View source for Limp

{{short description|Type of asymmetric abnormality of the gait}}
{{other uses}}
{{redirect|Lameness|lameness in horses|Lameness (equine)}}
{{Use dmy dates|date=April 2022}}
{{Infobox medical condition (new)
| name            = Limp
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| image           = Hinken 2010 PD smallscreen PD 2012.ogg
| caption         = Limping
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| field           = [[Neurology]], [[pediatrics]], [[orthopedics]]
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A '''limp''' is a type of [[gait abnormality|asymmetric abnormality]] of the [[gait (human)|gait]]. Limping may be caused by pain, weakness, neuromuscular imbalance, or a skeletal deformity.  The most common underlying cause of a painful limp is [[physical trauma]]; however, in the absence of trauma, other serious causes, such as [[septic arthritis]] or [[slipped capital femoral epiphysis]], may be present.  The diagnostic approach involves ruling out potentially serious causes via the use of [[X-ray]]s, [[blood test]]s, and sometimes [[joint aspiration]]. Initial treatment involves [[pain management]].  A limp is the presenting problem in about 4% of children who visit hospital emergency departments.<ref name=Singer85>{{cite journal |author=Singer JI |title=The cause of gait disturbance in 425 pediatric patients |journal=Pediatr Emerg Care |volume=1 |issue=1 |pages=7–10 |date=March 1985 |pmid=3843430 |doi= 10.1097/00006565-198503000-00003|s2cid=1198461 }}</ref>

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==Definition==
A limp is a type of asymmetric abnormality of the [[gait (human)|gait]].  When due to pain it is referred to as an [[antalgic gait]], in which the foot is in contact with the ground for a shorter duration than usual; in severe cases there may be a refusal to walk.<ref name=Review10/> Hip deformities with associated muscular weakness, on the other hand, may be present with a [[Trendelenburg gait]], with the body shifted over the affected hip.<ref name=Review10/>

==Differential diagnosis==
The causes of limping are many and can be either serious or non-serious.  It usually results from pain, weakness, neuromuscular imbalance, or a skeletal deformity.<ref name=Review10>{{cite journal |vauthors=Laine JC, Kaiser SP, Diab M |title=High-risk pediatric orthopedic pitfalls |journal=Emerg. Med. Clin. North Am. |volume=28 |issue=1 |pages=85–102, viii |date=February 2010 |pmid=19945600 |doi=10.1016/j.emc.2009.09.008 }}</ref> In 30% of cases, the underlying cause remains unknown after appropriate investigations.<ref name=Review10/> The most common underlying cause of limping in children is minor [[physical trauma]].  In those with no history of trauma, 40% are due to [[transient synovitis]] and 2% are from [[Legg–Calvé–Perthes syndrome]].<ref name=Fish09>{{cite journal |vauthors=Fischer SU, Beattie TF |title=The limping child: epidemiology, assessment and outcome |journal=J Bone Joint Surg Br |volume=81 |issue=6 |pages=1029–34 |date=November 1999 |pmid=10615981 |doi= 10.1302/0301-620X.81B6.9607|s2cid=2141675 }}</ref> Other important causes are infectious arthritis, osteomyelitis, and slipped capital femoral epiphysis in children.<ref>{{Cite web |title=Septic Arthritis & Osteomyelitis |url=https://www.pmmonline.org/doctor/limping-child/key-conditions/red-flag-conditions/septic-arthritis-osteomyelitis/ |access-date=2024-10-21 |website=www.pmmonline.org |language=en}}</ref><ref>{{Cite web |title=Slipped Capital Femoral Epiphysis (SCFE) |url=https://www.msdmanuals.com/professional/pediatrics/bone-disorders-in-children/slipped-capital-femoral-epiphysis-scfe |access-date=2024-10-21 |website=MSD Manual Professional Edition |language=en}}</ref>

===Infection===

====Septic arthritis====
[[Septic arthritis]] can be difficult to separate from less serious conditions such as [[transient synovitis]].  Factors that can help indicate septic arthritis rather than synovitis include a WBC count greater than 12×10<sup>9</sup>/l, fever greater than {{convert|38.5|°C|°F}}, [[Erythrocyte sedimentation rate|ESR]] greater than 40&nbsp;mm/h, [[C-reactive protein|CRP]] greater than 2.0&nbsp;mg/dL, and refusal to walk.<ref>{{cite journal |vauthors=Kocher MS, Mandiga R, Zurakowski D, Barnewolt C, Kasser JR |title=Validation of a clinical prediction rule for the differentiation between septic arthritis and transient synovitis of the hip in children |journal=J Bone Joint Surg Am |volume=86-A |issue=8 |pages=1629–35 |date=August 2004 |doi=10.2106/00004623-200408000-00005 |pmid=15292409 }}</ref> People with septic arthritis usually look clinically toxic or sick.<ref name=Review09/> Even in the absence of any of these factors, however, septic arthritis may be present.<ref name="Caird MS, Flynn JM, Leung YL, Millman JE, D'Italia JG, Dormans JP 2006 1251–7">{{cite journal |vauthors=Caird MS, Flynn JM, Leung YL, Millman JE, D'Italia JG, Dormans JP |title=Factors distinguishing septic arthritis from transient synovitis of the hip in children. A prospective study |journal=J Bone Joint Surg Am |volume=88 |issue=6 |pages=1251–7 |date=June 2006 |pmid=16757758 |doi=10.2106/JBJS.E.00216 }}</ref> Joint aspiration is required to confirm the diagnosis.<ref name="Caird MS, Flynn JM, Leung YL, Millman JE, D'Italia JG, Dormans JP 2006 1251–7"/>

====Other====
Other infections that classically lead to a limp include [[Lyme disease]] (a bacterial infection spread by [[Ixodes|deer ticks]]) and [[osteomyelitis]] (an infection of the bone).<ref name=Frick06/>

===Mechanical===

====Trauma====
Accidental or deliberate [[physical trauma]] may result in either a fracture, muscle bruising, or a contusion.<ref name=Frick06/> It is the leading cause of a limp.<ref name=Review10/> Deliberate abuse is important to consider.

====Slipped capital femoral epiphysis====
[[Slipped capital femoral epiphysis]] (SCFE) is a condition in which the [[growth plate]] of the head of the femur slips over the underlying bone.  It most commonly presents with hip pain in males during puberty and is associated with [[obesity]].<ref name=Review10/> The majority of people affected have a painful limp and in half of cases both hips are affected.<ref name=Review10/> Nearly a quarter of people present with only knee pain.<ref name=Frick06>{{cite journal |author=Frick SL |title=Evaluation of the child who has hip pain |journal=Orthop. Clin. North Am. |volume=37 |issue=2 |pages=133–40, v |date=April 2006 |pmid=16638444 |doi=10.1016/j.ocl.2005.12.003 }}</ref> Treatment involves non-weight-bearing movement and surgery.<ref name=Review10/> If not identified early, [[osteonecrosis]] or death of the head of the femur may occur.<ref name=Frick06/>

====Other====
A non-painful limp may be due to a number of mechanical conditions including [[hip dysplasia (human)|hip dysplasia]] and leg length differences.<ref name=Frick06/>

===Inflammatory===

====Transient synovitis====
[[Transient synovitis]] is a [[reactive arthritis]] of the hip of unknown cause.<ref name=Review10/> People are usually able to walk and may have a low grade fever.<ref name=Review10/> They usually look clinically nontoxic or otherwise healthy.<ref name=Review09/> It may only be diagnosed once all other potential serious causes are excluded.  With symptomatic care it usually resolves over one week.<ref name=Review10/>

====Juvenile rheumatoid arthritis====
[[Juvenile rheumatoid arthritis]] presents gradually with early morning stiffness, fatigue, and weight loss.<ref name=Review09/>

===Vascular===

====Legg–Calvé–Perthes syndrome====
[[Legg–Calvé–Perthes syndrome]] is a degenerative disease of the head of the femur which results in bone loss and deformity.  It usually presents as a chronic condition.<ref name=Frick06/>

===Neoplastic===
Cancers including [[acute lymphocytic leukemia]], [[osteosarcoma]], and [[Ewing’s sarcoma]] may result in a gradual onset of limping in children.  It is often associated with night sweating, easy bruising, weight loss, and pain most prominent at night.<ref name=Review09/><ref name=Frick06/>

==Diagnostic approach==
The diagnosis of the cause of a limp is often made based on history, physical exam findings, laboratory tests, and radiological examination.  If a limp is associated with pain it should be urgently investigated, while non-painful limps can be approached and investigated more gradually.<ref name=Review09>{{cite journal |vauthors=Sawyer JR, Kapoor M |title=The limping child: a systematic approach to diagnosis |journal=Am Fam Physician |volume=79 |issue=3 |pages=215–24 |date=February 2009 |pmid=19202969 }}</ref> Young children have difficulty determining the location of leg pain, thus in this population, ''knee pain equals hip pain''.<ref name=Frick06/> SCFE can usually be excluded by an x-ray of the hips.<ref name=Review10/> An ultrasound or x-ray guided aspiration of the hip joint maybe required to rule out an infectious process within the hip.<ref name=Review10/>

==Epidemiology==
A limp at one hospital emergency department was the presenting complaint in 4% of children.<ref name=Singer85/> It occurs twice as commonly in boys as in girls.<ref name=Fish09/>

==References==
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== External links ==
{{Medical resources
|  DiseasesDB     = 22069
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|  ICD9           = {{ICD9|719.7}}
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|  eMedicineSubj  = article
|  eMedicineTopic = 802506
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{{Arthropathies and related conditions}}
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[[Category:Gait abnormalities]]
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