Limp/hip pain

Hip pain is common in children and adolescents and has a broad range of causes, ranging from the benign to the potentially devastating. Transient synovitis, one of the most common causes of hip pain in children, must be differentiated from septic arthritis. Hip pain may be caused by conditions unique to the growing paediatric skeleton including Perthes, slipped capital femoral epiphysis and apophyseal avulsion fractures of the pelvis as well as growth related disorders.

Paediatric red flags

Children presenting with red flags, indicating the possibility of more serious underlying pathology, warrant urgent assessment, with some cases requiring referral directly to the Emergency Department or CAU.

Unremitting pain
Night pain (Pain that awakens the child from sleep)
Systemic symptoms; fever, malaise, unexplained weight loss, sickness
Changes in bladder and bowel habit
Hot, swollen and inflamed joint(s)
Early morning stiffness (may indicate JIA) with persistent swelling
Painful guarded movement/ muscle spasm/ significant loss of range of motion, in absence of trauma
Regression of development / loss or deterioration of function
Antalgic gait / inability to weight bear / gait disturbance / lower limb asymmetry
Sensation changes (pins and needles/ numbness), absent or exaggerated reflexes, unexplained muscle weakness

This list is not exhaustive nor a diagnostic tool, but areas to consider

Action	Description
Key assessment points	Assess gait and function Check posture, leg length, symmetry Check hip range of movement; hip rotation and abduction should be full and symmetrical if there is no pathology pGALS: Check spine Temperature/observations
Initial GP management	Exclude serious pathology Exclude inflammatory cause (Bloods – if inflammatory processes suspected) Direct to Paediatric Physio Website for appropriate information leaflets Children's physiotherapy leaflets (uhd.nhs.uk)
Refer to Paediatric Physiotherapy	Tight/weak muscles/poor core stability/Persisting or chronic pain Reduced weight bearing or gait changes Lateral hip pain / ‘snapping hip’ syndrome Reduced function/activity levels due to pain, e.g. running, jumping, PE Rehab following a period of inactivity/post-surgery
Refer to ED/Acute Paediatricians urgently via the Children’s Assessment Unit (CAU)	Acute limp or obviously painful or restricted hip movements Unable to weight bear A fever and/or red flags suggesting serious pathology Severe pain, agitated, reduced peripheral pulses or muscle weakness which may indicate neurovascular compromise/ compartment syndrome Suspicion of accidental injury
Refer for x-ray	Urgent X-ray for a limping child, history of trauma or reduced hip ROM Routine x-ray for patients with mildly reduced hip range of motion, leg length difference or hip pain indicating pathology such as DDH
Refer to Paediatric Orthopaedics	A well child with a working diagnosis of transient synovitis but the symptoms fail to resolve within 1 week of onset or for follow-up A child presents with limp on multiple different occasions There is uncertainty about the diagnosis Diagnosis of Perthes/Avascular necrosis/DDH confirmed on x-ray
Refer to Podiatry or Orthotics	Flat feet/calcaneo-valgus foot posture is accentuating lower limb position, causing hip pain, rubbing or uneven shoe wear

Pages in this section

Baby feet positional issues

Back pain

Childhood growing pains

Complex Regional Pain Syndrome (CRPS)

Curly toes

Developmental Dysplasia of the Hip (DHH)

Flat feet (pes planus)

Genu Valgum (knock knees)

Genu Varum (Bow legs)

Heel, foot and ankle pain

Hypermobility

Infant Head Shape Abnormalities

Torticollis/head turning preference/plagiocephaly

Where should you seek help?

If it is non-urgent, speak to your local pharmacist or health visitor.
If your child has any of the above features, urgently see your GP. For an urgent out-of-hours GP appointment, call NHS 111.
You should only call 999 or go to your nearest A&E department in critical or life threatening situations.

Pharmacists are experts in many aspects of healthcare and can offer advice on a wide range of long-term conditions and common illnesses such as coughs, colds and stomach upsets. You don’t need an appointment and many have private consultation areas, so they are a good first port of call. Your pharmacist will say if you need further medical attention.

Sound advice

Visit a pharmacy if your child is ill, but does not need to see a GP.
Remember that if your child's condition gets worse, you should seek further medical advice immediately.
Help your child to understand - watch this video with them about going to the pharmacy.

For information on common childhood illnesses go to What is wrong with my child?

Health visitors are nurses or midwives who are passionate about promoting healthy lifestyles and preventing illness through the delivery of the Healthy Child Programme. They work with you through your pregnancy up until your child is ready to start school.

Health Visitors can also make referrals for you to other health professionals for example hearing or vision concerns or to the Community Paediatricians or to the child and adolescent mental health services.

Contact them by phoning your Health Visitor Team or local Children’s Centre.

Sound advice

Health visitors also provide advice, support and guidance in caring for your child, including:

Breastfeeding, weaning and healthy eating
Exercise, hygiene and safety
Your child’s growth and development
Emotional health and wellbeing, including postnatal depression
Safety in the home
Stopping smoking
Contraception and sexual health
Sleep and behaviour management (including temper tantrums!)
Toilet training
Minor illnesses

For more information watch the video: What does a health visitor do?

Midwives provide advice, care and support for women and their babies during pregnancy, labour and the early postnatal period. They provide health education and parenting advice until care is transferred to a health visitor. This usually happens when your baby is about 2 weeks old.

Sound Advice

A midwife is an expert in normal pregnancy and birth.

GPs assess, treat and manage a whole range of health problems. They also provide health education, give vaccinations and carry out simple surgical procedures. Your GP will arrange a referral to a hospital specialist should you need it.

Sound advice

You have a choice of service:

Doctors/GPs can treat many illnesses that do not warrant a visit to A&E.
Help your child to understand – watch this video with them about visiting the GP or going to a walk in centre

For information on common childhood illnesses go to What is wrong with my child?

If you’re not sure which NHS service you need, call 111. An adviser will ask you questions to assess your symptoms and then give you the advice you need, or direct you straightaway to the best service for you in your area.

Sound advice

Use NHS 111 if you are unsure what to do next, have any questions about a condition or treatment or require information about local health services.

For information on common childhood illnesses go to What is wrong with my child?

A&E departments provide vital care for life-threatening emergencies, such as loss of consciousness, suspected heart attacks, breathing difficulties, or severe bleeding that cannot be stopped. If you’re not sure it’s an emergency, call 111 for advice.

Sound advice

Many visits to A&E and calls to 999 could be resolved by any other NHS services.
If your child's condition is not critical, choose another service to get them the best possible treatment.
Help your child to understand – watch this video with them about going to A&E or riding in an ambulance

School nurses care for children and young people, aged 5-19, and their families, to ensure their health needs are supported within their school and community. They work closely with education staff and other agencies to support parents, carers and the children and young people, with physical and/or emotional health needs.

Contacting the School Nurse

Primary and secondary schools have an allocated school nurse – telephone your child’s school to ask for the contact details of your named school nurse.

There is also a specialist nurse who works with families who choose to educate their children at home.

Sound Advice

Before your child starts school your health visitor will meet with the school nursing team to transfer their care to the school nursing service. The school nursing team consists of a school nursing lead, specialist public health practitioners and school health staff nurses.

They all have a role in preventing disease and promoting health and wellbeing, by:-

encouraging healthier lifestyles
offering immunisations
giving information, advice and support to children, young people and their families
supporting children with complex health needs

Each member of the team has links with many other professionals who also work with children including community paediatricians, child and adolescent mental health teams, health visitors and speech and language therapists. The school health nursing service also forms part of the multi-agency services for children, young people and families where there are child protection or safeguarding issues.