Chronic/recurrent musculoskeletal pain


These guidelines have been produced to guide clinical decision making for general practitioners (GPs). They are not strict protocols. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.


Chronic or recurrent musculoskeletal pain is a common childhood presentation in primary care. In most cases, children do not have a serious underlying condition. Most are self-limiting and improve over time. 

The “red flags” associated with conditions requiring further investigation and management are:

  • Fever
  • Swollen, warm and stiff joints (especially if worse in the morning)
  • Limping
  • Nocturnal pain
  • Systemic symptoms (e.g. weight loss, vomiting, diarrhoea, blood in stools, unexplained chronic fatigue)
  • Functional limitations or impact on daily activities (e.g. inability to walk, not going to school)
  • Depression, anxiety, or psychologic disturbance

Pre-referral history, examination, investigations

  • Clinical history including:
    • Onset
    • Diurnal patterns in the pain
    • Aggravating/relieving factors
    • Effect of pain on daily living
  • Thorough musculoskeletal examination
  • Depending on clinical picture:
    • Blood tests
      • FBC
      • ESR
      • CRP
      • U&E’s
      • LFT
      • TFT
      • Ferritin
      • Urinalysis
      • Imaging (e.g. X-ray, Ultrasound, MRI of affected site/s)

Pre-referral management

  • Assessment of impact of pain on:
    • daily activities
    • school
    • sleep
    • mood
    • appetite
  • Consider referral to a community Physiotherapist for possible biomechanical causes
  • Consider podiatry assessment for supportive shoes/trial over-the-counter orthotics
  • Consider trial of regular NSAID therapy e.g. Ibuprofen, Naproxen, Celecoxib
    • Opioids are not clinically indicated
  • HEADSS adolescent psychosocial assessment
    • Refer to community Psychologist if warranted

When to refer

  • If there are any of the above “red flag” features or concerns
  • Abnormal investigation results warranting further specialist assessment
  • Persistent / chronic musculoskeletal pain despite pre-referral management guidelines being followed
  • Persistent functional impairment e.g. inability to walk, poor school attendance

How to refer

  • Routine non-urgent referrals from a GP or a Consultant should go to the Central Referral Service
  • Routine non-urgent referrals from private hospitals go to the PCH Referral Office (Fax: 6456 0097 or email
  • Urgent referrals (less than seven days) go to the PCH Referral Office. Please call Perth Children’s Hospital Switch on 6456 222 to discuss referral with the on-call Rheumatologist

Essential information to include in your referral

  • History
  • Examination findings
  • Results of any investigations
  • Pre-referral management strategies trialled and outcome

Useful resources


Reviewer/Team: Rheumatology Department Last reviewed: Jan 2023

Review date: Jan 2026

This document can be made available in alternative formats on request for a person with a disability.

Referring Service

Rheumatology Department