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Children frequently present to primary care, emergency departments and paediatricians with musculoskeletal (MSK) problems, and hence all of these professionals should be competent to perform a MSK assessment.1 Many of these children will have self-limiting illness/injury, however some will be presenting with chronic or life-threatening disease.2–4 The challenge is to reassure those with self-limiting disease, while identifying those presenting for the first time with new inflammatory arthritis such as juvenile idiopathic arthritis (JIA), or other serious conditions which can present with MSK features, such as malignancies, infections and neuromuscular diseases.
There is a growing acceptance that early diagnosis and aggressive management of JIA leads to improved functional outcomes,5–7 while early access to therapies for non-inflammatory MSK disease reduces recovery times and prevents progression to pain amplification syndromes.8–10 This evidence stands in stark contrast to the reality experienced by many children with MSK disease, who still suffer long delays between disease onset and referral to a specialist service.11 ,12 Part of this delay is undoubtedly due to the paucity of training about MSK disease delivered to UK trainees in frontline specialties.13–16 This paper aims to dispel some of the myths that have developed regarding the diagnosis of joint disease in children.
Children with musculoskeletal disease present with joint pain
Although pain is the most common MSK symptom encountered by frontline paediatric clinicians, it is unusual for this to be the principal presenting feature of serious MSK disease.17 The majority of children with JIA present with stiffness, joint swelling, limp or functional impairment, with pain either not apparent or not verbalised. More frequently, parents notice abnormalities in an uncomplaining child such as clumsiness, a change in mood or avoidance of activities or play that were previously enjoyed. There may …