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Distinguishing Inflammatory from Mechanical Features

The history explores concerns and observations made by the parent / caregiver or child. Open probing questions are important. Consider red flag features.

 InflammatoryMechanicalMuscle 
Pain
Yes, but may not be verbally expressed, particularly in younger children (below 4 years). May manifest as change of mood or avoidance of activities.
Usually a predominant feature.        
Rarely, pain in calves.
Relationship to activity
Movement may ease symptoms, inactivity may cause gelling.
Usually worse with and after activity.
Reduced endurance, may complain of pain in legs after activity.
Morning stiffness
Present. Important to ask about self-care (e.g., dressing), behaviour and activities in the mornings. Stiffness may manifest as 'gelling' after periods of rest (e.g., difficulty getting up from sitting on the floor).
Usually absent. 
Absent.
Swelling
Yes, and usually persistent for several days to weeks, waxing and waning over months.
Usually worse with, and after activity.
Calf hypertrophy (overdeveloped calf muscles, out of proportion with rest of body).
Locking
Usually absent.
May be present.
Absent.
Giving way
Usually absent.
May be present. 
May be present.
Worst time of day
Usually mornings.
Often after school or evening.
Mornings can be worse after activity.
Restriction of movement
Often present, can be profound.
May be present.
May have ankle tightness.
Systemic features 
Fever, anorexia, weight loss may occur with inflammatory disease (and autoinflammatory or multisystem diseases in particular) but infection (including Tuberculosis) and malignancy need to be excluded. A travel history or awareness of infections in endemic areas is important. 
Not present. 
May be present.

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