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Intermittent Limp 1

A 5 year old boy presents to accident and emergency with a 5 day history of intermittent limp. His parents are concerned as he is crying when he walks. He has previously been happy to walk and had started to walk aged 15 months. He was otherwise well with no systemic complaints. 

On examination he looked well, was afebrile but was limping. General examination was unremarkable, his abdomen was soft and non-tender and his testes appeared normal. He was reluctant to weight bear but hip movements appeared pain free and with normal range of movement. Other joints appeared normal. 

The local limping child protocol was followed.

Hip radiographs were reported as normal. Hip ultrasound showed no effusion. Blood tests (complete blood count, acute phase reactants) were normal. 

No apparent cause for his limp was found. 

He was referred to paediatric rheumatology. The history was probed further and it was apparent that he had pain worse on weight bearing. Examination of his feet showed a large verrucae on the sole of his foot - this was very tender. 

The diagnosis was a verruca on his foot !

This case highlights the importance of careful clinical examination as the most crucial aspect of the evaluation; checking soles of the feet for easily missed problems and easily treatable benign problems is important. Verrucae, ingrowing toe nails, splinter / foreign body and even ill-fitting shoes are frequent causes of limp and should be considered before escalating investigations and especially if they are invasive, involve radiation or require sedation. 

The photograph below shows the soles of the feet and surface anatomy. 


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