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Non-Traumatic MSK Injuries Module


TopicNon-traumatic MSK injuries
AuthorStephen Gilmartin
DurationUp to 2 hours
Equipment requiredAV to project x-ray images
  • Basics (10 mins)
  • Main session: (2 x 15 minute) case discussions covering the key points and evidence
  • Advanced session: (2 x 20 minutes) case discussions covering grey areas, diagnostic dilemmas; advanced management and escalation
  • Quiz (10 mins)
  • Infographic sharing (5 mins): 5 take home learning points

Expectation is for the learners to have understood the basics before the session.

Anatomy video:

Assessment tips:

If possible or for further resource

Apophysitis, avulsions, Spondolysis:


  • Differential diagnosis of non-traumatic pain
  • Diagnoses not to miss
  • How to diagnose some of the common causes of non-traumatic MSK pain.
  • How to treat these causes
  • What diagnosis can cause long term morbidity
  • When to seek prompt speciality help.

Non-traumatic pain is a common presentation in children and one which has a wide differential.  Lower limbs are most commonly involved. The potential diagnoses range from benign and self-limiting to life and limb-threatening. 

There is often a history of an innocuous traumatic event which has prompted the attendance for assessment, but this often has little to do with the underlying diagnosis.

Clinicians should have a standardised approach to the history and examination of non-traumatic MSK pain to ensure no diagnoses are missed

The underlying cause varies between age groups as children become susceptible to specific conditions as they progress through childhood.

Common causes

DiagnosisLocationAgeHistoryExamX-ray changes
Apophysitis Any apophysisF 10-14/M12-16Gradual onset
Pain worse on activity
Eases after rest
Point tenderness over apophysis
With or without swelling
Sclerosis and fragmentation
Osteochondrosis Joints: Commonly elbow/hip/foot4-18 dependent on siteGradual onset
Pain worse on activity
Eases after rest
Mild swelling
Stiff and painful joint
Irregular growth of epiphysis
Osteochondritis dissecans Commonly knee and ankle>10Gradual/sudden onset
Pain worse on activity
Associated intermittent swelling
Swollen joint in acute phase
Tender joint line
Lucency about the cortical surface 
May be occult
Osteomyelitis Commonly in areas of high bone turnover such as metaphysis/epiphysisAny ageGradual onset
Point tenderness
Soft tissue swelling
Local osteopenia
Bony lysis or cortical loss
Periosteal reaction
Spondylolysis Lumbar spineAdolescentsGradual onset
History of repetitive activity involving back extension
Pain on extensions and rotation of lumbar spineLimited compared to CT
Scotty dog sign: oblique view, break in pars interarticularis can have appearance of collar on dog
Avulsion fractures Any tendon/ligament attachmentAdolescentsSudden onset
History of pain following sudden muscle contraction
Swelling and bruising if superficial
Pain and weakness with resisted movement 
Widening of open apophysis
With or without displacement and angulation
Patellofemoral pain Anterior kneeAdolescentsGradual onset
Worse on running/jumping and ascending stairs
Commonly in young girls
Weak quadriceps
Altered tracking of patella
Pain on flexion of knee
Slipper upper femoral epiphysis Hip/Knee10-16Gradual/sudden limp
May be non-weight bearing
Reduced ROM of hip
Out toeing
Forced external rotation on hip flexion
Displacement of epiphysis from physis.
Inflammatory arthritis Any jointAny ageGradual onset
May have multiple joints involved
Associated systemic symptoms
Swelling of one or more joints
Systemic features
Soft tissue swelling
Loss of joint space
Joint subluxation
Irregular growth
Malignancy Commonly in areas of high bone turnover such as metaphysis/epiphysisAny ageGradual onset
Systemic symptoms
May have pyrexia
May have swelling and tenderness
Bone destruction
Irregular borders
Wide zone of transition 
Septic arthritis Any jointAny ageGradual onset
Red hot swollen joint
Non weight bearing
Swollen, erythematous painful joint
Normal in early stages



Marie is a 12-year-old girl who presents to you complaining of anterior knee pain.  She is an active volleyball player and is trying hard to make her school team.  The pain is getting worse over the past month and is now affecting her ability to train. She denies any trauma.

What are your differential diagnoses?

What factors in the history and exam would you like to elicit in order to narrow the diagnosis?

You feel she has apophysitis of her tibial tuberosity. 

What is the pathophysiology of apophysitis?

Can you name any other common sites affected by apophysitis?

What investigations would you like to perform?

What is your treatment plan?

What are your differentials?

What factors in the history and exam will help your diagnosis?

What is the pathophysiology of apophysitis?

What other sites are affected by apophysitis?

What investigations would you like to perform?

What is your treatment plan?

Exercise programmes

Good podcast for extended learning

Katie is a 9-year-old complaining of left foot pain.  The pain has been getting worse over the past month and she is now beginning to develop some stiffness.  She is a keen athlete and trains five times per week.  She denies any trauma and is systemically well.

What are some of the differential diagnosis?

What changes do you see on the x-ray?

What is the diagnosis?

What is the pathophysiology?

What other sites can be affected?

What is your treatment plan for this patient?

What is on your list of differentials?

What changes do see on the x-ray?

What is your diagnosis?

What is the pathophysiology?

What other sites can be affected?

What is your treatment plan?

A 15-year-old girl attends with intermittent pain and swelling to her left knee for the past two months.  She is a keen soccer player but pain on the medial aspect of her knee is affecting her ability to run. She complains that after every game her knee swells and is now taking increasingly longer to subside. On exam she is walking with a limp, her knee is swollen and she has pain to the medial joint line.  Her knee feels stable with all ligaments intact on testing.

 You decide to do an x-ray:

Describe the x-ray findings.

Are you aware of any grading system used for Osteochondritis dissecans?

What investigations should you consider?

What are the x-ray findings?

What is the grading system?

What investigations should you consider?

What is the treatment?

Judith is a 10-year-old girl who is attending with pain and stiffness to bilateral wrists with intermittent swelling to fingers.  She has no history of trauma. You think she may have arthritis.

What will you want to decipher during your history and exam?

Our patient has bilateral wrist, metacarpophalangeal and proximal inter phalangeal joints involvement.  She complains of some morning stiffness but denies any previous medical problems.  She cannot remember any trauma and has not had any temperatures or rashes.

What are your differentials?

You think this patient has Juvenile Idiopathic Arthritis. What is JIA?

What investigations will help with this diagnosis?

What is your chosen treatment for JIA?

Apart from rheumatology who else should see this patient with JIA?

What do you need to know in the history?

What are your differentials?

What is JIA?

What investigations will help?

What is your chosen treatment?

Who else should see this patient?

Question 1

Answer 1

Question 2

Answer 2

Question 3

Answer 3

Question 4

Answer 4


Brenner, J. S. (2007). Overuse Injuries, Overtraining, and Burnout in Child and Adolescent Athletes. Pediatrics, 119(6), 1242 LP – 1245

Rathleff, M. S., Winiarski, L., Krommes, K., Graven-Nielsen, T., Hölmich, P., Olesen, J. L., … Thorborg, K. (2020). Activity Modification and Knee Strengthening for Osgood-Schlatter Disease: A Prospective Cohort Study. Orthopaedic Journal of Sports Medicine.

James, A. M., Williams, C. M., & Haines, T. P. (2013). “Effectiveness of interventions in reducing pain and maintaining physical activity in children and adolescents with calcaneal apophysitis (Sever’s disease): a systematic review.” Journal of Foot and Ankle Research, 6(1), 16.


Achar, S., & Yamanaka, J. (2019). Apophysitis and Osteochondrosis: Common

Causes of Pain in Growing Bones. American Family Physician, 99(10), 610–


Chan, J. Y., & Young, J. L. (2019). Köhler Disease: Avascular Necrosis in the Child. Foot and Ankle Clinics, 24(1), 83–88.

Osteochondritis dissecans

Masquijo, J., & Kothari, A. (2019). Juvenile osteochondritis dissecans (JOCD) of the knee: current

concepts review. EFORT Open Reviews, 4(5), 201–212.

American Academy of Orthopedic Surgeons. Clinical practice guideline on the diagnosis and treatment of osteochondritis dissecans. Rosemont, IL: American Academy of Orthopedic Surgeons, 2010.


Alberto Martini et al, for the Pediatric Rheumatology International Trials Organization (PRINTO) Toward New Classification Criteria for Juvenile Idiopathic Arthritis: First Steps, Pediatric Rheumatology International Trials Organization International Consensus, The Journal of Rheumatology Feb 2019, 46 (2) 190-197

Jason Palman, Stephanie Shoop-Worrall, Kimme Hyrich, Janet E. McDonagh, Update on the epidemiology, risk factors and disease outcomes of Juvenile idiopathic arthritis, Best Practice & Research Clinical Rheumatology, Volume 32, Issue 2, 2018, Pages 206-222,

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  • Irish emergency medicine trainee with an interest in sports medicine and education. Enjoy gaelic games and keep myself busy by trying to stay developmentally more advanced than my toddler.


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