Pain is a common presenting feature in children. Young children may not articulate pain but will protect painful areas or cry with movement. Be alert to non-verbal clues.

Trauma is a common cause of musculoskeletal pain but be aware that trauma is common and may be a ‘red herring’ as other pathologies may co-exist. A history of temporally related significant trauma must be elicited where there is loss of function of the affected region e.g., inability to bear weight after significant lower limb trauma. Often the history of trauma may draw attention to the previously existing pathology. Be aware of non-accidental injury.

The spectrum of causes of pain at sites includes mechanical, inflammatory, infection, rheumatic fever, metabolic disease and malignancy. Be aware of red flags.

The history of pain may be vague and often poorly localised in the history. Always be alert to general health, check all joints as a minimum with pGALS, and consider referred pain (e.g., hip problems with knee pain).

Growing pains do exist but need careful consideration - be aware of the ‘rules’.

Chronic pain without apparent pathology can associate with psychosocial factors and specialist multi-professional care is needed.

If there are clinical concerns, even if examination appears normal and blood tests are normal, do refer (i.e., to paediatric rheumatology or orthopaedics).

A painful scoliosis warrants urgent referral.

Night pain, irrespective of the location, warrants concern if very frequent, increasing or refractory. Be aware of red flags and that benign bone tumours and the arthralgia/arthritis of rheumatic fever may respond to NSAIDS.

Managing pain depends on the cause and may include analgesia, physiotherapy, advice on footwear or exercise. Pain that is not responsive and without an apparent cause needs referral (i.e., paediatric rheumatology or orthopaedics).