GPAtlas🧭 When to suspect (and when to reassure)
Musculoskeletal complaints are one of the commonest reasons a child is brought to the GP – roughly 1 in 8 children are affected, and a quarter of all patients a GP sees each year are under 18. The great majority are either physiological "normal variants" of the growing child or self-limiting conditions that resolve with reassurance alone. Around a quarter to a half of new paediatric orthopaedic referrals are for normal variants.
The core skill in primary care is pattern recognition: separating the benign presentation from its occasional "evil twin". Reassuring features are symmetry, absence of pain, an age-appropriate finding, normal development, a well child and a normal examination. The combination of asymmetry, pain, a limp, systemic features, developmental regression, or a finding at the wrong age is what should prompt investigation or referral.
| Presentation | Usually physiological / benign if… | Refer or investigate if… |
|---|---|---|
| Back pain | Older child / adolescent, mechanical and activity-related, normal exam, systemically well | Age < 10y (especially < 4y), nocturnal / rest pain, systemic features, neurological signs, persists > 4 weeks |
| Bow legs (genu varum) | Symmetrical, painless, child < 2–3y, otherwise well | Asymmetric, painful, progressive, persists / worsens beyond ~3y, or short stature (Blount disease, rickets) |
| Knock knees (genu valgum) | Symmetrical, painless, most marked at 3–4y, resolving | Asymmetric, painful, wide intermalleolar distance, persists beyond ~7y, or short stature |
| Growing pains | Bilateral, evening / night, never present on waking, no limp, normal exam, normal milestones | Unilateral, daytime, limp, joint swelling, systemic features, or any abnormal finding |
| Late walking | Walking achieved by ~18 months, other milestones normal | Not walking by 15m (girls) / 18m (boys), hand preference < 1y, regression, abnormal neurology |
| Toe walking | Intermittent, can heel-strike on request, age < 3y, normal development | Persists > 3y, asymmetric, cannot get heels down, new-onset, regression, tight calves |
| Hypermobility | Asymptomatic, no functional impact | Recurrent dislocations, chronic pain, or connective-tissue features (see History) |
Source: NICE · Paediatric Musculoskeletal Matters
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