Arthritis or bone and joint pain in children

Paediatrics · Symptom or situation · updated 2026-10-31

BioMG follows French guidelines. Adapt it to the guidelines and the tests available where you practise.

Frequency: JIA: about 5 000 children under 16 in France ^[1]; "growing pains": 3 to 37% of children depending on the studies ^[2]

Severity sign: refer as an emergency

No tests in the community: paediatric emergency department the same day.
Very painful, febrile monoarthritis (septic arthritis); fever with rash or impaired general condition. Associated cytopenia or bone pain (haematological malignancy): specialist opinion without delay.

Detailed explanation and international comparison (in French): read it in English (machine translation)

Arthritis (swelling, limp, stiffness) without severity signs

Laboratory tests

FBC with blood film
CRP
Antinuclear antibodies (arthritis for 6 weeks or more)if neededChronic arthritis (6 weeks or more): ANA identify the JIA at risk of chronic anterior uveitis, especially before age 6; they are positive in 75% of oligoarthritis ^[1,3].
Serum creatinineif neededSuspected JIA: tests of the PNDS diagnostic work-up ^[1].
ASTif neededSuspected JIA: tests of the PNDS diagnostic work-up ^[1].
ALTif neededSuspected JIA: tests of the PNDS diagnostic work-up ^[1].
LDH (if cytopenia, bone pain or impaired general condition)if neededA marked rise in LDH should raise the possibility of malignancy; a moderate rise is possible in systemic JIA ^[1].
Rheumatoid factorif neededArthritis in a child over 6, especially polyarticular: identification of juvenile rheumatoid arthritis (rheumatoid factor-positive form) ^[1,3]. Rheumatoid factor is counted as positive (ILAR classification) only if positive on at least 2 occasions, at least 3 months apart, during the first 6 months of the disease ^[6].
Anti-CCP antibodiesif neededArthritis in a child over 6, especially polyarticular: identification of juvenile rheumatoid arthritis (rheumatoid factor-positive form) ^[1,3]. Rheumatoid factor is counted as positive (ILAR classification) only if positive on at least 2 occasions, at least 3 months apart, during the first 6 months of the disease ^[6].
Lyme serology (if tick bite in an endemic area)if neededMonoarthritis or oligoarthritis after a tick bite in a borreliosis-endemic area ^[1,3]. Without exposure or examination findings, Lyme serology is not requested ^[7].
PTif needednon-French guidelineHaemarthrosis (haemorrhagic effusion) or suspected haemophilia: an American Family Physician review then considers a coagulation screen indicated, the aPTT being prolonged in haemophilia (expert opinion, 2015) ^[5].
aPTTif needednon-French guidelineHaemarthrosis (haemorrhagic effusion) or suspected haemophilia: an American Family Physician review then considers a coagulation screen indicated, the aPTT being prolonged in haemophilia (expert opinion, 2015) ^[5].

Urine tests

Urine dipstick (proteinuria, haematuria)

Other test

If JIA suspected or ANA positive in a child under 6 years: prompt slit-lamp eye examination.

Detailed explanation and international comparison (in French): read it in English (machine translation)

Do not order

HLA-B27 as first-line: to be discussed with the expert centre; it can neither confirm nor exclude JIA with enthesitis (present in 70% of patients but also in 6 to 10% of the Caucasian population) ^[1].
ESR: no longer in the fee schedule ^[8].
Glycosylated ferritin: of no value outside a research protocol for the diagnosis of Still's disease (neither sensitive nor specific) ^[1].
HLA-B27 outside a clinical suspicion of juvenile spondyloarthropathy (arthritis with enthesitis, inflammatory low back and buttock pain, sacroiliitis, acute anterior uveitis, family history): low screening value, 5 to 10% of healthy North Americans being carriers ^[7].
Lyme serology for musculoskeletal symptoms without exposure (endemic area, tick bite) or examination findings: risk of false positives and unnecessary treatment ^[7].

Limb pain typical of "growing pains"

No laboratory or imaging test if the picture is typical.

Detailed explanation and international comparison (in French): read it in English (machine translation)

Do not order

Antinuclear antibodies “to screen for” rheumatic disease in limb pain: a very poorly specific test (often positive at low titre in healthy children), with no value to confirm or exclude JIA; reserve for the question of lupus ^[4].
Rheumatoid factor, anti-CCP for pain without arthritis or in a child under 6: the PNDS proposes them only after age 6, in the work-up of arthritis ^[1].
Laboratory tests or imaging (X-rays, scintigraphy) for typical growing pains ^[2].
Antinuclear antibodies as screening without specific signs of rheumatic disease: up to 20% of healthy people are positive; in JIA, positive ANA signal a risk of uveitis but are not used to make the diagnosis (Canadian Choosing Wisely recommendation) ^[7].
Rheumatoid factor or anti-CCP in a child with arthralgia but no arthritis on examination (effusion, or at least 2 signs among warmth, tenderness, pain on forced movement, limitation) ^[7].

Sources (10)