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

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

For children and adolescents, the most sensitive examination findings that support a likely diagnosis of suspected inflammatory arthritis (eg JIA) are:

  • joint swelling
  • pain at the extremes of a joint’s range of movement
  • reduced range of motion
  • joint-line tenderness.

If these signs are absent, a diagnosis of acute inflammatory arthritis is unlikely; however, if they are present, an inflammatory arthritis is highly likely. Joint effusion, warmth and erythema may also be present. Joints affected by inflammatory arthritis may be asymptomatic, so it is important to examine all joints.

Extra-articular examination findings strongly associated with suspected inflammatory diseases include:

Examination findings in children and adolescents with undifferentiated musculoskeletal symptoms may include:

  • sympathetic synovial effusion1—may be associated with osteomyelitis in bone adjacent to the joint
  • bony tenderness—may suggest a bony stress lesion (eg stress fracture) or osteomyelitis
  • bone swelling or deformity—may suggest a bone tumour
  • joint contracture, leg-length discrepancy or muscle wasting—may suggest chronicity
  • hepatosplenomegaly or lymphadenopathy—associated with systemic inflammatory disease or haematological malignancy (eg leukaemia)
  • bruising, petechiae or purpura—associated with bleeding tendency, haematological malignancy, or nonaccidental injury (child abuse)
  • scoliosis—important to detect and manage in childhood (time critical)
  • new heart murmur or signs of cardiac failure—associated with acute rheumatic fever
  • rash—associated with many systemic inflammatory diseases, including acute rheumatic fever, systemc JIA (a subtype of JIA formerly known as Still disease), SLE and psoriatic arthritis
  • multiple tender points, extreme hyperaesthesia or bizarre gait patterns—may suggest diffuse amplified musculoskeletal pain syndrome (AMPS)
  • growth delay—any significant deviation from the normal percentiles for growth parameters (eg weight, height [considered in the context of the child’s pubertal status]) may suggest systemic inflammatory disease.
An example of differentiating benign from serious musculoskeletal pain is given in Features to help differentiate benign pain of childhood (including nocturnal limb pain) from more serious pathology in children and adolescents. This table specifically compares history and examination findings of benign pain of childhood (eg benign nocturnal limb pain2) with more serious pathology (eg systemic inflammatory disease).
Table 1. Features to help differentiate benign pain of childhood (including nocturnal limb pain) from more serious pathology in children and adolescents

[NB1]

Clinical features suggesting benign pain of childhood (including nocturnal limb pain)

Clinical features suggesting more serious pathology

well child

unwell looking child

fever, weight loss or pallor

nonarticular and poorly localised pain (eg shins, calves, backs of knees)

articular pain

bilateral pain

unilateral or bilateral pain

intermittent pain, with pain-free intervals

persistent pain

normal gait

presence of a limp or refusal to walk

pain occurs late in the day or at bedtime

night pain

normal clinical examination

objective signs of inflammation (eg swelling, stress pain, reduced range of motion, erythema, focal tenderness)

Note: NB1: Benign nocturnal limb pain is often referred to as ‘growing pain’.
1 A sympathetic synovial effusion can occur in association with disease in a structure adjacent to the joint.Return
2 Benign nocturnal limb pain is often referred to as ‘growing pain’.Return