The musculoskeletal history

General

Ensure to involve the child/young person as well as the carer - opening questions help to establish rapport.
Enquire about:
- general concerns: e.g. pain, swelling, stiffness, deformity, limp
- observations from others: e.g. teachers
- duration of symptoms – consider acute, chronic or subacute
- history of trauma, injury or prior illness
- fluctuation and frequency of symptoms – any diurnal variation
Family history: e.g. inflammatory arthritis, muscle disease, autoimmune diseases, fever syndromes, infections (ask about TB).
Social history: consider consanguinity.
Medical history: previous illnesses/surgery/conditions that predispose to arthritis (e.g Down’s syndrome/inflammatory bowel disease).
Vaccination history: e.g. rubella causing a reactive arthritis.
Travel history: e.g. reactive arthritis or Lyme disease.
Sexual history (adolescent): e.g. STI causing a reactive arthritis. Consideration of safeguarding concerns is paramount.
Medications and drugs: including illicit substances. Consider risk for HIV, Hepatitis B, C.
Diet: e.g. calcium intake and vitamin D, specifically considering rickets.
Growth and development: birth history, general and MSK development, motor milestones. Review growth chart. Important to know what is normal. Further information on gait, normal variants, and motor milestones can be found on the PMM website.

SOCRATES: Site, Onset, Character, Radiation, Associated features, Timing/duration, Exacerbating/alleviating factors (e.g. response to NSAIDs), Severity.
Unilateral, focal, persistent pain is concerning.
Referred pain from the hip may present as thigh or knee pain e.g. transient synovitis.
Flitting pain from one joint to another with or without joint swelling can be indicative of acute rheumatic fever.
Persistent night waking with other concerning features (limp, unilateral pain) – think of red-flag conditions. Leg pain at night can also be due to growing pains but caution is needed (see Q&A section for further advice on this).
Mechanical or inflammatory pain – mechanical (worse with activity, end of the day) or inflammatory pain (associated with stiffness or gelling, worse in morning, may improve with activity). Further information on pain can be found on the PMM website.

Along with the presence of pain and stiffness, swelling can help identify an inflammatory cause from a non-inflammatory or mechanical cause.
Swelling can be overlooked if symmetrical or subtle: Important to be aware of how children’s joints change with age. Further information regarding swelling can be found on the PMM website.

May be noticed by parents or carers as one or more of the following:

Change in activities, regression of milestones (e.g. reluctance to dress or use stairs when previously able to do so).
Limp or difficulty weight-bearing; may be worse in mornings.
Episode of ‘gelling’ after periods of rest: this term may be used to describe slowness or difficulties in joint movement after periods of rest – e.g. after a car journey or arising from sitting position.

Systemic enquiry of key systems: skin, eyes, brain, heart, lungs, kidney – involvement may suggest multisystem disease, inflammatory arthritis or muscle disease.
Other signs of inflammatory disease include fever, lethargy, weight loss, night sweats, mouth ulcers, hair loss, lymphadenopathy.
Careful consideration to exclude these signs from those found in other red-flag conditions.
Presence of a limp requires careful immediate assessment particularly in association with a fever (e.g. in leukaemia). Other red-flag symptoms include weight loss, lethargy, bruising, night pain.
Further information on the limping child can be found on the PMM website.
It is important to remember that any child with a limp that is not resolving requires a medical review. Careful safety netting to parents is important including to return if deterioration in symptoms is noted, the child is not weight bearing or they become systemically unwell (e.g. fever, bruising, fatigue, weight loss).
Red-flag conditions include malignancy (leukaemia), infection (septic arthritis, osteomyelitis, rheumatic fever, TB) or non-accidental injury (child abuse).
Further information about red flags can be found on the PMM website.

Ask about:

General and interests – play, games, sport, hobbies, school (concentration).
Recent events in home or school environment.
Change in behaviour, mood, interference with sleep.
Impact at school: deterioration in schoolwork (e.g. handwriting), attendance, interaction with peers.
Limitation of activities (dressing, toileting, stairs), restriction of participation (play, sport, exercise, school).

Has there been regression in motor milestones?
Is the child requiring assistance with activities of daily living that they previously could complete without help?
Have they become less active with apparent reduction in exercise tolerance?
Do they prefer to be carried down the stairs in the morning?
Have there been reports of change at school or nursery (e.g. schoolwork, handwriting, walking, sitting or transferring ability)?

Are they seeking comfort or rubbing their joints?
Do they dislike having their hand held or having their nails cut?
Are they less willing to partake in games or structured physiotherapy?
Have they made subtle adaptations such as ‘bottom shuffling’ down the stairs, or holding a banister with their whole arm rather than their hand?
Have there been reports of change at school or nursery (e.g. mood, irritability, fatigue)?