of rehabilitation:

• If symptoms are first noted in the therapy clinic, refer to a doctor or the emergency room right away, as septic arthritis can be a medical emergency
• After medical treatment:
  • regaining range of motion
  • improving weight-bearing tolerance and ability
  • gait training

Osteomyelitis

"Bone infection is called osteomyelitis ... Healthy intact bone is resistant to infection. The bone becomes susceptible to disease with the introduction of a large inoculum of bacteria, from trauma, ischemia, or the presence of foreign bodies".

• Acute hematogenous osteomyelitis affecting the metaphysis of the long bones occurs more frequently in children than adults. In adults, the vertebrae are more commonly involved. The knee is most commonly affected in children - areas commonly affected include the distal femur and proximal tibia
• Most common in children under the age of 3 years
• Requires immediate referral and medical intervention with treatment beginning as soon as possible

Clinical signs

• Localised bone tenderness
• High fever and chills
• Significant swelling of the joint
• Reluctance to bear weight through the involved limb
• Significant laboratory findings will include elevated leukocytes, elevated erythrocyte sedimentation rate (ESR) and elevated C-reactive protein (CRP)

Potential rehabilitation examination findings

• If lower extremity bones are involved: difficulty with weight bearing
• Pelvic bone involvement: able to weight bear to some degree, may display a waddling gait pattern
• Vertebral bone involved: back pain, point tenderness, limited flexion or extension, and potentially a change in spinal curvature
• The child may also report a recent minor blunt trauma to the affected area

Aetiology

• Often associated with a bloodborne infection
• Most commonly a bacterial infection caused by Staphylococcus aureus, but can also be viral, fungal, or parasitic in origin

Interventions

• Effective treatment of osteomyelitis requires both medical and surgical specialities:
  • surgical debridement of all diseased bone is often required and, at times, repeated surgical debridement is indicated
  • prolonged and targeted antibiotic therapy is "the cornerstone of treatment for osteomyelitis"
• Vacuum-assisted wound closure devices can be effectively utilised to speed the closure of large or deep wounds resulting from extensive debridement
• Medical treatments can be required for as long as two months

Role of rehabilitation:

• After medical treatment:
  • regaining range of motion
  • improving weight bearing tolerance and ability
  • gait training

Special topic: Kocher criteria

According to Jowkar et al., the Kocher criteria can be useful in differentiating between septic arthritis of the hip and transient synovitis as a cause of limping gait in children. A 2022 study by Bisht et al. found that a modified Kocher criteria can also be useful for predicting a diagnosis of septic arthritis of the knee.

The Kocher criteria:

1. Unable to weight bear
2. Temperature > 38.5°C / 101.3°F
3. Erythrocyte sedimentation rate (ESR) > 40mm/hr
4. White blood cell count (WBC) > 12,000 cells/mm3

Scoring for the Kocher criteria is as follows:

• + 1 criterion - 3% probability for septic arthritis
• + 2 criteria - 40% probability for septic arthritis
• + 3 criteria - 93% probability for septic arthritis
• + 4 criteria - 99.6% probability for septic arthritis

The Modified Kocher criteria includes the added category of C-reactive protein (CRP) >2.0 mg/dL.

When using the modified Kocher criteria, the combination of an inability to bear weight and an elevated CRP has a significant association with septic knee.

Vascular Causes

Key clinical indications: no fever or history of a traumatic event.

Legg-Calvé-Perthes Disease

Also known as: coxa plana, Legg-Perthes, Legg Calvé, Perthes disease

Legg-Calvé-Perthes disease is idiopathic osteonecrosis or idiopathic avascular necrosis of the capital femoral epiphysis of the femoral head.

• Most common in children aged 3-12 years, with the highest rate of occurrence at 4-8 years
• Male to female ratio 4:1 to 5:1
• Other risk factors include (1) low socioeconomic status, (2) dietary issues, (3) secondhand smoke exposure, and (4) perinatal human immunodeficiency virus (HIV) infection

Clinical signs

• Sudden onset of limping gait without fever, swelling, or recent traumatic event
• Antalgic gait in the acute phase progresses to Trendelenburg gait in the chronic phase
• Subjective report of pain: initially, may have no complaints of pain, but as the disease progresses, may report pain with activity
  • if pain is present, it is often localised to the hip or referred to the knee, thigh, or abdomen
  • pain with hip rotation commonly refers to the anteriomedial thigh and / or knee

Potential rehabilitation examination findings

• Decreased hip abduction and internal (medial) rotation range of motion
• Disuse atrophy of the thigh and buttock musculature
• Leg length discrepancy

Aetiology

• The exact aetiology is unknown - it may be idiopathic or caused by another mechanism that disrupts blood flow to the femoral epiphysis, such as trauma, coagulopathy, or steroid use

Interventions

Interventions for Legg-Calvé-Perthes disease will depend upon the age of the patient and the disease stage at which it is identified. There are multiple classification and staging systems for Legg-Calvé-Perthes disease. Two widely used systems are outlined in Tables 3 and 4 below.

Table 3. Waldenstrom classification

	Stage Name	Findings	Timeframe
1	Initial or Necrosis Stage	Blood supply to the femoral head is disrupted Bone cell death begins Region becomes highly inflamed Limping gait will begin during this phase	Up to 6 months
2	Fragmentation Stage	Necrotic bone removed, new bone formation occurs New bone growth is weaker, and the femoral head is suspectable to compression into a flatter shape Acetabulum shape becomes irregular	1-2 years
3	Reossification Stage	The highest amount of new bone growth New bone is becoming stronger Femoral head is taking on its new shape	Longest phase, can last multiple years
4	Residual or Healed Stage	Bone regrowth is complete Femoral head achieves its final shape	Continues until skeletal maturity

The Herring classification, also known as the Lateral Pillar classification, is based on the height of the lateral pillar of the capital femoral epiphysis using anterior/posterior imaging of the pelvis. This classification system provides clinically useful and predictive prognostic information.

Table 4. Herring (Lateral Pillar) Classification

	Clinical Findings	Prognosis
Group A	Lateral pillar maintains full height No density changes identified	Good outcome regardless of age at diagnosis
Group B	Lateral pillar maintains >50% height	Poor outcome in patients with bone age > 6 years
Group B/C	Lateral pillar is narrowed (2-3mm) or poorly ossified Maintains approximately 50% height	(Recently added to increase consistency and prognosis of classification)
Group C	Lateral pillar maintains < 50% height	Poor outcomes regardless of age at diagnosis

The goals of treatment include (1) pain and symptom management, (2) restoration of hip range of motion, and (3) maintaining alignment of the femoral head in the acetabulum.

Non-operative interventions:

• Recommended patient population: children aged 6 years or younger or lateral pillar A classification
• Activity: mobility and activity limitations, including a recommendation for decreased weight-bearing, physiotherapy still indicated within activity limitations (see role of rehabilitation section below)
• Current literature does not support the use of bracing, casting, or orthotics
• Pain management, including the use of non-steroidal anti-inflammatory drugs (NSAIDS)
• Referral to orthopaedist for disease monitoring
• Up to 60% of patients will only require non-operative interventions

Operative interventions:

Femoral or Pelvic Osteotomy

• Recommended patient population: children aged 8 years or older; lateral pillar B and B/C have more successful surgical outcomes than lateral pillar A or C

Valgus or Shelf Osteotomies

• Recommended patient population: children with hinge abduction
• Outcome goal = to improve abductor mechanism

New and controversial surgical options include hip arthroscopy and hip arthrodiastasis

Role of rehabilitation:

• Outcome goals: preventing deformation of the femoral head and preserving hip range of motion
• Treatment modalities:
  • bedrest
  • traction
  • reduced weight-bearing status
  • strengthening the gluteus medius muscle
  • balance training
  • gait training within mobility precautions

Slipped Capital Femoral Epiphysis (SCFE)

"Slipped capital femoral epiphysis (slipped upper femoral epiphysis) is a common hip pathology in pre-adolescents and adolescents. It occurs when the femoral epiphysis is abnormally displaced posteriorly and inferiorly relative to the femoral head and neck."

• Most common in pre-adolescents and adolescents, with the highest rate of occurrence at 10-15 years
• Other risk factors include obesity and the male gender. It can also be associated with certain genetic predispositions
• Diagnosis can be difficult due to either an atypical presentation (i.e. knee or thigh pain) or the chronic nature of an individual's presentation
• Associated medical complications include (1) avascular necrosis and (2) chondrolysis (which according to the Pediatric Orthopedic Society of North America, is a "rapidly progressive loss of articular cartilage from both the femoral and acetabular sides of the hip") of the hip.

Clinical signs

Acute SCFE

• Common with twisting injuries or traumatic falls
• More mild complaints
• Atypical pain presentation in the groin, thigh, knee
• Limited weight-bearing tolerance on the involved side
• Position of comfort: external rotation with a "shortened" limb

Chronic SCFE

• More frequently seen
• Patient reports an ongoing history of "vague pain" in the groin or thigh
• No swelling
• Loss of hip internal rotation, flexion and abduction range of motion
• Gluteus medius weakness
• Decreased femoral anteversion
• Position of comfort: external rotation with a "shortened" limb

Potential rehabilitation examination findings

• Limited internal rotation of the involved limb
• Passive internal rotation may elicit pain
• Loss of hip internal rotation, flexion and abduction range of motion (more chronic cases)
• Positive Drehmann sign (passive hip flexion to 90 degrees causes obligatory hip external rotation)
• Gait assessment: shuffling gait, Trendelenburg gait, antalgic gait
• Atrophy of thigh musculature may or may not be present

If SCFE is suspected upon a rehabilitation evaluation or assessment, encourage the patient to reduce weight bearing, limit activities, and refer to a medical doctor as soon as possible.

There are multiple grading or classification scales for SCFE:

• The Southwick Slip Angle Classification grades the severity of SCFE based on the difference in the epiphyseal diaphyseal angle between the involved and the uninvolved (contralateral) hip, both in anteroposterior and lateral radiographs of the hip. Mild cases < 30 degrees, moderate cases 30-50 degrees, and severe cases with > 50 degrees of difference. In bilateral cases, a set reference is used for comparison: 145 degrees on the anteroposterior radiographs and 10 degrees on the lateral radiographs.

SCFE can also be graded based on the percentage of slippage. Grade I is up to 33%, Grade II 34 to 50%, and Grade III over 50%.

Aetiology

• Most cases are idiopathic
• There is an association between the development of SCFE and patients with endocrine disorders, renal disorders, and Down syndrome

Interventions

Medical interventions typically include surgical fixation with the goals of (1) decreasing femoral displacement, (2) maintaining range of motion, and (3) preventing premature degenerative arthritis.

In situ fixation with Percutaneous Screws  

• The aim is to prevent further slippage of the epiphysis
• Up to 6 weeks post-operatively: stable slips can weight bear as tolerated, unstable slips are limited to partial weight bearing status

Open Reduction and Internal Fixation (ORIF)

• The aim is to correct the femoral deformity and stabilise the epiphysis while protecting the femoral head blood supply
• Up to 6 weeks post-operatively: limited to partial weight bearing status

Femoral Osteotomy

• Indicated for more severe deformity with a slip greater than 30 to 45 degrees

Osteochondroplasty

• Indicated for mild and moderate chronic deformity cases where a prominent metaphyseal bump causes pain and restricts range of motion

Role of rehabilitation:

After medical treatment:

• regaining range of motion, especially abduction and internal (medial) rotation
• improving weight-bearing tolerance and ability
• gait training
• follow-up and reassessments throughout the patient's lifetime as they may experience degenerative changes of the involved hip later in life
• if they experience complications, such as avascular necrosis or chondrolysis, they will require guidance on how to modify activities, decrease weight bearing through the involved limb, and only do gentle range of motion to maintain motion

Activity Exacerbation

Key clinical indications: no fever with limping gait exacerbated by an increase in activity

Osteochondritis Dissecans

Osteochondritis dissecans ranges "in severity from being asymptomatic to mild pain or advanced cases having symptoms of joint instability and locking. The lesions can progress from stable to fragmentation of the overlying cartilage with the formation of a loose body in the affected joint space."

• Also known as an osteochondral lesion
• It is a local injury to the articular surface of the bone caused by the separation of the cartilage from the subchondral bone
• Most commonly occurs in the knee, but can also occur in the elbow and ankle
• Can occur throughout the lifespan, but the majority of cases occur in individuals aged 10 to 20 years
• Male to female ratio 2:1

Stable fragments (lesions): held in place by intact overlying articular cartilage. Progression of the defect to involve the overlying cartilage is possible, which leads to instability of the fragment.

Unstable fragments (lesions): may remain in place or become a loose body within the joint.

Clinical signs

• Effusion or swelling
• Pain on palpation

Potential rehabilitation examination findings

• Catching and locking during passive range of motion
• Decreased or painful range of motion

Aetiology

• The aetiology is not fully understood and is likely multi-factorial in origin
• Causes can include:
  • genetic predisposition
  • inflammation
  • ischaemia
  • spontaneous avascular necrosis
  • repetitive trauma

Interventions

Selection of treatment interventions will depend upon the (1) age at diagnosis, (2) time of presentation, (3) symptom severity, and (5) lesion stability.

Stable lesions:

• Conservative management is preferred with immobilisation and protective weight bearing
• Failure of conservative treatment may require retroarticular or transarticular drilling techniques

Unstable or displaced lesions:

• Surgical intervention is required and is typically performed arthroscopically
• The knee is the location most often requiring surgery
• Potential surgical interventions include (1) fixation, (2) debridement, (3) microfracture, and (4) cartilage grafting and / or transplantation

Role of rehabilitation:

Most often involved in the treatment of stable lesions:

• improving range of motion
• increasing weight-bearing activities and tolerance
• strengthening to knee stabilising musculature

When providing post-surgical treatment:

• pain management
• range of motion
• gradual increase in weight-bearing activities and tolerance

Osgood-Schlatter Syndrome

"[Osgood-Schlatter Syndrome] associates atraumatic, insidious onset of anterior knee pain, with tenderness at the patellar tendon insertion site at the tibial tuberosity. The condition is self-limited and occurs secondary to repetitive extensor mechanism stress activities such as jumping and sprinting."

• Also known as an osteochondrosis, tibial tubercle apophysitis, or traction apophysitis of the tibial tubercle
• A common cause of anterior knee pain in skeletally immature (male 12-15 years, female 8-12 years) athletes
• Commonly associated with soccer (football), basketball, volleyball, and is often seen in sprinters and gymnasts
• Onset is gradual and commonly associated with repetitive activities of the knee
• While the syndrome is benign, recovery can be long and result in an absence from sport

Clinical signs

• Tenderness over the tibial tubercle
• Bony lump along the tibial tubercle

Potential rehabilitation examination findings

• Slight limping or an antalgic gait

Aetiology

• Overuse injury in active adolescents
• Occurs secondary to repetitive microtraumas from the strong pull of the patellar tendon at its insertion on the relatively soft tibial tubercle apophysis
  • in severe cases, this force can cause a partial avulsion of the tibial tubercle apophysis
  • the force is increased with higher levels of activity
  • more susceptible to injury after periods of rapid growth
  • in rare cases can lead to a complete avulsion fracture

Predisposing factors include poor flexibility of (1) quadriceps and (2) hamstrings or (3) other evidence of extensor mechanism misalignment.

Interventions

The treatment intervention is determined by the pain level. Symptomatic treatment can include:

• ice
• NSAIDs
• activity modification
• relative rest from inciting activities
  

Role of rehabilitation:

Will need to gradually correct the underlying predisposing biomechanical factors in a balanced way with rest from activity and pain management:

• swelling management
• gradual strengthening activities, especially of the quadriceps
• gradual weight-bearing activities and tolerance
• stretching
• activity modification and therapeutic rest
• supportive brace as needed

Sever's Disease

Sever's disease "is a common cause of heel pain in the skeletally immature athlete. It is considered to be the result of an overuse injury to the secondary ossification center by a traction apohysitis at the Achilles tendon insertion site on the calcaneus."

• Also known as calcaneal apophysitis
• Self-limiting condition
• Often coincides with the onset of a rapid growth spurt and / or a sudden increase in sports-related activity
• More common in males, with a median age of 12 years for males and 11 years for females
• Most commonly involved sports include (1) basketball, (2) football (soccer), (3) track, (4) cross-country, and (5) gymnastics

Clinical signs

• Diagnosis is clinical and does not require imaging studies
• Complaints of heel pain, can be unilateral or bilateral and usually worse during and after activity
  • pain improves with rest and resolves by the next day after activity
• Negative for erythema or ecchymosis
• Mild swelling may be present around the Achilles insertion on the heel

Potential rehabilitation examination findings

• Tenderness over the calcaneal insertion of the Achilles insertion on the heel
• Positive squeeze test
• Aggravated by standing on tiptoes (Sever Sign)
• Lack of heel cord flexibility and / or dorsiflexion weakness
• Limping or antalgic gait

Aetiology

• Occurs secondary to repetitive microtraumas from the strong pull of the Achilles tendon at its insertion on the relatively soft calcaneal apophysis
  • in rare cases, may lead to a full avulsion fracture

Contributing factors include (1) repetitive sports activity (such as running and / or jumping), (2) heel cord tightness, (3) ankle dorsiflexion weakness, (4) poor shock absorption or supportive athletic shoes, and (5) performing on hard surfaces. Poor shock absorption can also come from biomechanical factors such as (1) genu varum, (2) forefoot varus, (3) pes cavus, or (4) pes planus.

Interventions

Interventions include activity modification and / or therapeutic rest as guided by pain.

Symptom management includes:

• ice
• anti-inflammatory medications
• heel cups or heel lifts
• immobilisation may be needed in severe cases

Role of rehabilitation:

• Heel cord stretching
• Inflammation management
• Gastrocnemius and soleus strengthening and weight-bearing activities

Resources

Clinical Resources:

• Kocher Criteria Calculator
• How to Tell a Septic Hip from Transient Synovitis

Optional Additional Reading:

• Jowkar R, Sharyf Pour Delavari M, Mohammadi M, Oladi S. Evaluation of Epidemiology and Etiologies of Acute Limping in Children Presented to the Emergency Department of Pediatric Hospital of Amirkola in Babol, Iran. Journal of Iranian Medical Council. 2021 Oct 1;4(4):244-8.