Orthopedic and musculoskeletal conditions in adolescence: The role of psychological screening in clinical care

Table 3 Psychological risk and protective factors in adolescents with orthopedic and musculoskeletal disorders

Domain	Risk factors or contextual markers	Protective factors
Psychological	Depressive symptoms; anxiety; pain catastrophizing; FA behaviors; low self-efficacy; negative body image; poor sleep quality; previous trauma or psychiatric disorder	Psychological flexibility; pain acceptance; adaptive coping strategies; high self-efficacy; emotional regulation capacity; optimism
Pain-related and neurobiological	CS symptoms; impaired conditioned pain modulation; high pain sensitivity; somatosensory hypersensitivity; altered pain-modulation profiles	Preserved pain modulation; adequate sleep; adaptive stress-response processes
Developmental, demographic, and structural context	Female sex; older adolescent age; racial or ethnic minority status, public insurance, and lower socioeconomic position as markers of structural inequity, discrimination, differential access to care, material disadvantage, and unequal exposure to social stressors rather than intrinsic biological vulnerability	Equitable access to healthcare; adequate health literacy; culturally responsive services; continuity of care; stable social and material support; opportunities for safe physical and social participation
Family and social	Parental pain catastrophizing; parental anxiety or depression; overprotective responses; poor family functioning; social isolation; peer victimization; low peer acceptance	Strong family support; positive family functioning; peer support; social connectedness; supportive school environment
Condition-related and treatment-related	Greater pain intensity; multisite or persistent pain; strong or exclusive athletic identity following sports injury; visible physical difference; prolonged or burdensome treatment; brace-related distress; preoperative psychiatric history; previous unfavorable treatment experiences	Earlier recognition and treatment; realistic expectations; positive therapeutic alliance; access to multidisciplinary support; adaptive athletic identity; positive previous treatment experiences
Clinical and healthcare-system factors	Absence of an established psychological assessment pathway; unclear referral procedures; fragmented care; provider stigma; limited psychosocial support; inadequate preoperative preparation; insufficient referral capacity; lack of follow-up after a concerning screening result	Clinically appropriate psychological screening; trained staff; defined interpretation and referral pathways; co-located or coordinated mental health services where available; interdisciplinary care; patient-centered communication; shared decision-making; timely assessment and follow-up

Racial or ethnic minority status, insurance status, and socioeconomic position should not be interpreted as intrinsic biological risk factors. Their associations with psychological and clinical outcomes may reflect structural inequities, discrimination, differential access to healthcare, material disadvantage, and unequal exposure to social stressors. The factors presented in this table are intended to support multidimensional clinical assessment and should not be used as stand-alone diagnostic criteria or universal referral thresholds. FA: Fear-avoidance; CS: Central sensitization.