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History Taking: What to Ask & Why?

Key Questions to Ask When Taking a Musculoskeletal History from the Parent or Carer or Child 

Open, probing questions are needed and enquire about concerns.

Questions to parent / carer (and the child as appropriate)

Points to check for 

Comments and interpretations 

What have you or anyone else noticed?

Behaviour, mood, joint swelling, limping, bruising, falls, difficulty getting up from the floor, difficulty in climbing stairs, inability to sit cross-legged or inability to squat ?

Limping, whether intermittent or persistent always warrants further assessment. Abnormal gait, waddling in child over 3 years of age is abnormal.  Deterioration in school performance (e.g. sport, handwriting) is always significant. Joint swelling is always significant but can be subtle and easily overlooked by the parent (and even health care professionals!), especially if the changes are symmetrical.

Falls, child seems unsteady on feet and falls more than his friends. Difficulty getting up from the floor once sitting down, unable to jump and struggling to climb stairs all imply muscle weakness.

Rather than describing stiffness, the parents may notice the child is reluctant to weight bear or limps in the mornings or ‘gels’ after periods of immobility (e.g. after long car rides or sitting in a classroom).

Difficulty in climbing stairs or inability to squat may suggest proximal weakness as well as joint disease (hip or knee).

Inability to sit cross legged may suggest hip (or knee) disease.

What is the child like in him or herself? 

Irritability, grumpy, “clingy”, reluctant to play, systemic features (e.g. fever, Anorexia, weight loss).

Young children in pain may not verbalise pain but may present with behavioural changes or avoidance of activities previously enjoyed.

Systemic features including “red flags” to suggest malignancy or infection.

Where is the pain (ask the child to point) and what is it like?

Take a pain history and focus on the site of the pain, exacerbating/relieving factors, timescale pattern.

Asymmetrical persistent site of pain is invariably a cause for concern. Referred pain from the hip may present with non-specific pain in the thigh or knee.

How is he/she in the mornings and during the day?

Diurnal variation and daytime symptoms (e.g. limping, difficulty walking, dressing, toileting, stairs?).

Pain on waking or daytime symptoms suggestive of stiffness or gelling (after periods of inactivity), are indicative of inflammatory joint (or muscle) disease.

What is he/she like with walking and running? Has there been any change in his activities?

Gait and Motor milestones and suggestion of delay or regression of achieved milestone, including speech and language.  Avoidance of activities that previously enjoyed (e.g. sport, play) are noteworthy.

Regression of achieved motor milestones, functional impairment or avoidance of activity (including play, sport or writing), are more suggestive of acquired joint or muscle disease (and especially inflammatory causes).

An assessment of global neuro-development is indicated with delay or regression in speech, language or motor skills.  Combination of motor development delay and language delay - think muscle disease. Clumsiness” is a non-specific term but may mask significant musculoskeletal or muscle or neurological disease.

How is he/she at school / nursery?

School attendance (any suggestion of school avoidance, bullying).

Behavioural problems in the young child may manifest as non-specific pains (headaches, tummy aches or leg pains). Sensitive questioning may reveal stressful events at home or school.

Does he/she wake at night with pain?

Pattern of night waking.

Night waking is a common feature of growing pains  (and usually intermittent, and often predictable). Conversely persistent night waking, especially if there are other concerns (such as pain on one side [unilateral pain], limping, unusual location or red flags) are of concern and invariably necessitate further investigation.

Can you predict when the pains may occur?

Relationship to physical activity (including during or after sporting activities).

Growing pains tend to be worse later in the day, evenings and often after busy days.

What do you do when he/she is in pain?

Response to analgesics, anti-inflammatory medication, massages, and reaction of parent.

Lack of response to simple analgesia is a concern. Vicious circle of reinforced behaviour can occur.

 Does the child take a long time to eat?

 Has the child always been a “difficult eater”? struggling to swallow or chew food?

This can be a sign of muscle weakness or fatigability

What is your main concern?

Sleep disturbance, cosmesis, anxiety about serious disease (Arthritis, Cancer, family history), pain control.

A family history of Muscle Disease, Arthritis or Autoimmune Disease may indicate a predisposition to muscle or joint disease. Observed “abnormalities” (such as flat feet, curly toes) may be part of normal development. The parent or carer will undoubtedly have anxieties and concerns about the child, often fear severe illness and both child and parent have an expectation of investigations (i.e. blood tests!).


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