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Causes of limp in children by age and acuity

Any age	Toddler and young child (1 to 5 years of age)	School age (5 to 12 years of age)	Older child and adolescent (13 to 19 years of age)
Acute
Abdominal/pelvic abscess, including pelvic inflammatory disease in adolescent females and periappendiceal abscess (referred pain) Blister or skin wound caused by poor-fitting footwear Contusion (soft tissue, muscle, or bone) Foot foreign body (eg, splinter) Fracture Osteomyelitis Malignancy* Meningitis Peripheral neuropathy (eg, Guillain-Barré syndrome) Postinfectious (reactive) arthritis Septic arthritis^¶ Spinal epidural abscess Viral myositis	Child abuse (eg, traumatic periosteitis or metaphyseal-epiphyseal fracture) Discitis^Δ Hand-foot-mouth disease (enterovirus infection) Hemarthrosis (hemophilia) IgA vasculitis (Henoch-Schönlein purpura) Immunization (IM shot) Salter-Harris I fracture Septic hip Toddler's fracture Transient synovitis	Ligament sprain or tear Salter-Harris I fracture	Gonococcal arthritis^Δ Ligament sprain or tear Muscle strain Slipped capital femoral epiphysis
Chronic
Abdominal/pelvic abscess, including pelvic inflammatory disease in adolescent females and periappendiceal abscess (referred pain) Benign bone tumor (eg, osteoid osteoma or osteoblastoma) JIA and other inflammatory disease^◊ Malignancy* Meningitis (meningeal irritation) Peripheral neuropathy Psoas abscess (referred pain) Spinal cord tumor Spinal epidural abscess Vertebral osteomyelitis	Cerebral palsy Developmental dysplasia of the hip Infantile Blount disease or other causes of pathologic bowing (eg, rickets, skeletal dysplasia, or asymmetric growth) Posterior fossa tumor (ataxia that may be misinterpreted as limp)	Apophysitis of the heel (Sever disease) Avascular necrosis of the hip (Legg-Calvé-Perthes disease) Closed spinal dysraphism with tethered cord Growing pains Leg length discrepancy Navicular osteochondrosis (Köhler disease) Osteochondritis dissecans Patellar apophysitis (Sinding-Larsen-Johansson disease) Tarsal coalition Transient synovitis	Apophysitis of the tibial tuberosity (Osgood Schlatter disease) Complex regional pain syndrome (lower leg) Fifth metatarsal traction apophysitis (Iselin disease) Herniated disc Metatarsal avascular necrosis (Freiberg disease) Osteochondritis dissecans Scoliosis Slipped capital femoral epiphysis Spondylolisthesis Spondylolysis Stress fracture Tendonitis

IgA: immunoglobulin A; IM: intramuscular; JIA: juvenile idiopathic arthritis.
* Malignancies that may present with lower extremity pain and limp include leukemia, lymphoma, osteogenic sarcoma, Ewing sarcoma, and metastatic neuroblastoma.
¶ Common pathogens causing septic arthritis include Staphylococcus aureus, Streptococcus pneumoniae, Kingella kingae, Lyme disease (visiting or residing in endemic region), and, in adolescents, disseminated gonococcal disease.
Δ This condition can also present with a chronic limp.
◊ In addition to JIA, other inflammatory diseases that may manifest as limp include erythema multiforme, Henoch-Schönlein purpura, acute rheumatic fever, inflammatory bowel disease, and systemic lupus erythematosus.

Adapted from: Kost S, Thompson AD. Limp. In: Fleisher and Ludwig's Textbook of Pediatric Emergency Medicine, 7^th edition, Shaw KN, Bachur RG (Eds), Wolters Kluwer, Philadelphia 2016. p. 280.

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