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Limping Child

Written 6th August 2026 - Last Update 30th August 2026

A limp is common (~4/1000 ED/urgent-care presentations) and usually benign, but the differential is wide and a few causes are limb- or life-threatening. This page is the differential-diagnosis hub — for the hip-specific causes (DDH, transient synovitis, Perthes, SCFE, septic arthritis of the hip) see Childhood Hip Disorders, which covers those in full with a comparison table; this page covers everything else, plus the general approach.

Red flags — think beyond the limb

  • Fever or systemic illness (lethargy, weight loss, night sweats, bruising/bleeding) — think infection (septic arthritis, osteomyelitis, pyomyositis) or malignancy, not a mechanical cause.
  • Non-weight-bearing, or refusal to move a limb at all — much more concerning than an antalgic limp.
  • Night pain, or pain not settling with simple analgesia — a bone tumour red flag.
  • Age <1 year, or a pre-ambulatory infant with any bruising or reluctance to move a limb (“if they don’t cruise, they don’t bruise”) — consider non-accidental injury.
  • Back or neurological findings (abnormal reflexes/tone, loss of lumbar lordosis, sphincter change) — think discitis or a spinal cause.

Age-based framework

  • Infant/pre-walker: non-accidental injury, DDH, infection.
  • Toddler (1–3 yrs): toddler’s fracture (see Lower Limb Fractures), transient synovitis, septic arthritis, leukaemia (peak incidence 2–4 yrs).
  • Child (4–10 yrs): transient synovitis, Perthes disease, septic arthritis, discitis (almost exclusively <5 yrs).
  • Adolescent: SCFE, accidental fracture, apophysitis, osteosarcoma.

History and examination

Ask about fever timing (before/during presentation — points to transient synovitis or septic arthritis), preceding trauma, preceding infection (viral prodrome, GI/GU infection), constitutional symptoms (weight loss, bruising/bleeding — malignancy), and relevant past history (Trisomy 21 → higher leukaemia risk; obesity → SCFE risk; immunosuppression or recent antibiotics can mask a septic joint’s usual presentation).

Examine the whole child undressed — back, both legs, all lower-limb joints — for bony tenderness, range of motion, plantar foreign bodies, rashes (purpura, typically buttock/lower limb, suggests IgA vasculitis — see IgA Vasculitis (Henoch-Schönlein Purpura)), lymphadenopathy/organomegaly (rheumatological or malignant disease), and abdominal/testicular findings (a psoas abscess or testicular torsion can present as a limp).

Not-to-miss infective causes

Septic arthritis and osteomyelitis are covered in full at Osteomyelitis (which includes a dedicated paediatric section) — the practical point for a limping child is that no combination of history, exam and bloods reliably excludes a septic joint; a child who is afebrile with normal inflammatory markers is reassuring but a persistently painful, reluctant-to-move joint still needs same-day assessment (ultrasound ± aspiration) rather than a “wait and see. “The Kocher criteria (non-weight-bearing, fever >38.5°C, ESR >40 mm/hr, WBC >12,000) estimate the probability of a septic hip but shouldn’t be used to rule one out in isolation.

Pyomyositis (a bacterial infection of skeletal muscle, usually Staph aureus, most often the thigh/hip/pelvic muscles) presents similarly — limp and fever, often with a history of minor unremarkable trauma to the area. Early on the muscle just feels “woody” with no other signs of infection, which makes it easy to miss; it progresses to a frank abscess (severe pain, swelling) if untreated. Needs same-day referral for imaging (ultrasound/MRI) and IV antibiotics ± drainage.

Benign acute childhood myositis

A self-limiting, post-viral (classically influenza) myositis affecting the calves, in children aged 6–8 — presents in the early convalescent phase of a viral illness with severe bilateral calf pain, refusal to weight-bear, and toe-walking. Strength and reflexes are normal despite the pain. It’s benign and self-resolving over a few days, but check a CK and urinalysis (risk of coinciding rhabdomyolysis) — admit if CK is substantially elevated (>5000), the child can’t tolerate oral fluids, or there are electrolyte disturbances; otherwise supportive care and rehydration at home (avoid NSAIDs given the rhabdomyolysis risk).

Reactive, autoimmune and tick-associated arthritis

  • Reactive arthritis — an asymmetric oligoarthritis of the lower limbs appearing 3 days–6 weeks after a GI (Salmonella, Shigella, Campylobacter) or GU infection; see Chlamydia for the STI-triggered form. Usually self-limiting with NSAIDs; treat any active underlying infection.
  • Juvenile idiopathic arthritis is covered in full at Juvenile Idiopathic Arthritis — a diagnosis of exclusion, so rule out infective/malignant causes first.
  • Gonococcal arthritis — consider in a sexually active adolescent with monoarthritis or an asymmetric oligoarthritis, especially with associated dermatitis/tenosynovitis; see Gonorrhoea.
  • Lyme arthritis is not relevant to Australian practice — Borrelia burgdorferi is not endemic here (see Lyme Disease for the Australian DSCATT position); only consider it with a genuine overseas tick-exposure history to an endemic region.

Bone tumours

Osteosarcoma and Ewing sarcoma are covered in full at Bone Neoplasia — both can present as an atraumatic limp with insidious, progressively worsening pain (often worse at night, weeks to months before diagnosis) ± a palpable mass.

Osteoid osteoma is a small, benign but painful lesion (most often proximal femur or tibial diaphysis, ages 5–25) that’s easy to miss because X-rays can look unremarkable — the giveaway is pain that is constant, worse at night, and classically relieved dramatically by NSAIDs. CT characterises the radiolucent nidus better than MRI (MRI can look alarmingly like malignancy). Usually managed conservatively (rest/NSAIDs, lesions often resolve over 5–7 years) with orthopaedic follow-up, not admission.

Easily-missed mechanical causes

  • Seymour fracture — a displaced Salter-Harris II fracture of a distal phalanx (in the lower limb, usually the great toe), from an axial stubbing injury forcing the toe into hyperflexion. Easily missed because the fracture is hidden under the nail bed, and the only clue may be a small proximal nail-fold haematoma with a limp. This is functionally an open fracture (the germinal matrix is interposed in the fracture site) — it needs irrigation, debridement and antibiotics, not just a splint, so refer rather than treat as a simple toe injury.
  • Plantar puncture wound / retained foreign body — always examine the sole of the foot in a limping child, even without an obvious wound history; non-verbal or reluctant children may only present with a limp. X-ray for metal/glass/rock (radio-opaque); ultrasound picks up wood/thorn material better. Wash out thoroughly, update tetanus. Antibiotics aren’t routinely needed if the child presents within 24 hours; add antistaphylococcal cover from 24–72 hours, and cover for Pseudomonas too if the puncture went through a shoe sole (a recognised risk factor) or presentation is delayed 4–5 days.
  • Toddler’s fracture — see Lower Limb Fractures.