Changes

September 2024 — minor update. The name of the topic changed to 'common musculoskeletal presentations in children' from 'developmental rheumatology in children'.

Update

Goals

To support primary healthcare professionals to:

• Recognize normal musculoskeletal developmental features and differentiate them from pathological findings.
• Offer reassurance to parents and carers where appropriate.
• Be aware of when further assessment is required.
• Refer for specialist assessment and management when indicated, and in an appropriate time scale.

Outcome measures

Audit criteria

QOF indicators

QIPP - Options for local implementation

NICE quality standards

Why is appropriate referral important?

Most musculoskeletal presentations in children are benign and self-limiting and may not need referral to a specialist. However, it is important that children are effectively triaged and receive specialist care where appropriate [Foster, 2013]. 

• Musculoskeletal complaints are a common cause of visits to primary care, but a large proportion of these are for children who are entirely healthy or who are developmentally within a normal physiological range. Bow legs, knock knees, flat feet, and in-toeing and out-toeing gaits are common, but may result in general practice consultations because of parental anxiety. Referral of children with physiologically normal conditions has a significant impact on secondary care resources, increases waiting lists, and may delay access to care for children requiring specialist treatment [Carli, 2012; Yeo, 2015; Rerucha, 2017].  
• Recognising normal developmental features and differentiating them from disease may allow reassurance of parents, reduce the need for referral, and facilitate appropriate referral of abnormal conditions [Yeo, 2015]. Primary care providers are in a position to provide this education and reassurance, and earlier intervention, if needed, can result in better outcomes [Foster, 2020].  
• Paediatric Musculoskeletal Matters (www.pmmonline.org) is a resource for clinicians working with children and young people. It aims to facilitate early diagnosis and appropriate referral to specialist care for children and young people with musculoskeletal conditions, and raise awareness and improve knowledge and skills (including tools to help with paediatric joint examination).

Back pain

• Low back pain is common in children and adolescents (although it is rare in pre-school aged children), with prevalence increasing with age [Calvo-Munoz, 2013; Jakes, 2015; MacDonald, 2017].  
• It is usually short-lived and not severe, but should be carefully assessed as it may limit activities and affect school attendance [Calvo-Munoz, 2013; Achar, 2020].
• In school-age children, most back pain will be non-specific and self-limiting and will not require further investigation, responding to simple measures such as rest from exacerbating activities and possibly physical therapy [Jakes, 2015; MacDonald, 2017]. Lack of red flag symptoms or examination abnormalities is usually reassuring that a sinister cause is unlikely, but where history or examination suggests underlying pathology, blood tests and imaging may be required [Cruikshank, 2014; Achar, 2020; Frosch, 2022].
• Despite most causes of low back pain being musculoskeletal and benign, potentially serious illnesses, although rare, need to be considered. Differential diagnoses to consider in a child or adolescent with back pain are broad, including [Cruikshank, 2014; MacDonald, 2017; Achar, 2020]: 
  • Muscular (for example poor posture, muscle spasm, and myalgia).
  • Infection (for example discitis, osteomyelitis, and epidural abscess).
  • Inflammation (for example juvenile idiopathic arthritis (JIA) and ankylosing spondylitis).
  • Tumour of bone, spinal cord, or bone marrow.
  • Structural conditions (for example scoliosis, spondylosis, spondylolisthesis, and intervertebral disc herniation).
  • Metabolic conditions (for example osteoporosis).
  • Chronic pain syndromes such as fibromyalgia.

Bow legs

• A large number of children are born with, or develop, bow legs (genu varum) which are often associated with physiological internal tibial torsion, for which the cause is unclear [Mooney, 2014]. Bow legs may also relate to intrauterine positioning, which leads to the contracture of the medial knee joint capsule. When children start to bear weight on their lower limbs this deformity is accentuated, therefore referrals are common in children aged 10–14 months as they start to stand and walk [Yeo, 2015]. 
  • The condition is typically bilateral, symmetrical, painless, and self-limited, and may be associated with out-toeing. It affects boys and girls equally, and most bow legs resolve spontaneously over time (it is unusual for the condition to persist after the age of 18 months to 2 years) [Foster, 2013; Rerucha, 2017]. 
  • Pathological bow legs may be due to rickets, skeletal dysplasia, trauma, infection, tumours or Blount's disease (abnormal growth of the medial proximal tibial metaphysis associated with obesity) [Yeo, 2015; Rerucha, 2017].

Clumsy child

• The term 'clumsy' describes motor coordination difficulties with both fine and gross motor skills. Children with coordination problems may fall frequently and can struggle to learn motor skills mastered by their peers (for example writing, dressing, self-feeding, and using scissors) [Hamilton, 2002; Blank, 2019; BMJ Best Practice, 2024].
  • Developmental coordination disorder is a common, chronic, neurodevelopmental disorder, in which the child's coordinated motor skills are below those expected, interfering with their daily activities. Learning difficulties, emotional problems, conduct disorder, and oppositional defiant disorder are more common in children with developmental coordination disorder and it can also co-exist with other neurodevelopmental and neurobehavioural disorders such as ADHD, autism spectrum disorder, and developmental dyslexia. It is more common in boys than girls [Hamilton, 2002; Blank, 2019].
  • Other causes of apparent clumsiness include visual impairment, orthopaedic disorders, mild cerebral palsy, hereditary ataxia, and congenital chorea [Hamilton, 2002]. 

Curly toes

• Underlapping toe ('curly' toe) deformity is thought to be congenital, affecting 3% of people, and it can be unilateral or bilateral. It is often noticed early in infancy and most commonly affects the fourth and fifth toes.
  • In an underlapping toe, the proximal phalanx is typically in varus at the metatarsophalangeal joint with flexion and there may be a rotational malalignment. The deformity is passively correctable in most cases and is rarely rigid.
  • In children with underlapping toes, most will have no symptoms or limitation of function, and the underlapping toe will often correct itself with weight-bearing or by the age of 6 years.
  • However, in some cases, intervention is needed, for example, if there is persistent pain and problems with footwear, although there is no gold standard approach to treatment.

[Talusan, 2013]

Flat feet

• The term flat feet (pes planus) describes a deformity of the feet where there is loss of the medial longitudinal arch of the foot, so that when the child stands, the normal foot arch looks flat against the floor [Evans, 2022; Raj, 2023].
• This is normal in babies and toddlers due to fatty tissue on the insoles of the feet, and usually resolves by 6 years of age [Foster, 2013; BMJ Best Practice, 2024]. Flexible, painless flat feet in otherwise healthy children in the absence of concerning features (abnormal neurology, lack of arch standing on tiptoes, asymmetry, stiff or swollen joints, pain or limp) are usually considered a normal variant up to that age [Versus Arthritis, 2021]. 
• Reported prevalence varies widely as there is no consensus on definition or criteria for diagnosis [Banwell, 2018]. It is one of the most common reasons for consultations for musculoskeletal problems in children [Yeo, 2015]. Children who are obese and overweight, have joint laxity, or have a positive family history are more likely to have flat feet [Yeo, 2015; Rerucha, 2017].  
• In a minority of cases, flat feet may be associated with significant pathology, in which case there are usually additional clinical features of concern. They may be a feature of juvenile idiopathic arthritis, cerebral palsy, or Down's syndrome,  or appear to be the case in conditions causing a high arch rather than actual flat feet, such as Charcot Marie Tooth or congenital talipes equino varus [Evans, 2022]. It may be familial and may be associated with features of hypermobility syndromes [Raj, 2023; PMM, 2024a].
• When symptomatic, flat feet can cause pain (foot, lower limb or back) or altered gait [Banwell, 2018; Raj, 2023; BMJ Best Practice, 2024].
• There is a lack of evidence for the benefit of treatment for healthy children with painless flat feet [Evans, 2022].

Growing pains

• The term 'growing pains' describes a common benign, non-inflammatory syndrome of recurrent discomfort in young children [Lehman, 2017].
• There is significant inconsistency and uncertainty within the literature regarding the definition, aetiology, prevalence and diagnostic criteria for growing pains [Pavone, 2019; O'Keeffe, 2022]:
  • The cause is unknown, and proposed causes have not been supported by research. There does seem to be a genetic susceptibility, and there is often a positive family history.
  • Reported prevalence rates range from 3.5% to 36.9% and above, depending on definition, setting and geographical area.
  • Most studies suggest growing pains occur between the ages of 3 and 12 years, although others report age of onset up to the age of 15 years.
• Typical features of growing pains (again this varies in the literature) include [Lehman, 2017; Versus Arthritis, 2021; O'Keeffe, 2022]:
  • Pains that are usually symmetrical in the lower limbs and not limited to joints.
  • Pain that usually comes on in the evening or at night and is never present after waking in the morning.
  • The child is systemically well and physical examination is normal (although there may be hypermobility and/or flat feet). 
  • Major motor milestones are normal.
  • The child does not limp and physical activity is not limited by the symptoms.
  • Most children with growing pains have pain-free days.
• The list of more serious conditions that need to be considered that can present similarly to growing pains is extensive and includes [Lehman, 2017]:  
  • Autoimmune and inflammatory conditions (for example juvenile dermatomyositis, juvenile idiopathic arthritis); infectious conditions (for example osteomyelitis, septic arthritis, and cellulitis).
  • Malignancy (for example leukaemia, Ewing sarcoma, and metastatic lesions).
  • Trauma (for example sprains and strains, acute or stress fracture, and nerve injury).
  • Structural conditions (for example slipped capital femoral epiphysis, joint hypermobility syndrome, and patellofemoral syndrome).
  • Metabolic conditions (for example vitamin D deficiency).
  • Non-inflammatory pain syndromes (for example fibromyalgia and restless leg syndrome).
• In contrast with these conditions, the physical examination in a child with growing pains is usually normal [Lehman, 2017]. 

Heel pain

• Heel pain is commonly reported in young children and adolescents and most causes are benign [Joseph, 2013; Kothari, 2023].
• The most common cause in this age group is calcaneal apophysitis (Sever's disease) [Fares, 2021; Kothari, 2023; Smith, 2024].
  • Pain results from the pull of the Achilles tendon on the unossified apophysis, causing inflammation. 
  • Affected children and adolescents usually present between 8 and 15 years of age with posterior heel pain related to activity or a growth spurt, which is usually relieved by rest.
  • Management for this self-limiting condition includes reassurance and avoiding exacerbating activities, but symptomatic relief may also require anti-inflammatory medication, ice, Achilles stretching, and heel cup shoe inserts.  
• Other causes of heel pain in children and adolescents include [Joseph, 2013; Kothari, 2023]:  
  • Achilles tendinitis — rare under 14 years of age. May occur in jumping athletes and people with a sudden increase in sporting activity. 
  • Plantar fasciitis — more common in adolescents but can occur in any age group, particularly in children who participate in sports with high levels of running, jumping and inclines, and may be seen in combination with Sever's disease. Presentation is with morning pain and stiffness, and pain during exercise which is relieved by rest.
  • Retrocalcaneal bursitis — may be caused by traumatic overactivity. 
  • Calcaneal fracture — stress fractures occur with repetitive trauma and may be misdiagnosed as a foot sprain. Fractures can also result from injuries such as a fall from a height, or direct blow to the calcaneus. 
  • Calcaneal tumours — rare. Often presents with progressive dull, deep pain in the heel and swelling. 
  • Calcaneal osteomyelitis — Signs may be non-specific and include redness, warmth, point tenderness, and oedema. There may be toe walking and fever along with heel pain. It can result from direct inoculation or acute haematogenous spread and may be associated with complications including chronic infection and growth problems. 
  • Retained foreign body — more common in children in warm countries who are outside with no shoes. 

Hypermobility

• Joint hypermobility (where joints move beyond their normal range of motion) is common in children, and may be a normal variant that decreases with age [BSR, 2019; Tofts, 2023]. 
• Diagnostic criteria and definitions have evolved and have caused controversy [BSR, 2020].
• Hypermobility may be localised, peripheral, or generalised, and may be [Castori, 2017; Malfait, 2017; PMM, 2024b]:
  • Asymptomatic isolated hypermobility.  
  • Part of a defined syndrome that includes hypermobility, the most common of which is Ehlers-Danlos syndrome, which encompasses a clinically and genetically heterogeneous group of connective tissue disorders. Other genetic syndromes where joint hypermobility may be a feature include Marfan, fragile-X, Down's, Williams, and Stickler syndromes, some types of osteogenesis imperfecta, pseudoxanthoma elasticum, and pseudoachondroplasia.
  • Symptomatic but not satisfying criteria for a syndrome, usually known as hypermobility spectrum disorder or sometimes joint hypermobility syndrome. 
• There is often a strong family history, and females are affected more than males [Versus Arthritis, 2021]. Prevalence studies vary widely depending on selection criteria, setting, and location, but one meta-analysis concluded that globally, the prevalence of joint hypermobility in children and adolescents was around 34% [Sobhani-Eraghi, 2020].
• Many children will have no symptoms, but it may cause symptoms or be associated with other features such as [Versus Arthritis, 2021; PMM, 2024b]:
  • Joint and muscle pain.
  • Clicking joints.
  • Fatigue.
  • Handwriting difficulty.
  • Reduced coordination and balance.
  • Flat feet.
  • Reduced general activity and function.
  • Skin, connective tissue, and/or multisystem disorders.
• Comorbidities reported include functional gastrointestinal and bladder disorders, chronic pain, chronic fatigue, dysautonomia often presenting as postural orthostatic tachycardia syndrome (POTS) in older children, anxiety, developmental coordination disorder (DCD), attention deficit hyperactivity disorder (ADHD), and inflammatory arthritis [Tofts, 2023].
• Hypermobility is assessed differently in children and adolescents compared to adults, and the diagnosis of the type of hypermobility may change over time [Tofts, 2023].

In-toeing

• In-toeing (sometimes described as pigeon-toeing) describes the medial or internal rotation of the foot relative to the direction the child is moving in [BMJ Best Practice, 2020]. The foot turns inward instead of pointing straight ahead when the child stands with legs straight. It is more common than out-toeing.
• The appearance of the feet in a child with in-toeing is a common cause for concern in parents. In-toeing is one of the most frequently encountered musculoskeletal findings and is often due to normal developmental variation. Up to 30% of children under the age of 6 may exhibit in-toeing gait as part of normal development [Evans, 2017]. Most in-toeing will rectify itself over time, but it is important to recognise conditions which do need intervention [Berry, 2018; Davis, 2018].  
• There are three main causes of in-toeing, in which the rotational component is considered normal from birth until about 10 years of age [Yeo, 2015; Rerucha, 2017; Berry, 2018; Davis, 2018]: 
  • Internal tibial torsion (the most common cause of in-toeing) — defined by the angular difference between the transmalleolar axis of the ankle and the bicondylar axis of the knee. Internal tibial torsion becomes most apparent when the child starts walking. Boys and girls are equally affected. It usually resolves by the age of 5.
  • Femoral anteversion — defined as the angular difference between the axis of the femoral neck and the transcondylar axis of the knee. This is commonly the cause in school-aged children, is more common in girls, and tends to be most severe between the ages of 4 and 7. It resolves in 80% by the age of 8 years. Children with femoral anteversion tend to sit with their legs in the W position. Treatment may be needed if the condition persists.
  • Metatarsus adductus — internal angulation of the forefoot (or metatarsals) on a neutral or flexible hindfoot. This is the most common congenital foot abnormality and usually resolves by the age of one. When the deformity is rigid, treatment is required. It is more common in girls than boys. Findings include a curved lateral border of the foot, a medial soft-tissue crease and an abnormal heel bisector line.
• However, there are a number of conditions for which in-toeing is a symptom, including neurological (cerebral palsy and spina bifida), musculoskeletal (slipped capital femoral epiphysis, and congenital hip dysplasia), and metabolic disorders (rickets, Blount's disease and osteogenesis imperfecta) [Berry, 2018]. 

Knock knees

• Knock knees (genu valgum) is usually a self-limited, asymptomatic condition, commonly occurs bilaterally between 3 and 6 years of age, and is more common in girls [Rerucha, 2017]. The appearance of knock knees is exacerbated by obesity, ligamentous laxity, and flat feet, and the condition may be associated with in-toeing. Referral of children with knock knees is common between 3 and 4 years, but most will resolve by 7 years of age [Foster, 2013; Yeo, 2015]. 
  • Pathological causes of knock knees include trauma, fracture, and previous osteomyelitis, and they may be associated with early osteoarthritis [Rerucha, 2017]. 
  • There are a number of potentially serious differential diagnoses of knock knees, including bone tumour, juvenile idiopathic arthritis, cerebral palsy, slipped capital epiphysis, vitamin D deficiency, Ehlers-Danlos, bone dysplasia, metabolic bone disease, Blount's disease, and joint hypermobility [Evans, 2017].

Late walking

• Most children start walking with assistance by 12–14 months [Foster, 2013; Versus Arthritis, 2021]. The National Institute for Health and Care Excellence (NICE) guidance suggests that it is expected that girls will be walking independently by 15 months, and boys by 18 months (corrected for gestational age) [NICE, 2023].
• Late walking (including bottom shuffling) may be familial, but underlying causes of late walking include neurodevelopmental disorders such as muscular dystrophy or cerebral palsy, particularly if there is also global delay with speech, hearing, vision, and fine motor milestones [NICE, 2023; BMJ Best Practice, 2024]. 
• Other causes of late walking include lysosomal storage diseases, rickets, spina bifida and developmental hip dysplasia [BMJ Best Practice, 2024; PMM, 2024a].

Out-toeing

• Out-toeing describes lateral or external rotation of the foot relative to the direction in which the child is moving, so that the feet point outwards [BMJ Best Practice, 2020; PMM, 2024a]. It is less common than in-toeing, and may be associated with bow legs and flat feet [Rerucha, 2017; BMJ Best Practice, 2020; BMJ Best Practice, 2024]. 
  • It is normal in early infancy, usually resolving by 18–24 months of age. In older children, it may be caused by external tibial torsion or femoral retroversion [Yeo, 2015; Rerucha, 2017]. 
  • Other conditions that should be considered include Perthes' disease and slipped capital femoral epiphysis, particularly if the child is older, or symptoms are unilateral [Yeo, 2015]. 

Tip toe walking

• Toe walking is an abnormality of gait where a child walks predominantly on their toes or forefoot, with absent heel strike [Bauer, 2022; BMJ Best Practice, 2024].  
  • Habitual toe walking is common in children up to the age of three years [Foster, 2013; BMJ Best Practice, 2024].
  • If there is no underlying cause, the condition is known as idiopathic (or habitual) toe walking. Most persistent toe walkers over the age of 3 years have idiopathic toe walking and the chances of spontaneous resolution are good, with almost 80% resolving by 10 years of age [Bauer, 2022]. The estimated prevalence of idiopathic toe walking is around 5% of healthy children, and affects boys more often than girls [Caserta, 2019].
  • However, idiopathic toe walking is a diagnosis of exclusion because toe walking can also be associated with pathological causes, including [Caserta, 2019; Bauer, 2022; BMJ Best Practice, 2024]: 
    • Brain lesions (for example cerebral palsy and hydrocephalus).
    • Spinal lesions (for example spina bifida and spinal space occupying lesion).
    • Neurological conditions (for example peripheral neuropathy).
    • Muscle disorders (for example Duchenne muscular dystrophy). 
    • Movement disorders.
    • Developmental disorders (for example autism spectrum disorder, intellectual disability, and language and communication disorders).
    • Short calf tendon/muscle.
    • Limb length discrepancy. 
    • Club foot (talipes equinovarus).
    • Lysosomal storage diseases.
  • The consequences of persisting idiopathic toe walking are not clear. There are no clinical trials comparing treatment to no treatment, and whilst some studies suggest little subsequent functional disturbance, deformity or pain, others have raised concerns about limited ankle dorsiflexion and functional problems, such as ankle sprains, less efficient gait, and increased pressure on the metatarsal heads causing pain in the foot, callouses, and stress fractures [Caserta, 2019; Bauer, 2022]. 

How should I assess a child with a suspected musculoskeletal problem?

For children presenting with musculoskeletal problems, a thorough history and examination is needed in order to differentiate normal variants from significant local or systemic conditions which may require intervention. Although this assessment may vary slightly with the presenting problem, this section gives an overall guide to the basic assessment, and links to resources with more detail. 

• Paediatric Musculoskeletal Matters (www.pmmonline.org) is a resource for clinicians working with children and young people. It aims to facilitate early diagnosis and appropriate referral to specialist care for children and young people with musculoskeletal conditions, and raise awareness and improve knowledge and skills (including tools to help with paediatric joint examination).

When assessing musculoskeletal symptoms, the clinician must be aware of:

• Normal motor milestones, for example:
  • 6-8 months — sits without support.
  • 12-14 months — walks independently.
  • 15 months — climbs up stairs on hands and knees.
  • 16 months — runs stiffly.
  • 2 years — walks up steps, both feet each step.
  • 3 years — walks up steps, alternate feet.
  • 4 years — hops on one foot. Walks up and down steps with alternate feet.
  • 6-7 years — balances on one foot 20 seconds.
• Normal variants, for example:
  • Bow legs — common from birth and in toddlers, most resolve by 18 months.
  • Knock knees — common between 3 and 6 years of age, most resolve by 7 years.
  • Flat feet — common in babies and toddlers, most have a flexible foot with a normal arch and resolve by 6 years.
  • Toe walking — common up to the age of 2–3 years.
  • In-toeing — common in childhood, most resolve spontaneously, with age of resolution dependent on the aetiology.
  • Out-toeing — less common, normal in early infancy, and usually resolves by the age of  2 to 4 years of age.
  • Curly toes — usually resolve once the child is weight bearing.

When taking a history, ask about:

• Parental concerns (for example, pain, gait, function, appearance, duration, progression, and underlying pathology).
• Symptoms and signs (for example, pain, gait problems, issues with shoes, limping, tripping, and falling). Enquire further about:
  • Pain — site, radiation, timing, duration, exacerbating and alleviating factors, symmetry, and night symptoms.
  • Joint swelling.
  • Limp.
  • Fluctuation of symptom(s).
  • Sitting habits (for example the W sitting position, common in children with increased femoral anteversion).
  • History of prior trauma or illness.
  • Fever.
  • Rashes.
  • Impact.
  • General health (systemic enquiry of key systems, general symptoms such as lethargy, weight loss, and night sweats).
• Family history (for example inflammatory arthritis, rotational or angular limb deformities, neuromuscular diseases, autoimmune diseases, and infections including TB).
• Past medical history, including birth, growth and development history, and milestone achievement/regression.
• Social history (for example, home situation, stresses, and sporting activities).
• Vaccination history.
• Travel history.
• Sexual history in the appropriate age group.
• Medication (and illicit substances in older age groups).
• Diet (particularly calcium and vitamin D when considering rickets).

When performing an examination:

• Introduce yourself and obtain consent. Arrange a chaperone as necessary.
• Observe the child entering the room and at rest/playing.
• Expose appropriately. Be aware of cultural and gender issues. Explain why you are examining/exposing.
• Look out for verbal and non-verbal indications of distress or pain while examining.
• Look out for dysmorphic features, asymmetry, joint swelling, abnormal posture, and muscle wasting.
• Check height and weight (and plot on growth chart).
• Observe the child standing from the front, back, and side.
• Look for skin changes or abnormalities.
• Consider neurological, respiratory, cardiac, or other system examinations and vital signs where the history or other findings make this appropriate.
• The pGALS (paediatric Gait, Arms, Legs and Spine) assessment is a helpful format for a musculoskeletal examination in a child. It describes how to systematically check gait, spine, limbs, joints, and assess angular or rotational deformities. See the Versus Arthritis handbook Musculoskeletal clinical assessment in children and young people or the Clinical Assessment section of the Paediatric Musculoskeletal Matters (PMM) International website for full details on performing this examination.
  • pGALSplus is an extended assessment, also described on the PMM website, allowing for further assessment of children with limp, clumsiness or joint pains, and helps differentiate conditions such as hypermobility, developmental co-ordination disorder and juvenile idiopathic arthritis.
• Keep in mind that more detailed assessments may be needed for rotational abnormalities (in-toeing and out-toeing) or angular deformities (bow legs and knock knees), including:
  • Measuring intermalleolar and intercondylar distances - the gap between the ankles and the knees respectively - for knock knees and bow legs.
  • Looking at the heel bisector line (from centre of heel, normally crosses between second and third toes, may be between lateral toes in metatarsus adductus, a cause of in-toeing gait).
  • Looking at the lateral border of the foot (usually straight, may be curved in metatarsus adductus).
  • Examining for internal tibial torsion or femoral anteversion (causes of in-toeing).
• Access the website for Paediatric Musculoskeletal services of Nottingham University Hospitals NHS Trust for details on assessing rotational profile. 

What are the red flags when assessing a child with a musculoskeletal problem?

• Admit to an emergency department children with:
  • Suspected septic arthritis.
  • Suspected osteomyelitis.
  • Suspected fracture.
  • Suspected slipped upper femoral epiphysis (SUFE) — hip, groin, and distal thigh pain in 10–16-year-olds; leg pain on weight bearing; and pain on passive hip movements.
• Seek specialist advice or urgently refer to:
  • Rheumatology:
    • Suspected inflammatory arthritis (for example joint swelling, early morning stiffness and pain, systemic illness, and motor milestone regression).
    • Back pain (with red flags).
  • Orthopaedics:
    • Limping children in whom SUFE is not suspected.
    • Back pain (with red flags).
    • Back problems (for example scoliosis, neurological symptoms, and systemic illness).
    • Bone pain.
  • Paediatrics:
    • Suspected neurological problem (for example muscle wasting or weakness and sensory changes).
    • Possible cancer (for example bruising, weight loss, systemic illness, morning headaches, nausea and vomiting, lymphadenopathy, and hepatosplenomegaly).
    • Back pain (with red flags).
    • Milestone delay or regression.
    • Persistent night waking.
    • Suspected non-accidental injury, for example incongruent history and presentation or physical findings (for more information see the CKS topic on Child maltreatment - recognition and management).
    • Bladder or bowel problems.
• Consider further investigation or referral (use clinical judgement) for a child or young person with:
  • Atypical symptoms.
  • Worsening symptoms.
  • Unremitting pain; night pain; and thoracic pain.
  • Non-mechanical pain.
  • Abnormal loss or deterioration of function.
  • Significant loss of movement.
  • Gait disturbance.
  • Significant lower limb asymmetry.
  • TB, cancer, HIV/AIDS, steroid use, and multiple fractures.
  • Skin changes, for example, cafe au lait, psoriasis, and bruising.

Scenario: Back pain in children

From birth to 16 years.

Scenario: Bow legs in children

From birth to 16 years.

Scenario: Clumsy child

From birth to 16 years.

Scenario: Curly toes in children

From birth to 16 years.

Scenario: Flat feet in children

From birth to 16 years.

Scenario: Growing pains

From birth to 16 years.

Scenario: Heel pain in children

From birth to 16 years.

Scenario: Hypermobility in children

From birth to 16 years.

Scenario: In-toeing gait in children

From birth to 16 years.

Scenario: Knock knees in children

From birth to 16 years.

Scenario: Delayed walking in children

From birth to 16 years.

Scenario: Out-toeing

From birth to 16 years.

Scenario: Tip-toe walking

From birth to 16 years.

Search strategy

Scope of search

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of developmental rheumatology in children.

Search dates

May 2019 - June 2024

Key search terms

The terms listed below are the core search terms that were used for EBSCOhost MEDLINE (searched 15th February 2019). These were combined with filters to identify guidelines, systematic reviews and primary care relevant literature in EBSCOhost MEDLINE. The strategy was adapted for The Cochrane Library databases. 

S61    S46 AND S54 AND S60 
S60    S55 OR S56 OR S57 OR S58 OR S59 
S59    AB ( juvenile* or child* or infant or infants or infancy or baby or babies or paediatric* or pediatric* or adolescen* or boy or boys or girl or girls or young or youth* or teenage* ) OR TI ( juvenile* or child* or infant or infants or infancy or baby or babies or paediatric* or pediatric* or adolescen* or boy or boys or girl or girls or young or youth* or teenage* ) OR SO (juvenile* or child* or infant or infants or infancy or baby or babies or paediatric* or pediatric* or adolescen* or boy or boys or girl or girls or young or youth* or teenage* )
S58    (MH "Pediatrics+") 
S57    (MH "Adolescent") 
S56    (MH "Child+") 
S55    (MH "Infant+") 
S54    S50 OR S51 OR S52 OR S53 
S53    AB ( refer* or triage* or assess* or red flag or red flags or rightpath or examination or PGALs or pathology or pathological) 
S52    (MH "Triage") 
S51    (MH "Physical Examination+") 
S50    (MH "Referral and Consultation+") 
S49    S47 AND S48 
S48    (MH "Pain+") 
S47    (MH "Heel") 
S46    S1 OR S2 OR S3 OR S4 OR S5 OR S6 OR S7 OR S8 OR S9 OR S10 OR S11 OR S12 OR S13 OR S20 OR S23 OR S24 OR S25 OR S26 OR S27 OR S28 OR S29 OR S30 OR S31 OR S32 OR S33 OR S34 OR S35 OR S36 OR S37 OR S38 OR S39 OR S40 OR S41 OR S42 OR S43 OR S44 OR S45 
S45    AB pigeon toe* OR TI pigeon toe* 
S44    AB ( rotational N1 (deformit* or variation* or abnormalit* or problem*) ) OR TI ( rotational N1 (deformit* or variation* or abnormalit* or problem*) ) 
S43    AB ( intoe* or in-toe* or outtoe* or out-toe* ) OR TI ( intoe* or in-toe* or outtoe* or out-toe* ) 
S42    AB ( joint instability or joint laxity ) OR TI ( joint instability or joint laxity ) 
S41    AB hypermobil* OR TI hypermobil* 
S40    (MH "Joint Instability") 
S39    TI spinal N0 pain* 
S38    TI back N1 pain* 
S37    (MH "Back Pain+") 
S36    TI juvenile N2 arthritis 
S35    (MH "Arthritis, Juvenile") 
S34    AB slipped capital femoral epiphys* OR TI slipped capital femoral epiphys* 
S33    (MH "Slipped Capital Femoral Epiphyses") 
S32    AB septic arthritis OR TI septic arthritis 
S31    (MH "Arthritis, Infectious+") 
S30    AB developmental coordination disorder OR TI developmental coordination disorder 
S29    TI dyspraxi* 
S28    AB ( clumsy or clumsiness ) OR TI ( clumsy or clumsiness ) 
S27    AB ( (delay* or late or onset or attainment) n1 walking ) OR TI ( (delay* or late or onset or attainment) n1 walking ) 
S26    AB calcaneal apophysitis OR TI calcaneal apophysitis 
S25    AB ( sever disease or severs disease or sever's disease ) OR TI ( sever disease or severs disease or sever's disease ) 
S24    AB (heel N0 pain*) OR TI (heel N0 pain*) 
S23    S21 AND S22 
S22    (MH "Pain+") 
S21    (MH "Heel") 
S20    S16 AND S19 
S19    S17 OR S18 
S18    (MH "Musculoskeletal Pain+") 
S17    (MH "Pain+") 
S16    S14 OR S15 
S15    (MH "Growth Disorders+") 
S14    (MH "Growth+") 
S13    TI ( (((musculoskeletal or limb* or (lower extremity) or leg or legs)) N2 pain*) ) 
S12    TI grow* N2 pain* 
S11    AB ( (tiptoe* N2 (walk* or gait*)) or (tip-toe* N2 (walk* or gait*)) or toe-walk* or toewalk* or (equinus N2 gait) ) OR TI ( (tiptoe* N2 (walk* or gait*)) or (tip-toe* N2 (walk* or gait*)) or toe-walk* or toewalk* or (equinus N2 gait) ) 
S10    AB ( (curly or curling or underlapping or varus) N1 toe* ) OR TI ( (curly or curling or underlapping or varus) N1 toe* ) 
S9    AB ( (angular N0 (deformit* or abnormalit* or deviation* or variant*)) ) OR TI ( (angular N0 (deformit* or abnormalit* or deviation* or variant*)) ) 
S8    AB ( (genu valgum or knockknee* or (knock n0 knee*)) ) OR TI ( (genu valgum or knockknee* or (knock n0 knee*)) ) 
S7    (MH "Genu Valgum") 
S6    AB ( (genu varum or (bow N0 leg*) or (bowleg*)) ) OR TI ( (genu varum or (bow N0 leg*) or (bowleg*)) ) 
S5    (MH "Genu Varum") 
S4    AB pes planovalgus OR TI pes planovalgus 
S3    AB pes planus OR TI pes planus 
S2    AB ( (flatfoot* or flatfeet* or (flat N0 foot*) or (flat N0 feet)) ) OR TI ( (flatfoot* or flatfeet* or (flat N0 foot*) or (flat N0 feet)) ) 
S1    (MH "Flatfoot") 

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• World Health Organization
• Guidelines International Network
• TRIP database
• Agency for Healthcare Research and Quality
• Institute for Clinical Systems Improvement
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Bandolier
• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• LactMed
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
• Accuracy of implementation of national guidance (in particular NICE guidelines).
• Usability.

Principles of the consultation process

• The process is inclusive and any individual may participate.
• To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
• Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
• Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
• External reviewers are not paid for commenting on the draft topics.
• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
• All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
• All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

• Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
• Stakeholders identified from the following groups are invited to review draft topics:
  • Experts in the topic area.
  • Professional organizations and societies (for example, Royal Colleges).
  • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
  • Guideline development groups where the topic is an implementation of a guideline.
  • The British National Formulary team.
  • The editorial team that develop MeReC Publications.
• Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

• Topic selection
• Scoping of topic
• Selection of clinical scenarios
• First draft internal review
• Second draft internal review
• External review
• Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
  • Eligible population
  • Current interventions
  • Likely uptake of new intervention or recommendation
  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

• Personal financial interests
• Personal family interest
• Personal non-financial interest
• Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.