Evaluating a limping child is a core skill in Pediatric Emergency Medicine, and it’s one of those presentations where your differential can expand quickly if you don’t anchor it with age, a careful exam, and a good sense of red flags. In this post, you’ll find a comprehensive overview of history-taking, physical exam, imaging, labs, and an age-based diagnostic framework, all designed to help you distinguish benign self-limited causes from those that demand urgent intervention.
Your first anchor point is the child’s age. This helps you narrow the wide differential:
In kids under 3, think trauma and congenital conditions.
Between 3 and 10, transient synovitis reigns supreme.
Over 10? Think SCFE, stress injuries, and systemic disease.
| Age Group | Common Causes of Limp |
|---|---|
| <3 years | Toddler’s fracture, septic arthritis, developmental dysplasia of the hip (DDH), trauma/abuse, leukemia |
| 3–10 years | Transient synovitis, trauma, septic arthritis, juvenile idiopathic arthritis (JIA), Legg-Calvé-Perthes |
| >10 years | Slipped capital femoral epiphysis (SCFE), osteomyelitis, stress fractures, overuse, malignancy |
[1–3]
A high-yield history can shortcut your entire evaluation. Ask:
- Onset: Sudden vs gradual?
- Recent illness: URI or GI symptoms may point toward transient synovitis.
- Trauma: Even minor, unwitnessed trauma in toddlers matters.
- Systemic symptoms: Fever, rash, weight loss, malaise.
- Worse in the morning? Think inflammatory arthritis.
- Location of pain: Not always the joint they’re guarding.
- Video evidence: Parents’ videos of ambulation at home are gold.
Also consider:
- Tick exposure or travel (→ Lyme arthritis or osteomyelitis)
- Prior episodes (→ JIA, reactive arthritis)
- Toileting regression (→ spinal pathology or pelvic issues)
[2,4,5]
Start by observing the child walk. Have them move across the room, not just take a few steps. Note:
- Antalgic gait (shortened stance phase)
- Stiff leg or Trendelenburg pattern
- Refusal to bear weight
Your hands-on exam should include:
- Palpating each limb entirely, not just the “hurting” one.
- Testing passive and active range of motion.
- Log rolling the hip — pain suggests intra-articular pathology.
- Squeezing the calf or heel to localize pain in younger kids.
- Assessing abdominal tenderness and testicular exam in boys (torsion and appendicitis can masquerade as limp).
- Looking at the soles for splinters, puncture wounds, ingrown nails, or petechiae.
[2,4]
Plain Films
Always your first stop.
- Get two views, minimum.
- Focus on the symptomatic joint—but if the diagnosis isn’t clear, image from hip to toes.
- Toddler’s fractures and SCFE can be subtle. Don’t skimp.
Ultrasound
- Great for detecting joint effusions, especially at the hip.
- Not diagnostic for septic arthritis.
- A small effusion could be transient synovitis or early infection.
- Normal ultrasound doesn’t rule out septic arthritis.
- Ultrasound is not part of the Kocher criteria — don’t let it falsely reassure you.
MRI
- Best for osteomyelitis, discitis, or deep soft tissue infections.
- Useful when x-rays are unrevealing and you’re worried about infection or malignancy.
- May require sedation in younger children.
[1,2,4,5]
Tailor labs to the level of concern:
- CBC – look for leukocytosis or pancytopenia.
- ESR and CRP – both are inflammatory markers; CRP rises/falls faster.
- Blood culture – if febrile or concern for septic arthritis.
- Lyme serology – if exposure risk is high.If Lyme is your top diagnosis and the child has a classic rash, it’s reasonable to start treatment while labs are pending or equivocal [5].
- ANA, RF – not useful in the ED unless the limp is chronic and you’re coordinating with Rheumatology.
[1,2,4,5]
These prediction rules help estimate the likelihood of septic arthritis of the hip:
- Fever >38.5°C
- Non–weight bearing
- ESR > 40 mm/hr (CRP > 2.0 mg/dL can be used instead)
- WBC > 12,000/mm³
| Positive Criteria | Estimated Risk of Septic Arthritis |
|---|---|
| 0 | <0.2% |
| 1 | ~3% |
| 2 | ~40% |
| 3 | ~93% |
| 4 | ~99% |
CRP and ESR are interchangeable in the Kocher criteria — CRP was not available when the original prediction rule was developed, but studies have shown similar performance when substituted [6].
Remember: Ultrasound isn’t part of the rule. The child in front of you matters more than the prediction model.
[6]
- Appendicitis: Can cause psoas irritation and limp.
- Testicular torsion: Especially with abdominal or groin pain.
- Discitis: Refusal to sit or walk.
- Leukemia: Bone pain, limp, fatigue, pallor, bruising.
- Pelvic abscess or psoas abscess: May mimic hip pain.
[1,2,4]
- Child is ill-appearing or febrile.
- Pain is severe or progressive.
- Lab markers of inflammation are elevated.
- No diagnosis, but the kid still won’t walk.
- You suspect non-accidental trauma or infection.
Don’t send these children home. If in doubt, admit and consult orthopedics.
The limping child is a diagnostic puzzle with serious implications if you miss something like septic arthritis, SCFE, or malignancy. Anchor your evaluation in the child’s age, start with a careful history and exam, use imaging and labs judiciously, and always watch the kid walk. And please, don’t forget to take off their shoes and check the feet.
- Terk MR, et al. Antalgic Gait in Children. StatPearls. 2023.
- Neuman MI, et al. Evaluation of limp in children. UpToDate. Accessed 2025.
- Bernard SA, et al. Differential diagnosis of limp in children. UpToDate. Accessed 2025.
- Schunk JE. Limping child. Pediatrics in Review. 2023;44(9):466-476. doi:10.1542/pir.2023-006052
- Boutis K. The limping child: a systematic approach. Pediatric Annals. 2015;44(9):e217-e222.
- Kocher MS, et al. Differentiating septic arthritis from transient synovitis of the hip in children. J Bone Joint Surg Am. 1999;81(12):1662-1670.
