Joint Pain and Hypermobility

Referrals from Primary Care of children with suspected Rheumatological diagnosis should be directed to General Paediatrics.

Back Pain in Children Guideline available here

Musculoskeletal and joint pains are the commonest reason for referrals for suspected rheumatological diagnosis in children.  The primary focus of assessment in these children is the distinction between inflammatory (mainly JIA) and non-inflammatory aetiology. 


Suspected Juvenile Idiopathic Arthritis (JIA):

JIA should be suspected in any child with a history of -

  • Persistent swollen painful joint (>3 weeks)
  • Unilateral or asymmetric pain
  • Widespread pain (e.g. Upper limbs or back)
  • Morning stiffness and/or movement restriction of affected joints especially after periods of rest (‘gelling’)
  • Young children without obvious pain but with limp or reluctance to walk
  • May be associated with change in behaviour, avoidance of activities previously enjoyed, regression of motor milestones (eg. walking and handwriting), school absences


There is no clear threshold definition of ‘suspected JIA’.  JIA can present with a variety of symptoms, which overlap with other diagnoses, and the signs can be subtle. Blood tests and radiographs can be normal. Referral to paediatrics should not be delayed by waiting for tests.


British Society for Paediatric and Adolescent Rheumatology (BSPAR) recommends that children with suspected JIA should have a paediatric rheumatology assessment within 10 weeks of onset of symptoms and within 4 weeks of referral. Please refer suspected JIA as URGENT.



Non-Inflammatory / Suspected Mechanical Joint pains / ‘Growing Pains’:

Many children with non-specific aches and pains, including ‘growing pains’, are often found to have joint hypermobility, although not all hypermobile children are symptomatic.


Growing pains occur in young children with lower leg aches, often in calves, feet and ankles, after periods of activity and usually end of the day, or evenings and wake children from sleep.


Features suggesting non-inflammatory ‘mechanical’ pains include:

  • Age range 3-12 years
  • Pains symmetrical in lower limbs and not limited to joints
  • Pains never present at the start of the day
  • Child doesn’t limp
  • Physical activities not limited by symptoms
  • Physical examination normal (with the exception of joint hypermobility/flat feet)
  • Systemically well
  • Major motor milestones normal.
  • Musculoskeletal pain exacerbated by exercise
  • Absence of morning joint stiffness
  • Absent or only minor and transient joint swelling


These children do not need Paediatric referral. Please see Paediatric Orthopaedic Physiotherapy Service for referral to paediatric physiotherapy services.


Suspected Symptomatic Hypermobility:

  • Joint hypermobility is common in children, with varying estimated prevalence dependent on age, ethnicity and defining criteria used.
  • Hypermobility is medically assessed using the simple Beighton score, but the usefulness of the Beighton score is debated, and there are no clearly established diagnostic criteria for childhood joint hypermobility. A Beighton score of ≥ 6/9 is common in the general UK childhood population.
  • Many children who would be defined as hypermobile by the Beighton score are asymptomatic, and hypermobility may be advantageous to many children.
  • Some children with hypermobility experience musculoskeletal pains and are described as having Symptomatic Hypermobility.  However, symptoms may not appear to correlate with the number of joints involved or the degree of hypermobility.


Typical Symptoms Include:

  • Joint and/or muscle aches and pains often occurring after activity, end of day or during the night
  • Lower limb more frequently affected (due to weight bearing nature of joints)
  • Muscle and joint stiffness, usually after exercise or increased activity
  • Fatigue often associated with reduced walking distance and reduced exercise tolerance
  • Difficulty standing still and poor organisation of movement
  • Postural problems
  • Easy bruising (benign and not of concern)
  • Clicking joints (not a concern unless obsessive/habitual and impacting on quality of life)
  • Reduced coordination and balance, late walking with bottom shuffling
  • Abdominal pain, gastrointestinal and urinary tract symptoms can be a feature of condition (however they are also very common in children generally and may not be related to hypermobility).  



This is not a life-threatening condition and may be advantageous to many. BSPAR treatment recommendations include multi-disciplinary team working, pain management, physiotherapy, OT, and clinical psychology. 


The Paediatric Rheumatology special interest clinic is not currently a gateway to these services beyond the availability to consultants in a general paediatric clinic.   

The British Society for Paediatric and Adolescent Rheumatology has produced guidance for clinicians, available at



The Association of Paediatric Chartered Physiotherapists produced a very useful patient/ parent information leaflet on hypermobility




If mild, or only causing single joint problems eg. Knee pain in a keen sports person then general MSK Physiotherapist should be able to manage the patient. If complex, repeat problems or multiple joints involved, rheumatology physio should manage them. Paediatric Orthopaedic Physiotherapy Service



Possible Hypermobile Ehlers Danlos Syndrome (Previously EDS Type III or EDS-hypermobile type (EDS-HT)):

It is not always helpful to give a diagnostic label of suspected hypermobile-EDS because the significant risks associated with the other forms of EDS can mistakenly be assumed to also apply to this group. There is also a significant symptom overlay with chronic musculoskeletal pain.  For this reason, the preferred term to use is symptomatic hypermobility until any diagnosis is confirmed.

Please note that the GP EDS toolkit is not validated in children.



Child with a Limp:

See RCHT Acute Atraumatic Limp in Children Clinical Guideline June 2021




British Society for Rheumatology: Guide for Management of Symptomatic Hypermobility in Children and Young People with this condition

NICE CKS Developmental rheumatology in children Revised May 2019

Paediatric Musculoskeletal Matters International: https://www.pmmmonline.org/doctor



Author: Dr S Burns

Contributors: Dr Andrew Collinson, Consultant Paediatrician RCHT

Date: December 2021

Review Date: December 2022