present, the physician should inquire about the location and severity A history of trauma should be addressed, keeping in mind the inherent difficulty in obtaining an accurate trauma history in very young children Conversely, obvious trauma in the absence of a consistent history raises the question of inflicted injury In more chronic presentations, any cyclical or recurrent patterns should be noted Stiffness and limp primarily in the morning suggest rheumatic disease, whereas evening symptoms suggest weakness or overuse injury A history of joint or limb swelling should be investigated, with attention to the degree of swelling and any migratory or recurrent patterns The medical history should include birth and developmental history Breech position is associated with developmental dysplasia of the hip, and mild cerebral palsy may present in childhood with abnormal gait History of viral infections, streptococcal pharyngitis, medication use, and immunizations may provide clues to the cause of limping A family history of rheumatic or autoimmune disease, neurologic disease, inflammatory bowel disease, hemoglobinopathy, or other bleeding disorders may help facilitate diagnosis Finally, the review of systems should include questions about past trauma, infections, neoplasia, endocrine disease, metabolic disease, and congenital anomalies Physical Examination The physical examination in a limping child should begin with observation of the child’s gait Ideally, the child should be observed walking in bare feet and wearing minimal clothing, preferably in a long hallway The physician should attempt to observe the child unobtrusively to avoid gait changes caused by selfconsciousness The observer should note the symmetry of stride length, the proportion of the gait cycle spent in stance phase, hip abductor muscle strength (with weakness manifested by Trendelenburg or waddling gait), in-toeing or outtoeing, and joint flexibility Muscle strength may be tested by asking the child to run, hop, and walk on toes and heels After observing the child in action, the physician should perform a complete examination with attention to the musculoskeletal and neurologic systems The musculoskeletal examination begins with inspection of the limbs and feet for swelling or deformity Supine positioning with the leg slightly flexed, abducted, and externally rotated at the hip is suggestive of fluid in the joint capsule The spine should be inspected for curvature, both standing and bending forward, and the soles of feet and toes should be checked for foreign bodies and calluses The bones, muscles, and joints should be palpated for areas of tenderness; range of motion of all joints should be checked; and limb lengths (from anterior-superior iliac spine to medial malleolus), as well as thigh and calf circumferences, should