Important features on history of new-onset musculoskeletal symptoms in children and adolescents

A comprehensive history, in combination with a thorough physical examination, can help to determine whether new-onset musculoskeletal symptoms in children and adolescents are concerning and whether they need referral to a specialist.

Young children or children with developmental disability may not be able to reliably report symptoms.

Important features to obtain from the history include the child or adolescent’s:

• age—some conditions are more common in certain age groups (eg hip-joint conditions, benign nocturnal limb pain)¹
• site and distribution of pain
  • articular pain—common in septic arthritis and juvenile idiopathic arthritis (JIA)
  • nonarticular pain—nonspecific; it occurs in many conditions, including mechanical and traumatic conditions, amplified musculoskeletal pain syndrome (AMPS), and malignancy
• symptom duration
  • acute symptoms (days to weeks)—common, most often related to activity or mechanical and traumatic conditions; importantly, consider infection as a precpitant of acute symptoms (eg viral arthritis, reactive arthritis, osteomyelitis with joint involvement, septic arthritis)
  • chronic symptoms (weeks to months)—often benign (eg traction apophysitis including Osgood-Schlatter disease and Sever disease); importantly, consider JIA, which typically presents with longstanding inflammatory symptoms
• symptom variation over the day
  • pain after activity—more suggestive of a noninflammatory condition
  • stiffness after inactivity (especially morning stiffness)—more suggestive of an inflammatory pathology; morning stiffness in toddlers may present as wanting to be carried on waking or crying with morning nappy changes
• symptom interference with daily activities
  • symptoms that interfere with daily activities strongly suggest a significant pathology
  • interference with a child’s daily activities may present as withdrawal from play, sporting or hobby activities, apparent loss of motor skills (eg a toddler who stops walking), or school absence (depending on their age)
• symptom impact on sleep—night pain that wakes a child aged 3 to 10 years is most often benign nocturnal limb pain¹; importantly, it may also suggest serious pathology such as malignancy, especially in teenagers
• associated systemic features—fever, malaise, fatigue, weight loss, rash or persistent diarrhoea may suggest a systemic pathology
• history of infection, infectious contacts and antibiotic use
  • reactive arthritis can occur after a recent urinary tract infection, gastrointestinal infection or sexually transmitted infection (STI); this is pertinent for sexually active children and adolescents, and may be an alerting feature (‘red flag’) for sexual abuse; see also STIs in infants and children if sexual abuse is suspected²
  • postviral arthritis is associated with reactive arthritis, especially irritable hip (transient synovitis), which is usually mild and self-limiting
  • viral arthritis—can be associated with arthralgia or arthritis
  • acute rheumatic fever—occurs after a Streptococcus pyogenes (group A streptococcus) infection, in particular pharyngitis or impetigo
  • tuberculous arthritis—consider in a child or adolescent with monoarthritis and a history of, or environmental exposure to, tuberculosis infection
• family history of rheumatological disease
  • relevant for spondyloarthritis, psoriasis and psoriatic arthritis
  • may also be a clue to pain ‘role models’ in amplified musculoskeletal pain syndrome (AMPS)
• growth and development—failure to thrive can indicate chronic systemic illness
• psychosocial history—including home environment, sexual history and substance use.