Diagnostic Approach to Pediatric Musculoskeletal Pain
Begin with systematic screening for red flags through targeted history and physical examination, as most pediatric musculoskeletal pain is benign and self-limiting, but missing serious pathology can result in permanent disability or death. 1, 2, 3
Essential History Elements
Obtain specific information about:
- Timing and onset: Constant pain, night pain, or pain lasting ≥4 weeks are red flags requiring imaging 1, 2, 3
- Location and radiation: Radicular pain suggests nerve root involvement 1, 2
- Pattern: Morning stiffness with limited range of motion suggests inflammatory conditions 1, 2
- Constitutional symptoms: Fever, unintentional weight loss, or fatigue raise suspicion for infection, malignancy, or rheumatic disease 1, 2, 4
- Neurological symptoms: Weakness, sensory changes, or bowel/bladder dysfunction require urgent evaluation 1, 2
- Activity changes: Decreased function or inability to perform usual activities 3, 4
- Family history: Relevant for inflammatory arthropathies 4, 5
Targeted Physical Examination
Perform a comprehensive examination looking beyond the symptomatic area, as extra-articular findings often reveal systemic disease. 4, 5
Key examination components include:
- Neurological screening: Motor strength, sensory testing, reflexes, and gait assessment—abnormal findings mandate immediate imaging 1, 2, 3
- Spinal examination: Palpate spinous processes for tenderness, assess curvature and alignment for deformity 1, 2, 3
- Range of motion testing: Limited motion with morning stiffness suggests inflammatory pathology 1, 2
- Gait evaluation: Abnormalities indicate neurological involvement or mechanical instability 1, 2
- Vital signs: Fever and tachycardia suggest infection or inflammatory processes 1, 2
- Extra-articular examination: Check for lymphadenopathy, skin changes, and signs of systemic disease 1, 2, 4
The pGALS (pediatric Gait, Arms, Legs, Spine) screening examination provides a structured approach to musculoskeletal assessment 5.
Laboratory Evaluation
Do not order "rheumatological screens" or autoimmune panels in primary care, as they have low pretest probability and lead to false positives. 6
Order laboratory tests only when red flags suggest infection or inflammatory disease:
- Complete blood count with differential: Evaluate for infection, malignancy, or inflammatory conditions 3, 4, 6
- Erythrocyte sedimentation rate and C-reactive protein: Elevated in infection and inflammatory arthritis 3, 4, 6
- Serum ferritin: When inflammatory disease suspected 3
- Lactate dehydrogenase: Helpful if malignancy suspected 6
Critical pitfall: Immature granulocytes >3% indicate sepsis or vertebral osteomyelitis requiring urgent intervention 3.
Antinuclear antibodies and rheumatoid factor have no diagnostic role in juvenile idiopathic arthritis and should not be ordered in primary care 6.
Imaging Algorithm
No Red Flags Present
Do not obtain imaging for uncomplicated musculoskeletal pain without red flags—manage conservatively. 1, 7, 3
Most pediatric musculoskeletal pain is mechanical and self-limiting, responding to conservative treatment without advanced interventions 7.
Red Flags Present
Obtain anteroposterior and lateral radiographs of the symptomatic region as first-line imaging. 1, 3
Radiographs can identify:
- Fractures 4, 6
- Primary bone tumors 1
- Spondylolysis 1
- Scheuermann disease 1
- Slipped upper femoral epiphysis 6
Critical pitfall: Negative radiographs do not exclude serious pathology—proceed to advanced imaging if red flags persist 1, 2, 3.
Do not obtain oblique lumbar spine views, as they double radiation exposure without additional diagnostic information 1.
Advanced Imaging When Radiographs Negative or Non-Diagnostic
Obtain MRI without and with IV contrast for suspected infection, malignancy, or inflammatory disease. 1, 3
MRI is the only modality that directly visualizes the spinal cord, ligaments, and intervertebral discs 1, 2. T2-weighted and fat-suppressed sequences are necessary to evaluate marrow edema and paraspinal pathology 1.
For suspected spondylolysis in young athletes: Tc-99m bone scan with SPECT has superior sensitivity to MRI for detecting active spondylolysis 1. SPECT bone scan can evaluate the entire axial skeleton and identify multifocal disease 1.
For progressive neurological deficits or suspected cauda equina syndrome: Obtain urgent MRI without contrast 2.
Common Etiologies by Presentation Pattern
Mechanical Pain (Most Common)
- Spondylolysis: Young athletes with back pain, detected on radiographs or SPECT bone scan 1, 3
- Overuse syndromes: Activity-related pain in athletes 8
- Hypermobility: Generalized joint laxity with pain 8
- Benign limb pain of childhood: Self-limiting, no red flags 8
Inflammatory Conditions
- Juvenile idiopathic arthritis: Morning stiffness, joint swelling, elevated inflammatory markers 4, 6, 5
- Spondyloarthropathies: Anterior chest wall pain in 30-60% of cases, may be first manifestation 1
- Acute rheumatic fever: Post-streptococcal, migratory polyarthritis 4
Serious Pathology Requiring Urgent Intervention
- Infection: Osteomyelitis, septic arthritis, discitis, epidural abscess—fever, elevated inflammatory markers, MRI with contrast shows enhancement 1, 3, 6
- Malignancy: Night pain, weight loss, history of cancer is best-performing red flag 2, 6
- Non-accidental injury: Inconsistent history, multiple injuries at different stages 6
Pain Assessment Tools
Pain should be assessed at every visit using valid, reliable, developmentally appropriate tools. 1
Pain is multidimensional with sensory (intensity, quality, location, duration), affective (emotional impact), and evaluative (functional interference) components 1.
The Painometer V2 smartphone application provides a validated electronic visual analog scale for pediatric pain assessment 1.
Management Approach
Conservative Management (No Red Flags)
Most pediatric musculoskeletal pain responds to conservative treatment without requiring advanced interventions 7.
Do not initiate conservative management when:
- Progressive neurological deficits are present 2
- Imaging reveals structural instability 2
- Serious pathology is confirmed or highly suspected 2
Treatment of Identified Pathology
Treat the underlying condition rather than pursuing symptomatic management alone when serious pathology is identified. 7, 3
Specific treatment depends on diagnosis:
- Infection: Antimicrobial therapy, possible surgical intervention 1
- Inflammatory arthritis: Disease-modifying antirheumatic drugs, biologics, NSAIDs 1
- Malignancy: Oncologic referral 6
- Structural abnormalities: Orthopedic consultation 6
Referral Indications
Refer to subspecialist when:
- Diagnosis is uncertain 4
- Subspecialty treatment is required 4
- Red flags persist despite negative initial workup 3
- Progressive neurological deficits develop 1, 2
Appropriate referrals include pediatric rheumatology, oncology, orthopedic surgery, or emergency department depending on suspected pathology 6.
Patient Communication
Explain that imaging is not needed in the absence of red flags, and provide education about the self-limiting nature of most musculoskeletal pain 2. This approach minimizes unnecessary radiation exposure while ensuring serious pathology is not missed.