CURRENT CONCEPTS REVIEW Limping in childhood Hugo DE BOECK, Peter VORLAT Limp is an abnormal gait which can be caused by EVALUATION OF GAIT pain, muscular dysfunction or deformity. Limp is never normal and the cause should be established. To assess a limp, a thorough understanding of There is a long list of possible diagnoses. A complete the normal gait pattern is necessary. Children’s gait history and thorough physical examination are the pattern differs from that of an adult, and the aspect most helpful tools in sorting out the various causes of of gait changes during childhood. Normal age-rela- limping. Laboratory tests and imaging studies should be ted gait must be differentiated from gait impair- based on findings in the history and physical exami- ment. Toddlers have their own specific gait pattern. nation. Certain causes of limping must be diagnosed They walk with a wide base and at a faster cadence at the first visit. Sometimes the cause of limping than an adult. At about three years of age, the child cannot be determined, and after exclusion of any is able to stand on one foot for longer than one serious disease, the child should be observed. Many second. The adult gait pattern develops between the of them will have spontaneous resolution without ages of three and five years. Normal gait is a rhyth- treatment. mic, smooth performance. Walking can be divided into two phases : the stance phase and the swing phase. During stance phase, one limb bears all the body weight. The stance phase starts with heel stri- INTRODUCTION ke and ends with toe off. During swing phase, the foot is not touching the ground. The swing phase Limping or even refusal to walk in children are starts with toe off and ends with heel strike. The common reasons for consulting. The ability to tell trunk normally maintains a neutral position while normal from abnormal gait is of fundamental the pelvis normally rotates a small amount. During importance to the orthopaedic surgeon. The term walking each joint of the lower limbs moves limp implies an abnormal gait pattern and should through a certain range. The hip flexes slightly at be differentiated from physiologic torsional defor- heel strike. The knee flexes about 70 degrees mities, such as intoeing and outtoeing, and from during swing phase and is extended at toe off. The physiologic frontal deformities. Normal gait is dependent not only on normal and painless joints and muscles, but also on an intact neurological system. Limp normally results from From the Department of Paediatric Orthopaedics, pain, weakness or deformity. However, there is a University Hospital (A.Z.-V.U.B.), Brussels, Belgium. Hugo De Boeck, MD, PhD, Professor. long list of potential diagnoses that may produce a Peter Vorlat, MD, Resident. limp in childhood. Limping may be caused by Correspondence and reprints : Hugo De Boeck, Paediatric something as simple as a poorly fitted shoe or a Orthopaedic Department, University Hospital (A.Z.-V.U.B.), stone in the shoe, but it may also be the first mani- Laarbeeklaan 101, 1090 Brussels, Belgium. festation of a malignant neoplasm. © 2003, Acta Orthopædica Belgica. Acta Orthopædica Belgica, Vol. 69 - 4 - 2003 302 H. DE BOECK, P. VORLAT ankle moves from about 10 degrees of dorsiflexion limb and allows walking with a stiff knee. to about 30 degrees of plantar flexion (9). Circumduction can also be seen in a patient with a painful ankle, as circumduction requires less ankle movement. TYPES OF LIMP Equinus gait : Equinus gait is usually caused by heel cord contraction, which leads to the typical The most common types of limping are : toe-walking. Equinus is often associated with a Antalgic limp : This common type of limp is recurvatum of the knee during stance phase. This is caused by pain. The stance phase is shortened on characteristic of conditions such as cerebral palsy. the affected side. The child shortens the stance Steppage gait : Walking with a foot drop is the phase to prevent pain. In addition he places his foot result of weakness of the ankle dorsiflexors usual- on the painful side more cautiously onto the ly associated with peroneal neuropathy. This can be ground, and to reduce the duration of weight- seen in conditions such as Charcot-Marie-Tooth bearing, the normal leg comes forwards more disease. quickly. Calcaneus gait : The child walks on the heel. Gluteus medius limp : This type of limp results This may result from a neuromuscular disease. The from an altered hip mechanism. During the stance child with a puncture wound on the ball of the foot phase, the gluteus medius muscle contracts on the may also walk on the heel. same side and normally maintains the pelvis level. Ataxic gait : The child walks with an unsteady If the gluteus medius is insufficient the pelvis drops broad-based gait. This can be seen in conditions on the opposite side. To preserve balance, the such as Friedreich’s ataxia. patient leans the trunk toward the affected side. Cautious gait : The child walks slowly and cau- This produces a typical lurch during the stance tiously to avoid jarring his back. This is typical for phase, and this results in a gait that swings from painful diseases of the spine such as discitis. side to side. This pathologic gait pattern is referred Hysterical gait : If no obvious physical disease to as a Trendelenburg gait or an abductor lurch. A can be found after thorough evaluation, conversion Trendelenburg gait may result from changes in ful- hysteria must be considered. There are two possible crum (the hip joint) such as can be seen in conge- varieties of hysterical gait. The grotesque limp pat- nital hip dislocation or changes in the lever arm tern : the gait is bizarre, unlike any other abnormal (the femoral neck) such as in congenital short neck, gait, and associated with atypical complaints often coxa vara or from muscle weakness such as is seen out of proportion. The features are inconsistent in some neuromuscular diseases. with any organic pathology. The grotesque limp is Bilateral involvement of the gluteus medius usually easier to diagnose than the other variety. muscles leads to a waddling gait. The imitative limp : the child reproduces the limp Gluteus maximus limp : The child walks with the of a relative or a friend. The limp looks the same as trunk in hyperextension to maintain the center of the limp due to a physical disease. Evaluation may gravity behind the hip joints. This is a characteris- be confusing, and the diagnosis is made by exclu- tic gait that can be seen in Duchenne muscular sion. dystrophy. Quadriceps femoris limp : The child locks the HISTORY knee during stance phase by placing the hand on the thigh and brings his center of gravity forward. By careful history taking the long list of poten- This is a characteristic gait in conditions such as tial causes can be narrowed to a few. The age of the poliomyelitis. child is an important factor that will make certain Circumduction gait : This gait pattern is charac- diagnoses more suspect (table I). The past medical terized by excessive hip abduction during swing history and the achievement of developmental phase. Circumduction functionally shortens the motor milestones should be reviewed. The onset Acta Orthopædica Belgica, Vol. 69 - 4 - 2003 LIMPING IN CHILDHOOD 303 Table I. — Common and occasional causes of limping mild discomfort suggests a previously undiagnosed in childhood neurological or neuromuscular disease. If limp is 1-3 years associated with pain, the site of origin must be Septic arthritis localised. The toddler age group is especially chal- Osteomyelitis lenging because these children cannot verbalise Trauma - Toddler fracture their complaints. Toddlers often refuse to bear Foreign body in the foot weight and pain is poorly localised (2, 8). In child- DDH1 JCA2 ren, the pattern of referred pain seems more Coxa vara obvious than in adults. Hip pain is often referred to Discoid meniscus the inner aspect of the thigh or the knee. The histo- Discitis ry should further focus on the characteristics of the Neurologic disorder pain. Severe acute pain suggests an acute infection Malignant neoplasm or a fracture. Constant pain may result from a chro- 4-9 years nic low-grade infection or a tumoral process. Trauma Lower extremity pain and limping may be the first Transient synovitis (10, 12, 14) Legg-Calvé-Perthes manifestation of leukaemia . Septic arthritis Pain worse in the morning may be a sign of juve- Osteomyelitis nile chronic arthritis. Calcaneal apophysitis Intermittent pain and especially pain related to Köhler’s disease physical activities suggests an overuse syndrome. Accessory navicular Pain in multiple joints is a manifestation of an inf- Ingrown toenail Neurological disorder lammatory arthritis. Duchenne muscular dystrophy JCA PHYSICAL EXAMINATION Lyme arthritis Benign bone lesion The physical examination should start with an Malignant neoplasm overall assessment. The temperature should be 10-15 years recorded, and if the child appears systematically ill, Trauma-stress fracture an infection or even leukaemia should be conside- Overuse syndrome SCFE3 red. Many things can be learned by simply obser- Freiberg’s infarction ving the child stand and walk. Concern about lower Osteochondritis dissecans limb position is one of the most frequent reasons Tarsal coalition that parents seek orthopedic advice. Most of these Malignant neoplasm conditions represent normal physiologic develop- 1 DDH : developmental dysplasia of the hip ment. They correct spontaneously and should be 2 JCA : juvenile chronic arthritis differentiated from a pathologic gait pattern. 3 SCFE : slipped capital femoral epiphysis Knowledge of their natural history avoids unneces- sary investigations and overtreatment. Evaluation of a limping child often requires patience. (when and how the limp started) and the duration Uncooperative children are difficult to evaluate (2).