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When painkillers don’t kill pain
  1. J Gauntlett-Gilbert1,
  2. C Meadows1,2,
  3. H Connell1,
  4. A V Ramanan1,2
  1. 1
    Pain Management Unit, Royal National Hospital for Rheumatic Diseases and The University of Bath, Bath, UK
  2. 2
    Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, Bristol, UK
  1. Dr A V Ramanan, Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, Upper Maudlin Street, King David Building, Bristol BS2 8BJ, UK; avramanan{at}

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A 13-year-old boy named Nick presents to the Accident and Emergency Department of his local hospital with severe pain in his left leg. He gives a history of having injured it five months previously during a rugby match, describing it as getting a “dead” leg that eventually got better. He subsequently injured the same leg during rugby again—this time, his knee. At the time the injury appeared trivial and he finished the rugby game. Over the following five days the pain worsens and he attends hospital.

The senior house officer in A&E feels that the history does not suggest significant injury as Nick has been walking around on the leg for several days. On examination she notes that his knee ligaments are stable but that his joints are generally quite hypermobile. She reassures Nick and his parents that there is no serious injury, his leg pain should improve with time, and that he does not need any further investigations or treatment. The doctor suggests some mild analgesics such as paracetamol and ibuprofen and Nick is discharged.


A small but significant proportion of the population has some hypermobile joints. Paediatric prevalence varies from study to study from about 5% to 30%. There appears to be a racial variation, with Caucasian children least affected.1 Benign hypermobility syndrome (BHS) is the term used when a person has pain associated with hypermobility which scores at least 4 out of a possible 9 on the Beighton hypermobility score, which looks for hypermobility in nine parts of the body. The diagnosis can be made using the Brighton criteria2 which use a combination of major and minor criteria (table 1). The patient may have arthralgia, which is either diffuse or quite localised, or just complain of generalised aches and pains which seem a bit non-descript. …

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  • Competing interests: None.