Sir, Musculoskeletal problems are common presenting symptoms in children and adolescents. They are usually of self-limiting origin but can be a presenting feature of severe, even life-threatening illness (e.g. leukaemia). Patients may present in varied guises to primary or secondary care (including paediatrics, orthopaedics, rheumatology and accident and emergency departments). Symptoms may not be volunteered and a competent musculoskeletal examination, coupled with understanding of the age-dependent variation of normal joint appearance, may be the only way to detect important joint abnormalities. It is imperative, therefore, that all clinicians caring for children and adolescents are competent in musculoskeletal assessment, to facilitate prompt diagnosis, early referral to appropriate specialist teams  and ultimately to optimize functional outcome.
Most clinical skills and especially core clinical examination techniques are taught at undergraduate level. However, competence in paediatric musculoskeletal examination is not a core requirement in most UK medical schools, and there is little reinforcement of its importance in clinical practice . This is unlikely to be a problem solely for UK medical schools, and a recent US study showed that paediatric trainees were not skilled in basic musculoskeletal assessment . This lack of competence is reflected in studies of adult general medical in-patients, where significant musculoskeletal problems were commonly overlooked, and documentation of the locomotor history-taking and examination findings is poor compared with other systems . This trend appears to be the same, if not worse, in paediatrics; an audit of 257 in-patients demonstrated documentation of locomotor history-taking in 3% and examination in 11%, which compared poorly with other systems, including the cardiovascular (95%), respiratory (97%) and nervous systems (38%) .
A validated adult musculoskeletal screening examination  is taught at all UK medical schools , but there is no such validated screening musculoskeletal examination for children or adolescents. Our aim was to review the availability of adequate material in textbooks readily available to medical students, either to supplement or to reinforce their formal teaching.
A list of 37 paediatric musculoskeletal examination skills considered a core requirement for qualifying medical students was collated as a consensus of opinion from paediatric rheumatologists (n = 2), adult rheumatologists (n = 2), paediatric orthopaedic surgeons (n = 2) and a paediatric musculoskeletal physiotherapist. Textbooks representing those readily available to medical students were reviewed and scored out of 37; one point was given for each item on the checklist if the examination or test was described so that it was reproducible by the reader. Twenty-two textbooks were reviewed (four on clinical skills, three with general musculoskeletal coverage, six on rheumatology and four on orthopaedics). The mean score was 4.1/37 (range 0–30) (Fig. 1), with 14 books scoring zero, only one textbook describing all of the joints, and two textbooks, specific to paediatric clinical skills, receiving scores of 30 and 26 respectively. The mean number of pages devoted to paediatric locomotor examination was 9.4 (range 0.5–29; approximately 8% of the total length of the book).
The area that scored the most points was gait; six textbooks contained adequate descriptions of (normal/abnormal) gait cycles. The least well-documented examination was that of the sacroiliac joints (one textbook). Four textbooks stated that examination of the musculoskeletal system needs to be tailored to the child's age and developmental milestones.
The low scores achieved by most textbooks imply that detailed descriptions of a specific paediatric musculoskeletal examination are not easily accessible to medical students. The textbooks included are likely to be representative of what is commonly available to students, although they do not constitute an exhaustive list. A similar study of textbooks of musculoskeletal examination of adults also found low overall scores . Our study shows that the situation is worse for paediatric musculoskeletal examination, with the exception of the examination of gait.
The musculoskeletal screening examination currently taught to medical students was designed and tested in adults but is claimed to be usable in children . However, the techniques of performing a full musculoskeletal examination in a child differ considerably from those for an adult and between children of different ages [6, 9, 10]. Children are not like small adults, and the examination has to be tailored to age and be developmentally appropriate.
This study shows that adequate descriptions of paediatric musculoskeletal examination are not easily available to medical students. We encourage medical schools to look at how they may be able to make this information more accessible. The core clinical examination skills are learned at undergraduate level and we strongly recommend that the basic skills of paediatric musculoskeletal examination be taught to medical students and that a validated paediatric musculoskeletal screening examination be devised. Clinicians in primary and secondary care in a wide variety of disciplines are likely to be exposed to children with musculoskeletal problems. The lack of teaching in paediatric musculoskeletal examination skills may compromise clinical competence in clinical practice, and the recognition of serious medical problems could be delayed by poor clinical skills.
The authors have declared no conflicts of interest.
Musculoskeletal Unit, Freeman Hospital and Departments of Rheumatology and Child Health, University of Newcastle upon Tyne, Newcastle upon Tyne, UK