Chronic/recurrent musculoskeletal pain

Disclaimer

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.

Introduction

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 PCH.Referrals@health.wa.gov.au)
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

Perth Children’s Hospital Pre-referral guideline: Anti-Nuclear Antibody positive (health.wa.gov.au)
Perth Children’s Hospital Pre-referral guideline: Back pain (health.wa.gov.au)
The Royal Children’s Hospital Melbourne: Engaging with and assessing the adolescent patient
The Royal Australian College of General Practitioners: Psychosocial assessment of young people
Health Pathways: Juvenile Idiopathic Arthritis

Reviewer/Team:	Rheumatology Department	Last reviewed:	Jan 2023
		Review date:	Jan 2026

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