Published online Sep 28, 2026. doi: 10.5528/wjtm.124390
Revised: July 18, 2026
Accepted: July 29, 2026
Published online: September 28, 2026
Processing time: 82 Days and 5.5 Hours
Adolescence represents a critical developmental period characterized by pro
Core Tip: Adolescents with orthopedic and musculoskeletal conditions may experience anxiety, depressive symptoms, body image concerns, pain catastrophizing, fear avoidance, and reduced quality of life. These factors may coexist with pain, functional limitation, treatment burden, and rehabilitation difficulties. This review examines the available evidence and discusses how brief validated psychological measures may support clinical assessment when appropriate systems exist for interpretation, safety evaluation, referral, and follow-up. However, screening is not diagnostic, and its optimal frequency and effectiveness in improving orthopedic outcomes remain uncertain. More prospective adolescent-specific research is needed.
- Citation: Marano G, Del Prete PM, Mazza O, Traversi G, Mazza M. Orthopedic and musculoskeletal conditions in adolescence: The role of psychological screening in clinical care. World J Transl Med 2026; 12(3): 124390
- URL: https://www.wjgnet.com/2220-6132/full/v12/i3/124390.htm
- DOI: https://dx.doi.org/10.5528/wjtm.124390
Adolescence is a period of major biological, psychological, and social transition, extending from pubertal maturation to the progressive assumption of adult roles and responsibilities[1,2]. Puberty influences brain development, emotional regulation, social cognition, and identity formation, while executive-control systems continue to mature over a longer developmental period[2,3]. This asynchronous maturation may increase sensitivity to environmental stressors, peer evaluation, emotional experiences, and changes in bodily appearance or functioning[2,4].
Adolescence is also a sensitive developmental window for the emergence of psychopathology, with a substantial proportion of psychiatric disorders first becoming apparent before early adulthood[5]. Pubertal and social-developmental changes may particularly increase vulnerability to internalizing symptoms such as anxiety and depression[3]. In the context of orthopedic and musculoskeletal (MSK) conditions, pain, visible deformity, functional restriction, interruption of sport, and altered peer participation may therefore interact with ongoing processes of emotional maturation and identity formation. Recognizing this developmental specificity is essential when evaluating the psychological con
MSK disorders constitute an important and increasing source of disability among adolescents and young adults. Global Burden of Disease data indicate that MSK conditions are among the leading causes of disability-adjusted life-years in this age group, with low back and neck pain accounting for a substantial proportion of the overall burden[6]. Early-onset MSK disorders may also result in prolonged exposure to pain, functional limitation, and reduced participation during critical educational and social-developmental periods[6].
Chronic pain affects approximately one in five children and adolescents worldwide, with MSK pain among the most frequently reported presentations and higher prevalence generally observed in girls[7]. Adolescent back and neck pain may interfere with school attendance, physical activity, sleep, and social functioning, and recurrent symptoms can persist into adulthood[7,8].
Adolescent idiopathic scoliosis (AIS) is one of the most common structural conditions encountered in pediatric orthopedic practice. A recent systematic review and meta-analysis estimated a global scoliosis prevalence of approximately 3%, with variation according to sex, age, body weight, and environmental or lifestyle factors[9]. Although severe progression occurs in only a minority of patients, scoliosis may have relevant physical, functional, and psychosocial consequences during adolescence[9].
Sports-related injuries represent another major component of adolescent MSK morbidity. Increased participation in organized sports, intensive training, and early specialization have contributed to the growing recognition of both acute and overuse injuries in younger athletes[10]. The characteristics of the growing MSK system, previous injury, training exposure, and sport-specific demands may influence injury patterns and recovery trajectories[10]. Together, chronic pain, spinal deformity, and sports-related injuries illustrate the heterogeneity and clinical relevance of MSK conditions during adolescence[6-10].
Although orthopedic and MSK care has traditionally emphasized structural correction, pain reduction, and functional recovery, increasing evidence indicates that adolescents with these conditions may also experience clinically relevant psychological distress[11]. Anxiety, depressive symptoms, body image dissatisfaction, reduced self-esteem, and impaired quality of life have been reported across different MSK populations and treatment pathways[11,12].
AIS provides the most extensively studied example. The diagnosis itself, visible trunk asymmetry, bracing, and surgical treatment may affect body image, identity, social participation, and emotional well-being[12-15]. Importantly, psychological burden is not always proportional to radiographic severity, and adolescents may report significant subjective distress even when structural impairment is limited[14,15]. Many patients also describe unmet needs for opportunities to discuss emotional concerns during orthopedic care[14].
Similar difficulties have been observed in other pediatric MSK populations. In adolescents and young adults with juvenile idiopathic arthritis, anxiety and depressive symptoms are common and may coexist with functional limitation, disease activity, and self-harm thoughts[16]. Evidence from orthopedic surgery and rehabilitation further suggests that pre-existing distress, limited social support, and pain-related psychological factors may be associated with variation in treatment adherence and recovery[11].
The available literature supports a clinically meaningful association between MSK conditions and psychological burden during adolescence. However, much of the evidence is observational, and the direction and strength of these relationships vary across diagnoses, treatments, and developmental contexts. Direct psychological assessment[11-13] is therefore needed because structural or functional measures alone may not capture the adolescent’s subjective experience[14-16].
Psychological assessment may be relevant in adolescent MSK care because emotional distress can remain unrecognized during routine orthopedic evaluation and may coexist with pain, functional limitation, treatment burden, and rehabilitation difficulties. Available studies also suggest that brief screening measures can be incorporated into selected pediatric orthopedic and related MSK settings[17-19].
In pediatric orthopedic sports clinics, the Patient Health Questionnaire (PHQ)-2 and PHQ-9 have been used to identify depressive symptoms and self-harm concerns requiring further assessment[17]. Evidence from adjacent pediatric settings, including rheumatology and prosthetics services, similarly indicates that psychological screening may be acceptable to patients and caregivers and may identify persistent psychosocial difficulties[18,19]. Integrated or co-located psychological services may also improve engagement compared with referral pathways separated from the medical encounter, although this evidence is derived primarily from broader pediatric chronic-care settings[20].
These findings support the feasibility and potential clinical value of psychological assessment, but they do not establish that screening itself improves orthopedic outcomes. Screening is most meaningful when accompanied by appropriate interpretation, focused clinical assessment, safety procedures, referral capacity, and follow-up. Its frequency and implementation should therefore be adapted to the clinical setting, patient needs, and available resources[17-20].
A biopsychosocial framework may help clinicians recognize how physical symptoms, functional limitations, psychological distress, and behavioral responses interact during adolescent MSK care.
In this review, the term “musculoskeletal care” is used deliberately as a broader clinical construct encompassing orthopedic conditions, chronic MSK pain, sports-related injuries, limb differences, and selected inflammatory MSK disorders managed within multidisciplinary pediatric pathways. Juvenile idiopathic arthritis is therefore included not as a conventional orthopedic disorder, but as an adjacent pediatric MSK condition that provides clinically relevant evidence regarding psychological burden, screening feasibility, and integrated care. Evidence from such adjacent populations is explicitly distinguished from evidence obtained directly in adolescent orthopedic cohorts.
AIS is used throughout this review as the principal illustrative orthopedic condition because it has the most developed adolescent-specific literature on body image, psychological distress, treatment burden, and patient-reported outcomes. This emphasis reflects the distribution of the available evidence rather than an assumption that scoliosis carries greater psychological importance than sports injuries, limb deformities, or chronic MSK pain. Evidence concerning the latter conditions is synthesized separately and is not considered less clinically relevant because it is less extensive.
Figure 1 summarizes the main pathways linking orthopedic disorders, psychological burden, behavioral responses, and downstream MSK outcomes in adolescence.
This article was designed as a purposive narrative review informed by a structured literature search, rather than as a systematic or scoping review. Its aim was to provide a clinically oriented synthesis of the psychological burden associated with orthopedic and MSK conditions during adolescence and to discuss the potential role of psychological screening in MSK care.
Relevant literature was identified through searches of PubMed/MEDLINE, Scopus, EMBASE, Web of Science, CINAHL, and PsycINFO. The searches were conducted iteratively during manuscript preparation and were last updated on 26 March 2026. The complete PubMed/MEDLINE search strategy used for the final update was: (“Adolescent“[Mesh] OR adolescen*[Title/Abstract] OR pediatric*[Title/Abstract] OR paediatric*[Title/Abstract] OR youth*[Title/Abstract] OR child*[Title/Abstract]) AND (“Musculoskeletal Diseases“[Mesh] OR orthop*[Title/Abstract] OR musculoskeletal* [Title/Abstract] OR scoliosis*[Title/Abstract] OR “sports injur*“[Title/Abstract] OR “limb deformit*“[Title/Abstract] OR “chronic musculoskeletal pain“[Title/Abstract]) AND (“Mental Health“[Mesh] OR psycholog*[Title/Abstract] OR anxi*[Title/Abstract] OR depress*[Title/Abstract] OR “body image“[Title/Abstract] OR “quality of life“[Title/Abstract] OR catastrophiz*[Title/Abstract] OR catastrophis*[Title/Abstract] OR “fear avoidance“[Title/Abstract] OR screen
Equivalent combinations were adapted to the syntax, controlled vocabulary, and indexing system of the other databases. Reference lists of relevant reviews and key primary studies were also examined to identify additional publications. No formal review protocol was registered.
Publications were considered relevant when they addressed children or adolescents with an orthopedic or MSK condition and reported psychological, behavioral, functional, or quality-of-life outcomes. The principal population of interest was adolescents aged 10-18 years. Studies including broader pediatric age ranges or young adults up to 25 years were retained only when adolescent-specific data were reported, when the majority of the sample fell within the adolescent age range, or when the condition and treatment trajectory clearly originated during adolescence. Findings derived predominantly from young-adult or adult samples were not presented as direct adolescent evidence.
Eligible sources included original observational and interventional studies, systematic reviews, meta-analyses, clinical guidelines, consensus statements, and clinically relevant narrative or scoping reviews. Studies focused exclusively on adult populations were not used as direct evidence for adolescent orthopedic practice but were occasionally considered when adolescent-specific evidence was unavailable and when they provided relevant mechanistic, methodological, or implementation context. Evidence derived from pediatric rheumatology, pain medicine, rehabilitation, or other pediatric specialties was similarly treated as adjacent evidence rather than as equivalent to evidence obtained directly from adolescent orthopedic cohorts.
Conference abstracts, unpublished dissertations, case reports, and publications without substantive clinical or empirical content were not prioritized. Seminal publications preceding the main search period were included selectively when they represented foundational contributions that had not been superseded by more recent evidence.
For interpretative purposes, the evidence included in this review was considered according to three levels of clinical proximity. Direct evidence comprised studies conducted specifically in adolescents receiving orthopedic or MSK care. Adjacent pediatric evidence included studies from pediatric rheumatology, rehabilitation, pain medicine, prosthetics, and other pediatric specialties addressing comparable psychological or functional constructs. Indirect evidence comprised studies conducted primarily in adults or in non-MSK clinical populations and was used only to inform mechanisms, implementation considerations, or areas in which adolescent-specific evidence remains limited. These evidence categories were not considered interchangeable, and recommendations were weighted primarily toward findings derived directly from adolescent orthopedic and MSK populations.
Study selection was conducted collaboratively by Marano G and Mazza M. Marano G screened titles and abstracts for relevance to the predefined clinical and psychological domains, while potentially eligible full texts were evaluated by Mazza M. Uncertain eligibility decisions were additionally reviewed by Del Prete PM, and disagreements were resolved through consensus among the three reviewers. Duplicate publications were removed during reference management and subsequently checked manually.
Because this was a purposive narrative review, independent duplicate screening, formal quantitative data extraction, record-level exclusion reporting, and a Preferred Reporting Items for Systematic reviews and Meta-Analyses-style study-selection flow diagram were not prespecified. Methodological quality was not translated into a formal score. Instead, it was considered descriptively on the basis of study design, population definition, sample size, appropriateness of outcome measures, control of relevant confounding factors, duration and completeness of follow-up, and consistency between the reported results and conclusions. When several publications addressed the same question, priority was given to systematic reviews, meta-analyses, clinical guidelines, large or multicenter cohorts, and prospective studies. These considerations informed the relative interpretative weight assigned to individual sources but did not constitute a formal risk-of-bias or certainty-of-evidence assessment.
Findings were synthesized descriptively and organized around the biopsychosocial framework. Particular attention was paid to the distinction between evidence derived directly from adolescent orthopedic populations, evidence from adjacent pediatric MSK or rehabilitation settings, and indirect evidence extrapolated from adult or other-specialty populations. No formal risk-of-bias instrument was applied; therefore, the conclusions should be interpreted as a critical narrative synthesis rather than as estimates derived from a systematic evidence-grading process.
AIS is the orthopedic condition most extensively studied in relation to psychological outcomes during adolescence. Its visible bodily effects occur during a developmental period in which appearance, identity, peer evaluation, and emotional regulation acquire particular importance[12,21]. The available literature therefore provides useful direct adolescent evidence, although the predominance of scoliosis studies relative to other MSK conditions should be recognized when interpreting the broader conclusions of this review.
Body image dissatisfaction is among the most consistently reported psychosocial concerns in adolescents with idiopathic scoliosis[15,21]. Compared with healthy peers, adolescents with scoliosis frequently report poorer self-image, and impairment may be present even in mild disease[21,22]. In braced patients, self-image and mental health are among the quality-of-life domains most commonly affected[23].
Although greater curve severity may be associated with poorer body image in some cohorts, subjective distress is not consistently proportional to radiographic measures[15,24]. This discrepancy indicates that Cobb angle and other structural parameters cannot substitute for direct assessment of the adolescent’s perception of appearance. Alterations in body schema have also been described, but this dimension remains less extensively studied and lacks standardized clinical assessment methods[15].
Several scoliosis-specific patient-reported measures, including the Scoliosis Research Society questionnaire, the Spinal Appearance Questionnaire, the Trunk Appearance Perception Scale, and the Body Image Disturbance Questionnaire-Scoliosis, may help characterize appearance-related concerns[21]. Their use should complement, rather than replace, clinical discussion of the patient’s subjective experience.
Psychological distress in adolescents with idiopathic scoliosis extends beyond body image. In a prospective study, approximately one-third of patients reported clinically significant emotional or psychological difficulties, and many parents were unaware of these concerns[25]. Distress was observed across observation, bracing, and surgical groups, suggesting that psychological burden cannot be attributed exclusively to a single treatment modality[25].
Depressive symptoms, perceived cosmetic deformity, curve severity, and trunk rotation have all been associated with quality of life, although psychological variables may contribute independently of objective deformity[26]. Bracing may add discomfort, visibility concerns, social anxiety, and adherence difficulties, particularly during the initial treatment period[13,23]. Many adolescents also report limited opportunities to discuss emotional concerns with healthcare professionals despite wishing to do so[14].
Overall, AIS illustrates how visible deformity, treatment demands, self-perception, and emotional functioning may interact. However, much of the evidence is observational, and direct assessment remains necessary[12-15,21] because radiographic severity alone does not reliably indicate the degree of psychological burden[22-26].
Sports-related injuries may represent a major psychological stressor during adolescence because they interrupt physical activity, peer participation, performance goals, and daily routines. Common early reactions include sadness, frustration, irritability, sleep disturbance, and temporary disengagement; these responses become clinically relevant when they persist, intensify, or appear disproportionate to the injury and recovery trajectory[27].
Evidence suggests a reciprocal association between sports injury and mental health. A systematic review and meta-analysis involving more than 200000 adolescents found that MSK injuries and concussion were associated with poorer mental health and well-being, while adolescents with pre-existing psychological difficulties also showed greater injury vulnerability[28]. These findings support a bidirectional model, although most included studies were observational and cannot establish causality.
Social support may protect against psychological deterioration, whereas performance pressure, limited mental health literacy, stigma, and reluctance to seek help may complicate recovery[27-29]. Orthopedic and rehabilitation professionals should therefore consider emotional symptoms, behavioral withdrawal, and help-seeking barriers when recovery appears delayed or inconsistent with the physical injury.
Athletic identity, defined as the extent to which the athlete role contributes to self-concept, is particularly relevant during adolescence[30]. When sport is the adolescent’s principal source of competence, belonging, and self-esteem, injury-related exclusion may contribute to depressive symptoms, anxiety, disordered eating, or identity disruption[29-31].
Strong athletic identity may have both adaptive and maladaptive effects. It can support motivation and rehabilitation engagement, but may also encourage symptom under-reporting, playing through pain, excessive rehabilitation, or pre
Psychological readiness should therefore complement physical criteria in return-to-sport decisions. Particular attention should be paid to fear of reinjury, kinesiophobia, mood symptoms, unrealistic recovery expectations, and pressure from the athlete, family, team, or sporting environment[29-31].
Limb deformities in children and adolescents include congenital limb reduction deficiencies, acquired amputations, and complex skeletal conditions such as fibrous dysplasia and McCune-Albright syndrome. Their psychosocial impact depends not only on functional limitation, but also on visibility, prosthetic use, peer reactions, and opportunities for social participation[32-34].
Adolescents with visible limb differences may experience both enacted stigma, including teasing or exclusion, and self-stigma, characterized by embarrassment, anticipated rejection, and internalized feelings of difference[33]. In pediatric patients with fibrous dysplasia or McCune-Albright syndrome, illness-related stigma has been associated with anxiety and depressive symptoms, with self-stigma appearing particularly relevant to anxiety and enacted stigma to depression[33].
Similar concerns have been identified in children and adolescents with lower-limb deficiency. Psychological screening has revealed frequent peer difficulties, self-consciousness, and social isolation, while peer support has been associated with lower anxiety and depression and better self-esteem[19]. These findings suggest that social relationships may function as either a source of vulnerability or an important protective factor.
Qualitative evidence further indicates that contact with peers who share similar limb differences may reduce loneliness, provide practical coping strategies, and support a more positive self-image[34]. Peer groups and condition-specific camps may also offer age-appropriate role models and facilitate identity development[34].
Functional impairment and psychological distress are related but not equivalent. Some studies have found broadly preserved psychosocial functioning in children with congenital limb deficiencies despite limitations in activity and participation, although methodological heterogeneity limits firm conclusions[32].
Mobility and upper-limb restrictions may nevertheless affect mental health indirectly by reducing access to sport, leisure activities, school participation, and peer relationships[19]. Adolescents may also experience uncertainty about future employment, independence, healthcare access, and the need for environmental adaptations during the transition to adulthood[34].
The psychological burden associated with limb deformities appears to reflect the interaction of visible difference, stigma, social participation, functional limitation, and future-oriented concerns. Clinical assessment should therefore consider both objective function and the adolescent’s subjective social and emotional experience[19,32-34].
Chronic MSK pain is common during adolescence and reflects the interaction of biological, psychological, and social processes[35]. Central sensitization (CS) and altered nociceptive processing may contribute particularly to neck, back, and multiregional pain, while depression, anxiety, pain catastrophizing, fear of movement, and poor sleep are consistently associated with greater functional impairment[35,36].
Adolescents with chronic MSK pain are not a homogeneous population. Phenotyping studies have identified subgroups differing in affective distress, pain catastrophizing, sleep quality, somatosensory characteristics, and disability[37]. This heterogeneity may help explain why similar pain intensity can be accompanied by markedly different levels of interference and functioning.
Meta-analytic evidence indicates that anxiety and depressive symptoms have relatively modest associations with pain intensity but stronger associations with disability, pain interference, catastrophizing, and quality of life[36]. These findings support a biopsychosocial interpretation of chronic pain, although the predominantly observational evidence does not establish whether psychological symptoms precede, result from, or reciprocally reinforce pain-related disability[35-37].
Chronic MSK pain may disrupt mobility, sleep, physical activity, social participation, concentration, and school attendance[38]. Qualitative evidence describes a combination of functional restriction, psychological distress, and experiences of alienation or marginalization, particularly when symptoms are invisible or poorly understood by others[38].
School absenteeism is common among adolescents with recurrent MSK pain and is associated with greater pain intensity, medication use, school-related stress, and previous absence[39]. Population-level evidence also indicates that children with chronic pain are more likely than pain-free peers to experience chronic absenteeism, reduced school engagement, grade repetition, and learning-related difficulties[40].
Functional impairment may also occur in adolescents who continue attending school. Pain-related fatigue, reduced concentration, limited participation in physical education, and difficulty maintaining peer relationships can produce clinically relevant presenteeism despite apparent attendance[41]. These educational and social consequences may reinforce withdrawal and disability, highlighting the importance of assessing participation rather than pain intensity alone[38-41].
Anxiety and depressive symptoms are frequently reported across orthopedic and MSK populations, although the directness and methodological strength of the evidence vary considerably. Adolescent-specific orthopedic studies provide the most clinically applicable findings, whereas adult chronic pain and mixed-age studies should be interpreted as contextual rather than directly transferable evidence.
In a large meta-analysis of chronic pain populations, Aaron et al[42] found high pooled prevalences of clinically significant depressive and anxiety symptoms. The included studies were clinically and methodologically heterogeneous, predominantly cross-sectional, and not restricted to adolescents or orthopedic settings. These estimates therefore cannot establish whether psychological symptoms preceded chronic pain, developed as a consequence of pain and disability, or reflected reciprocal vulnerability, and they should not be considered direct prevalence estimates for adolescent orthopedic patients[42].
Adjacent pediatric evidence is provided by a multicenter study of adolescents and young adults with juvenile idiopathic arthritis, in which approximately one-third had a positive screen for anxiety or depression. Greater functional limitation, poorer perceived health, female sex, and older age were associated with increased symptom burden, whereas regular sports participation appeared protective[16]. These findings support the relevance of psychological assessment in pediatric MSK care but do not establish causal relationships.
Evidence from elective orthopedic populations also suggests that anxiety and depressive symptoms may be more frequent than in the general population, particularly in patients with conditions that substantially restrict mobility. Because the study by Kuik and Łuczkiewicz[43] included a broader elective orthopedic population rather than a specifically adolescent cohort, its findings should be regarded as indirect supportive evidence.
In sports-related injury, depressive symptoms may be most pronounced during the early postoperative or rehabilitation period and may decrease as recovery progresses. A systematic review of anterior cruciate ligament injuries found that depressive symptoms were especially evident shortly after reconstruction, while anxiety was more commonly described in relation to return-to-sport concerns than as persistent clinically elevated symptomatology[44]. Strong athletic identity may further increase vulnerability when injury disrupts self-concept, social belonging, and expected performance[29].
Overall, anxiety and depressive symptoms appear clinically relevant across adolescent MSK conditions, but their prevalence, duration, and prognostic significance differ according to diagnosis, treatment stage, developmental context, and study design. Screening findings should therefore be interpreted as indicators for further assessment rather than as evidence of a psychiatric diagnosis[16,29,42-44].
Body-image concerns are most extensively documented in AIS and are discussed in detail in the condition-specific section. In brief, subjective appearance-related distress may be present even with relatively mild deformity and is not reliably predicted by radiographic severity[15,22,45,46]. This evidence is predominantly cross-sectional and condition-specific; it should therefore not be generalized to other MSK disorders or interpreted as demonstrating a causal effect.
MSK pain and chronic health conditions may impair health-related quality of life across physical, emotional, and social domains. However, the available evidence is heterogeneous and is not always derived from specifically orthopedic adolescent populations.
Wang et al[47] identified distinct health-related quality-of-life profiles in adolescents and young adults with chronic conditions. Approximately half of the sample showed moderate or severe impairment, with psychological symptoms, fatigue, pain interference, and physical functioning contributing to differences between profiles. Female sex and chronic pain were associated with greater impairment[47]. Because the sample included heterogeneous chronic conditions, these findings should be regarded as adjacent pediatric evidence rather than as direct estimates for adolescent orthopedic populations.
Seth et al[48] examined children and adolescents with disabling chronic pain undergoing intensive interdisciplinary pain treatment. Health-related quality of life improved substantially between admission and discharge, particularly in physical, emotional, and school functioning. Nevertheless, a considerable proportion of patients continued to report impaired quality of life at discharge, indicating that short-term clinical improvement may not correspond to full recovery across all developmental domains[48].
These findings suggest that quality of life should be assessed as a multidimensional outcome rather than inferred from pain intensity or physical function alone. They also indicate that improvements in pain-related functioning may coexist with persistent emotional, educational, or social difficulties[47,48].
Adolescents with chronic MSK pain may experience loneliness, social anxiety, withdrawal, peer victimization, and reduced peer acceptance[49,50]. Systematic reviews indicate that these difficulties are associated with restricted participation in school, sport, leisure activities, and other age-appropriate social contexts[49,50].
The relationship between pain and social functioning may be reciprocal. Reduced attendance and unpredictable symptoms can limit opportunities to establish and maintain friendships, while low peer acceptance may itself be asso
Co-occurring mental health symptoms may further worsen social functioning. Bateman et al[52] found greater social impairment among adolescents with both chronic pain and psychological symptoms than among those with pain alone. However, perceived friendship quality did not differ consistently across groups, suggesting that participation and subjective relationship quality may represent distinct dimensions.
Assessment should therefore consider school and leisure participation, peer relationships, loneliness, perceived support, and the possible discrepancy between self-reported and externally observed social functioning. Multi-informant approaches may be useful when clinically feasible, although the evidence remains heterogeneous and predominantly observational[49-52].
CS refers to increased responsiveness of central nociceptive pathways and may contribute to disproportionate or widespread pain, hyperalgesia, sleep disturbance, fatigue, and functional impairment[53,54]. Most mechanistic evidence derives from adult chronic-pain populations, limiting direct application to adolescent orthopedic care.
Adolescent studies nevertheless suggest that developmental differences in sensory and affective pain processing may influence pain experience[55]. Symptoms associated with sensitization have also been linked to multiregional pain, psychological distress, poor sleep, and disability in adolescents[35]. Prospective evidence indicates that impaired endogenous pain inhibition and depressive symptoms during acute MSK pain may be associated with subsequent pain persistence and poorer functioning[56].
These findings support a biopsychosocial assessment of persistent or disproportionate pain but do not establish a causal pathway or justify inferring CS from symptom severity alone. Clinicians should continue to evaluate potentially relevant peripheral pathology while considering sleep, mood, fear, function, and treatment response[35,53-56].
Pain catastrophizing is characterized by rumination, magnification, and helplessness in response to actual or anticipated pain. In pediatric chronic pain populations, it is consistently associated with greater pain intensity, disability, emotional distress, and poorer quality of life[57,58].
Developmental factors may influence its clinical significance. Age appears to moderate the association between catastrophizing and pain interference, with particularly strong effects reported during adolescence[57]. This finding is consistent with the growing importance of cognitive appraisal, autonomy, identity, and functional expectations during this developmental stage.
Catastrophizing may also help explain why similar levels of pain are associated with different degrees of disability. In adolescents with chronic MSK pain, it has been shown to partially mediate the relationship between pain intensity and functional limitation and to mediate the association between protective parental responses and disability[59]. Because these findings were cross-sectional, however, they should not be interpreted as proof of a causal mechanism.
Direct orthopedic evidence is available from adolescents undergoing posterior spinal fusion for idiopathic scoliosis. Ramo et al[60] found that elevated preoperative catastrophizing was associated with poorer pain, activity, mental health, and quality-of-life scores before surgery and with persistently lower patient-reported outcomes at follow-up, despite overall postoperative improvement. This supports its possible prognostic relevance but does not establish that reducing catastrophizing would necessarily improve surgical outcomes.
Catastrophizing and anxiety are related but not interchangeable. In pediatric chronic pain samples, catastrophizing has shown stronger associations with pain intensity and disability, whereas anxiety may be more closely related to broader quality-of-life impairment[61]. Clinical assessment should therefore examine both constructs rather than treating them as equivalent.
Pain catastrophizing may be a clinically useful marker of vulnerability in adolescent MSK care. Its interpretation should consider pain severity, developmental stage, family responses, mood symptoms, functional expectations, and treatment context, and should not rely on a single universal cutoff[57-61].
The fear-avoidance (FA) model describes how threatening interpretations of pain may contribute to persistent disability. According to this framework, catastrophizing may increase pain-related fear, which can promote avoidance of movement or activity, reduced participation, physical deconditioning, and emotional distress[62,63]. Conversely, gradual engagement with activity may support recovery when it is clinically safe and appropriately paced[63].
Pain-related fear includes fear of pain itself, fear of movement, fear of reinjury, and anxiety about activities expected to provoke symptoms[62]. These dimensions may be assessed with instruments such as the Tampa Scale for Kinesiophobia, the Fear-Avoidance Beliefs Questionnaire, and pain-anxiety measures, although their intended populations and scoring conventions differ[64]. In adolescents, interpretation should also consider developmental stage, parental responses, sport-related expectations, and the distinction between adaptive caution after injury and persistent maladaptive avoidance.
Meta-analytic evidence indicates that fear of pain is associated with negative affect, anxiety, depression, disability, and, to a lesser extent, pain intensity[64]. Pain catastrophizing shows overlapping but generally stronger associations with several of these outcomes[64]. However, much of this evidence is cross-sectional and derives from mixed-age or adult populations, limiting conclusions about temporal sequence and direct applicability to adolescent orthopedic care.
Clinically, FA behaviors may be suspected when an adolescent demonstrates disproportionate restriction of activity, delayed rehabilitation progression, persistent fear of reinjury, or reluctance to resume school, sport, or daily activities despite adequate tissue healing. Assessment should distinguish protective behavior during acute recovery from persistent avoidance that interferes with function. FA measures should support clinical formulation rather than serve as stand-alone diagnostic tests or universal referral thresholds[62-64].
Chronic pain and mood symptoms are frequently associated through a potentially reciprocal relationship. Persistent pain may increase the likelihood of depression and anxiety, while pre-existing emotional distress may heighten pain sensitivity, functional interference, and the risk of persistent symptoms[65]. Much of the epidemiological evidence is cross-sectional or derived from adult populations, and the direction of these relationships cannot always be determined.
Pain modulation and mood regulation involve partially overlapping biological systems. Serotonergic, noradrenergic, and dopaminergic pathways contribute to descending pain control, emotional regulation, motivation, and reward processing[66]. Alterations in these systems may therefore help explain the co-occurrence of low mood, anhedonia, reduced coping capacity, and amplified pain perception[66].
Glutamatergic and gamma-aminobutyric acid signaling, stress-response pathways, cortical-limbic networks, and neuroimmune processes have also been implicated in both chronic pain and depression[54,66]. Persistent pain may be associated with altered functioning of the prefrontal cortex, anterior cingulate cortex, insula, amygdala, and related regulatory networks, although much of this evidence comes from adult neuroimaging studies and preclinical models[65,66]. These mechanisms should therefore be regarded as biologically plausible explanatory pathways rather than as established adolescent orthopedic biomarkers.
Adolescent MSK evidence supports the clinical relevance of mood symptoms without fully establishing the underlying mechanisms. Depression, anxiety, stress, and poor sleep are associated with CS symptoms, pain-related disability, and multiregional pain in adolescent populations[35]. Shared pain-processing and emotion-processing systems may be especially relevant during adolescence, when affective, motivational, and regulatory networks are still developing[54].
Clinically, mood symptoms should not be regarded solely as secondary reactions to pain or as proof that pain is psychogenic. Their presence may indicate greater biopsychosocial complexity and should prompt assessment of pain distribution, functional impairment, sleep, school and social participation, emotional distress, and safety concerns. At the same time, psychological assessment should complement rather than replace evaluation of structural, inflammatory, or mechanical contributors to pain[35,54,65,66].
Psychological factors may influence adolescent pain outcomes differently during the transition from acute to persistent pain and during the maintenance of established chronic pain[67-69]. Available evidence suggests that their associations are generally stronger with disability, pain interference, catastrophizing, and quality of life than with pain intensity itself[36].
Prospective surgical studies provide direct evidence regarding the transition to chronic postsurgical pain. Pagé et al[67] found that persistent pain shortly after discharge and the affective unpleasantness of pain were associated with later chronic postsurgical pain in children and adolescents undergoing major surgery. These findings suggest that early pain trajectories and the emotional dimension of pain may be more informative than immediate postoperative pain intensity alone.
In adolescents undergoing spinal fusion for idiopathic scoliosis, depressive symptoms and poor sleep quality have been associated with persistent postsurgical pain, while acute pain at two weeks also identified patients at increased risk of later chronic pain[68]. Pain catastrophizing, anxiety, and parental factors were not consistently retained as independent predictors after adjustment for other variables, indicating that the relative importance of psychological factors may depend on the clinical model and covariates considered[68].
Similar patterns have been observed after acute MSK injury. Fisher et al[69] found that fear of pain predicted chronic pain onset following lower-limb injury, whereas depressive symptoms and poor sleep were more closely associated with later physical disability. Parental anxiety, catastrophizing, and protective responses also showed associations with selected functional outcomes, although they did not uniformly predict pain persistence[69].
Meta-analytic evidence further indicates that anxiety and depression have modest associations with pain intensity but stronger relationships with functional interference and quality of life[36]. The pattern may also vary with pain duration and developmental stage, although such moderator findings remain exploratory.
Acute pain persistence, pain unpleasantness, depressive symptoms, sleep disturbance, and fear of pain may identify adolescents at greater risk of chronic pain or poor functional recovery. These findings support risk stratification and closer follow-up, but they do not establish that any single psychological factor causes chronification or that modifying it will necessarily prevent persistent pain[36,67-69].
Rehabilitation adherence is influenced by the interaction of treatment demands, pain, emotional responses, self-efficacy, family support, and the adolescent’s expectations regarding recovery. Psychological factors may affect both conservative treatment adherence and engagement in postoperative or sports rehabilitation[70-72].
In AIS, a systematic review and meta-analysis found that negative body image, stress, and poorer quality of life were associated with lower brace adherence[70]. Counseling, objective feedback, and mindfulness-based approaches showed potential benefits, while consistent adherence during the early treatment period was associated with better longer-term compliance[70]. The included studies were heterogeneous, and the findings do not establish that any single psychosocial intervention is universally effective.
In sports and postoperative rehabilitation, fear of pain or reinjury, catastrophizing, and low self-efficacy may reduce participation or delay progression[71]. By contrast, self-efficacy, goal setting, and positive self-talk have been associated with greater effort during therapy and better completion of home exercises[71]. Some of this evidence derives from adult orthopedic or mixed-age sport populations and should therefore be interpreted cautiously when applied to adolescents.
A systematic review of psychological interventions after sports-related MSK injury identified potential benefits from goal setting, counseling, positive self-talk, relaxation, guided imagery, emotional disclosure, and modeling strategies[72]. These interventions were associated with selected improvements in adherence, mood, reinjury anxiety, pain, or functional measures, but the evidence base was small and methodologically heterogeneous[72].
Clinically, poor adherence should not be interpreted automatically as lack of motivation. Assessment should consider pain, fear, treatment burden, body image, emotional distress, competing school or family demands, understanding of the rehabilitation plan, and access to support. Psychological strategies may complement rehabilitation when they are developmentally appropriate and delivered within professional boundaries[70-72].
Preoperative psychological status may contribute to variability in postoperative recovery among adolescents undergoing orthopedic surgery. In adolescents treated with hip preservation surgery, Richard et al[73] found that poorer preoperative mental health was associated with greater postoperative pain at six months. Patients who had earlier or repeated contact with a psychologist also reported more favorable pain, physical-function, and mental-health outcomes, although the observational design does not establish that psychological consultation itself caused these improvements[73].
Direct adolescent evidence is also available from spinal-fusion cohorts. Li et al[74] reported that changes in anxiety and pain catastrophizing during the early postoperative period partially mediated the association between acute postsurgical pain and chronic postsurgical pain at six months. Changes in depressive symptoms and parental distress were not consistently identified as significant mediators, suggesting that different psychological factors may contribute differently to postoperative trajectories[74].
Thorsell Cederberg et al[75] similarly found that preoperative pain intensity and adolescent pain catastrophizing predicted poorer pain, functioning, and health-related quality of life one year after spinal fusion. By contrast, psychological flexibility and pain acceptance in adolescents, together with parental psychological flexibility, were associated with more favorable recovery[75]. These findings identify potentially relevant risk and resilience markers but do not demonstrate that directly modifying them will necessarily improve surgical outcomes.
Evidence regarding preoperative psychological interventions is less adolescent-specific. In a systematic review and meta-analysis of elective orthopedic surgery, Tong et al[76] found modest improvements in postoperative anxiety and the mental component of health-related quality of life, but no significant pooled reduction in acute postoperative pain. The overall certainty of this evidence was limited by small samples, heterogeneous interventions, mixed populations, and risk of bias[76].
Overall, preoperative distress, catastrophizing, pain intensity, psychological flexibility, and pain acceptance may help identify adolescents at risk for less favorable postoperative recovery. Their assessment may support individualized preparation and follow-up, but current evidence does not justify assuming that psychological screening or intervention will uniformly reduce pain or complications after orthopedic surgery[73-76].
Chronic pain beginning in childhood or adolescence may persist into adulthood and affect physical, psychological, educational, vocational, and social functioning[77]. Much of the available evidence derives from tertiary pain clinics or heterogeneous chronic pain populations rather than from condition-specific orthopedic cohorts.
In a prospective six-year follow-up study, Murray et al[78] found that a substantial proportion of adolescents treated for chronic pain continued to report pain and pain-related interference in young adulthood. Greater adolescent pain intensity, multiple pain locations, anxiety symptoms, and poor sleep were associated with less favorable later outcomes[78]. These findings support the potential prognostic relevance of emotional and sleep-related factors, although they do not establish causal effects.
Long-term persistence has also been documented in juvenile-onset fibromyalgia. Kashikar-Zuck et al[79] reported that many affected adolescents continued to experience fibromyalgia or subclinical symptoms in adulthood, together with impaired physical functioning. Worsening depressive-symptom trajectories were associated with poorer functioning over time, suggesting that emotional comorbidity may identify a subgroup at particular risk[79].
Population-based evidence indicates that adolescent chronic pain may also be associated with later educational, vocational, and social disadvantage. Murray et al[80] found lower educational attainment and less favorable employment-related outcomes in young adults with a history of adolescent chronic pain, even after adjustment for selected sociodemographic and psychological variables. Some social domains appeared more preserved, underscoring the heterogeneity of long-term trajectories.
Long-term improvement remains possible. Zernikow et al[81] reported sustained reductions in pain, disability, and school or work absence after intensive interdisciplinary pain treatment in a substantial proportion of adolescents. Patients without overall improvement continued to use more healthcare resources and reported greater financial burden, while younger age at treatment was associated with better outcome[81].
Adolescent chronic pain may have consequences extending beyond symptom persistence to education, employment, participation, and healthcare use. Early assessment of pain severity, mood, sleep, disability, and social participation may help identify patients requiring closer follow-up, but evidence that early psychological screening or intervention prevents long-term disadvantage remains limited[77-81].
The rationale for psychological screening in adolescent MSK care derives from general adolescent preventive recommendations, evidence of clinically relevant distress in selected MSK populations, and the limitations of relying exclusively on unstructured clinical judgment.
The United States Preventive Services Task Force recommends screening adolescents aged 12-18 years for major depressive disorder when adequate systems are available for diagnosis, treatment, and follow-up[82]. This recom
Adjacent pediatric evidence suggests that screening may identify persistent psychosocial concerns in young people with complex MSK conditions. In a multidisciplinary prosthetics clinic, children and adolescents with lower-limb deficiency frequently showed psychosocial difficulties on standardized assessment, and many concerns persisted at subsequent visits[19]. These findings support longitudinal attention to emotional and social functioning, although they do not establish that repeated screening improves orthopedic outcomes.
More direct recommendations have been proposed for pediatric injury care. Price et al[83] concluded that structured screening can improve recognition of post-traumatic psychological symptoms and reduce under-referral compared with clinician judgment alone. However, this guidance was developed for pediatric injury populations and should not auto
Psychological screening may be clinically useful at selected time points, particularly after traumatic injury, during prolonged or complex treatment, or when pain, functional limitation, behavioral change, or emotional distress is evident. Screening should complement clinical discussion and should be implemented only where positive or concerning findings can lead to timely assessment, safety evaluation, referral, and follow-up[19,82,83].
Despite increasing recognition of psychological distress in adolescent MSK populations, routine screening remains difficult to implement. The main barriers operate at clinician, workflow, organizational, relational, and health-system levels[84-87].
Indirect evidence from pediatric dental and orthodontic settings illustrates the gap between perceived importance and actual practice. Ticku et al[84] found that most clinicians considered screening for anxiety and depression important, but relatively few performed it routinely. Limited training, low confidence, uncertainty about referral resources, and concern about how patients might perceive psychological questioning were among the principal barriers[84]. Although this evidence is not orthopedic-specific, it highlights professional obstacles that may also affect other adolescent specialty settings.
A systematic review of universal mental health screening in pediatric primary care similarly found that screening uptake and subsequent engagement with mental health services were often limited[85]. Implementation programs frequently lacked clear procedures for explaining screening, protecting confidentiality, interpreting results, and determining the appropriate response to a positive screen[85]. These observations indicate that adding a questionnaire to routine care is insufficient without clinical decision support and defined follow-up responsibilities.
More directly relevant orthopedic evidence comes from trauma settings. In a qualitative study across three orthopedic trauma centers, Vranceanu et al[86] identified time pressure, high patient volume, limited psychosocial training, clinician discomfort, stigma, inadequate staffing, and unclear referral pathways as major barriers to integrated care. These constraints suggest that screening protocols must fit existing workflows and should not depend exclusively on individual clinician initiative.
Broader implementation research in adolescent primary care has identified similar challenges, including lack of clinic protocols, uncertainty about managing positive findings, confidentiality and parental-involvement concerns, inadequate reimbursement, and limited access to specialist services[87]. These issues are particularly relevant in pediatric MSK care, where parents are often closely involved and urgent safety concerns may emerge unexpectedly.
Effective implementation therefore requires more than instrument selection. Services should define who administers and scores the measure, who reviews the result, how confidentiality is managed, when parents are involved, how urgent findings are escalated, and how referrals and follow-up are documented. Screening is unlikely to be sustainable unless these responsibilities are integrated into routine workflow and supported by adequate referral capacity[84-87].
Several brief self-report instruments may support the identification of depressive symptoms, anxiety, pain-related cognitions, and functional interference in adolescents receiving MSK care. However, these measures differ substantially in developmental range, intended purpose, administration format, scoring conventions, licensing requirements, and the extent to which they have been evaluated specifically in orthopedic populations. They should therefore be regarded as screening or symptom-monitoring instruments rather than diagnostic tests.
The PHQ-2 is an ultra-brief initial screen for depressive symptoms and may be followed by the PHQ-9 when further assessment is indicated. The PHQ-9 has been used in adolescent orthopedic and pediatric subspecialty settings and can be completed electronically within routine clinical workflows[88]. Nevertheless, the optimal threshold may vary according to population and purpose. Published adolescent validation studies have used different thresholds, and a numerical score should always be interpreted together with symptom duration, functional impairment, clinical context, and direct assessment. Particular attention is required for item 9 of the PHQ-9, which addresses thoughts of death or self-harm. Any non-zero response requires prompt clinical clarification and must not be interpreted solely through the total questionnaire score. Assessment should address the nature and frequency of the thought, current intent, planning, access to means, previous self-harm, protective factors, and immediate safety. Where risk is suspected, locally approved emer
The Generalized Anxiety Disorder-2 and Generalized Anxiety Disorder-7 scales may be used to identify and quantify anxiety symptoms, while pediatric Patient-Reported Outcomes Measurement Information System measures provide brief assessment of anxiety, depressive symptoms, pain interference, physical function, and broader health domains[89]. Patient-Reported Outcomes Measurement Information System scores are norm-referenced and should be interpreted using the documentation and reference population applicable to the specific pediatric measure and administration for
Pain-specific instruments may add clinically relevant information when pain catastrophizing, fear of movement, avoidance, or pain-related disability appears to influence participation or rehabilitation. The Pain Catastrophizing Scale for Children assesses exaggerated negative cognitive and emotional responses to pain, whereas the Fear of Pain Questionnaire for Children evaluates pain-related fear and avoidance. These measures have demonstrated useful psychometric properties in pediatric pain populations, but proposed reference values are not universally transferable across diagnoses, cultures, languages, or treatment settings[90-93]. They should not be used as stand-alone diagnostic thresholds or as automatic determinants of referral.
Instrument selection should be guided by the clinical question, patient age and developmental level, language availability, respondent burden, mode of administration, local expertise, and the existence of an actionable response pathway. Before implementation, clinicians should consult the official instrument source to confirm the exact version, scoring method, permitted use, translation status, and any licensing or registration requirements. Evidence supporting use in general pediatric or chronic pain populations should not automatically be considered equivalent to validation in adolescent orthopedic care. To provide a concise clinical comparison without implying universal validation or stan
| Instrument | Main construct/use | Approximate burden | Evidence context | Essential caveat |
| PHQ-2 | Initial screening for depressive symptoms | 2 items | Pediatric and adolescent clinical settings[17,90,92] | A positive result requires further assessment and is not diagnostic |
| PHQ-9 | Assessment of depressive symptom severity after an initial concern or positive brief screen | 9 items | Used in adolescent orthopedic and pediatric subspecialty workflows[17,88,94] | Any endorsement of item 9 requires prompt direct safety clarification regardless of the total score |
| GAD-2/GAD-7 | Initial assessment and quantification of anxiety symptoms | 2 or 7 items | General adolescent and pediatric mental-health populations[16,89,90] | Orthopedic-specific validation and optimal thresholds remain limited |
| PROMIS pediatric measures | Anxiety, depressive symptoms, pain interference, physical function, and related domains | Short forms or computerized adaptive testing | Pediatric and selected MSK populations[89,95,96] | Use the scoring documentation and reference population applicable to the selected version |
| Pain catastrophizing scale for children | Catastrophic thoughts and feelings related to pain | 13 items | Pediatric chronic-pain populations[58,59,91,92] | Reference values are not universal diagnostic or referral thresholds |
| Fear of pain questionnaire for children | Pain-related fear and activity avoidance | 24 items | Pediatric chronic-pain populations[91,93] | Interpretation should distinguish adaptive caution from persistent function-limiting avoidance |
Psychological screening can be incorporated into outpatient workflows when responsibilities, timing, documentation, and follow-up procedures are clearly defined. It should be noted that most implementation evidence derives from pediatric primary care or chronic-disease services rather than adolescent orthopedic clinics and should therefore be interpreted as adjacent evidence[97-100].
In pediatric primary care, electronic health-record prompts and delegation of screening to trained medical assistants have been associated with substantial increases in depression-screening rates[97]. This experience suggests that screening is more sustainable when it is embedded within routine intake procedures rather than added informally to the physician encounter. The temporary decline observed during workflow disruption also indicates that implementation depends on adaptable protocols and clearly assigned responsibilities[97].
Electronic screening completed before consultation is generally feasible and acceptable and may avoid substantially increasing visit duration[98]. Nevertheless, research-supported procedures do not always translate directly into routine practice. Sustainable implementation requires involvement of clinical staff, adaptation to local workflow, staff training, and clear procedures for reviewing and responding to results[98].
Evidence from cystic-fibrosis programs similarly suggests that standardized screening can be acceptable to patients, caregivers, and clinical teams[99]. Common barriers included limited staff time, restricted space, perceived respondent burden, and practical difficulties in scoring and storing results[99]. Electronic platforms with automated scoring and secure documentation may reduce some of these barriers, although they do not resolve limitations in clinical interpretation or referral capacity.
A systematic review of pediatric implementation strategies identified several potentially useful approaches, including integration of behavioral-health professionals, learning collaboratives, clinician reminders and feedback, and digital technologies[100]. Multifaceted strategies generally appeared more effective than isolated measures, but they also required greater organizational support, and the overall evidence remained limited[100].
For adolescent MSK services, the most transferable principles are therefore to embed screening at predefined clinical points, assign responsibility for administration and review, use secure and efficient scoring systems, train staff, and establish referral and follow-up procedures before implementation. Feasibility should be evaluated locally, and successful case identification should not be assumed to demonstrate improved orthopedic outcomes[97-100].
Orthopedic surgeons are often the principal clinical contact for adolescents with MSK conditions and are therefore well positioned to recognize psychological or behavioral concerns that may affect treatment participation and recovery. Their role is not to diagnose or independently treat psychiatric disorders, but to identify possible distress, initiate proportionate clinical discussion, evaluate immediate safety concerns, and facilitate referral when indicated[101,102].
A biopsychosocial approach requires attention not only to structural pathology and physical function, but also to pain-related beliefs, emotional distress, expectations, family context, and barriers to adherence[101,102]. Screening, recognition, and referral have been proposed as core responsibilities within orthopedic practice, although implementation should be adapted to the clinical setting and available resources[102]. A positive questionnaire result should prompt focused assessment rather than automatic psychiatric labeling.
Adolescent patients may not spontaneously disclose anxiety or other emotional concerns, particularly in perioperative settings. Shore et al[103] noted that clinician impression alone may not correspond reliably with adolescents’ self-reported anxiety and that preoperative distress may be associated with pain, analgesic use, and recovery. Brief validated measures may support recognition when used within an established pathway, but no single instrument or screening interval should be regarded as universally required.
The orthopedic surgeon may also contribute through clear information, realistic expectation setting, supportive communication, shared decision-making, and monitoring of changes in pain, function, adherence, mood, and behavior[101]. When clinically significant or persistent concerns emerge, responsibility should shift to appropriately trained mental health professionals. Thus, the surgeon acts as a point of recognition and coordination rather than as a substitute for psychological or psychiatric care[101-104].
Collaboration with mental health professionals may help orthopedic teams respond appropriately when psychological needs exceed the scope of routine MSK care. Such collaboration may include consultation, focused assessment, treatment planning, crisis management, and support for communication among clinicians, patients, and families. However, direct evidence concerning integrated mental health care in adolescent orthopedic settings remains limited.
Evidence from orthopedic trauma populations indicates a substantial burden of depression, anxiety, post-traumatic symptoms, and broader psychological distress[105]. Because this literature predominantly concerns adults and traumatic injury, it should be interpreted as indirect evidence rather than as a direct estimate for adolescents receiving elective or general orthopedic care. Nevertheless, it highlights the limitations of managing complex psychosocial needs within an exclusively biomedical pathway[105].
Qualitative evidence from orthopedic trauma centers suggests that clinicians generally recognize the potential value of integrated psychosocial services but identify major implementation barriers, including time pressure, limited training, stigma, insufficient staffing, and unclear referral procedures[106]. Suggested facilitators include direct or “warm” hand-offs, designated care coordinators, clear communication protocols, and use of the electronic medical record to support referral and follow-up[106]. These findings are useful for service design, although they do not demonstrate improved patient outcomes.
Adjacent pediatric evidence is available from integrated mental health models in primary care. Yonek et al[107] identified population-based care, measurement-based care, and access to evidence-based mental health treatment as recurring components of effective programs. Care management, psychiatric consultation, shared workflows, and treatment-to-target approaches may further support coordination. However, these models were not developed specifically for orthopedic populations and require adaptation before application to adolescent MSK services.
One pilot feasibility trial examined collaborative care in adults with MSK conditions and coexisting anxiety or depressive symptoms[108]. Participants and clinicians generally valued the recognition of both physical and mental health needs, but adherence, retention, and interdisciplinary communication were problematic[108]. This study therefore supports the acceptability of the model more clearly than its effectiveness and cannot be extrapolated directly to adolescent care.
In adolescent MSK settings, collaboration should be proportionate to clinical need and local capacity. Mild or transient concerns may be addressed through supportive communication and monitoring, whereas persistent, complex, or high-risk presentations require formal psychological or psychiatric assessment. Successful collaboration depends on defined professional roles, timely communication, confidentiality procedures, referral capacity, and confirmation that follow-up has occurred[105-108].
Physiotherapists and rehabilitation professionals have repeated contact with adolescents during recovery and are therefore well positioned to recognize fear of movement, avoidance, low self-efficacy, distress, and barriers to treatment engagement. Psychologically informed practice integrates these dimensions into rehabilitation without transforming physiotherapists into mental health professionals[109].
Keefe et al[109] described psychologically informed practice as an approach situated between exclusively biomechanical rehabilitation and formal psychological treatment. Relevant competencies include supportive interviewing, realistic goal setting, graded activity, reinforcement of autonomy, and attention to beliefs and expectations about pain and recovery. More complex psychological interventions should remain within the scope of appropriately trained mental health professionals.
Observational evidence suggests that experienced physiotherapists may already use psychologically informed behaviors, including building a therapeutic alliance, reducing perceived threat, reframing unhelpful beliefs, and fostering self-efficacy[110]. Importantly, physiotherapists in this work distinguished these strategies from formal psychotherapy and emphasized the need for collaboration with psychologists when patients presented more complex needs[110].
Implementation barriers include limited confidence, uncertainty about professional boundaries, inadequate referral pathways, insufficient supervision, and time constraints[111]. Training alone may therefore be insufficient unless accompanied by organizational support and clear escalation procedures[111].
Brief training can nevertheless influence professional attitudes. Jacobs et al[112] found that a one-day psychologically informed physiotherapy course shifted clinicians away from a predominantly biomedical orientation and toward greater emphasis on function, acceptance, and biopsychosocial care[112]. The absence of long-term follow-up means that sustained changes in clinical behavior remain uncertain.
In adolescent MSK care, physiotherapists should be trained to identify common psychological barriers, communicate supportively, use graded and goal-oriented rehabilitation, and recognize when referral is required. Their role is to integrate psychological awareness into physical rehabilitation, not to diagnose or independently treat psychiatric disorders[109-112]. A pragmatic training pathway for orthopedic surgeons, physiotherapists, and rehabilitation professionals could combine a brief core curriculum with supervised clinical application. The core program should cover ado
A blended one-day program of approximately 6-8 hours may provide an initial introduction to psychologically informed MSK care, consistent with the format evaluated by Jacobs et al[112]. However, such a course should not be regarded as sufficient to establish independent competence in managing sensitive disclosures or possible self-harm. Initial teaching should therefore be followed by periodic supervised practice, multidisciplinary simulation, refresher modules, and access to consultation from mental health professionals. Before undertaking these tasks independently, clinicians should demonstrate competence through observed role-play or simulation-based assessment using locally approved referral, safeguarding, and urgent-safety procedures[106,108,111,112].
Expected competencies should be limited to what non-mental-health clinicians can safely recognize and initiate: (1) Communicating supportively; (2) Identifying concerning symptoms; (3) Clarifying the immediate meaning of a positive screen; (4) Documenting findings; and (5) Activating an established referral or urgent-safety pathway. Their role is not to perform a comprehensive suicide-risk formulation, make a psychiatric diagnosis, or provide formal psychological treatment. These responsibilities should remain with appropriately trained mental health professionals. The proposed training framework is pragmatic rather than validated, and future studies should assess knowledge retention, observed competence, adherence to professional boundaries, supervision requirements, referral appropriateness, and patient safety.
Integrated care pathways combine medical, physical, psychological, and social interventions within a coordinated biopsychosocial framework. Most available evidence concerns pediatric chronic pain rather than adolescent orthopedic care specifically, but it provides useful principles for organizing services according to symptom severity, disability, treatment response, and family needs[113,114].
Harrison et al[113] described a continuum ranging from individual outpatient treatment to intensive interdisciplinary pain treatment. More intensive programs are generally reserved for patients with severe pain-related disability or insufficient response to lower-intensity care. Systematic-review evidence suggests that interdisciplinary pain treatment may improve disability, pain, and selected emotional outcomes, although study designs and treatment components are heterogeneous[113].
Kovačević et al[114] emphasized that effective pathways should integrate medical management, physical rehabilitation, psychological intervention, family support, and regular outcome monitoring. The specific composition and intensity of treatment should be individualized rather than applied uniformly across patients.
An inpatient model described by Maynard et al[115] combined physical and occupational rehabilitation, psychological pain management, parent training, educational support, and structured discharge planning. Patients showed improvements in function, school attendance, sleep, mobility, and medication use, but the retrospective design and small sample limit conclusions regarding comparative effectiveness[115].
Outpatient interdisciplinary care may also be feasible. Salerno et al[116] described a pediatric specialized pain clinic integrating pediatric pain medicine, physiotherapy, psychology, nursing, lifestyle interventions, and selected pharmacological treatment. Improvements were reported in pain, sleep, mood, daily participation, and school attendance, although the observational design does not establish which components produced these outcomes. The frequent need for community-based psychological and rehabilitation services also highlights the importance of coordination across levels of care.
Co-location may facilitate access. In a systematic review of pediatric hospital services, Marshall et al[20] found higher engagement when psychological consultation was provided at the same time and location as the medical visit than when families were referred to separate services. However, engagement should not be equated with improved orthopedic outcomes.
For adolescent MSK care, the most transferable principles are stepped intensity, shared treatment goals, clearly defined professional roles, family involvement, coordinated documentation, and continuity between hospital and community services. These pathways should be viewed as adaptable organizational models rather than validated universal algo
The clinical implications of the literature should be interpreted according to the type of evidence available. Four distinct questions need to be considered separately: (1) Whether psychological factors are associated with orthopedic or MSK conditions; (2) Whether they predict subsequent clinical outcomes; (3) Whether psychological screening is feasible and acceptable in routine care; and (4) Whether screening followed by targeted intervention improves orthopedic outcomes.
Evidence for association is the most extensive and is derived predominantly from cross-sectional and observational studies. These studies consistently identify relationships between MSK conditions and anxiety, depressive symptoms, body image dissatisfaction, pain catastrophizing, fear avoidance, impaired quality of life, and functional limitation. Cross-sectional associations do not establish directionality or causation, and psychological distress may function as a predisposing factor, a consequence of pain or disability, or part of a reciprocal process.
Prognostic evidence is more limited but clinically relevant. Prospective studies suggest that preoperative distress, pain catastrophizing, fear of movement, poor psychological readiness, and related variables may predict pain, disability, treatment adherence, return to sport, or postoperative recovery. Nevertheless, prognostic associations do not demonstrate that modifying the identified factor will necessarily improve the orthopedic outcome.
Evidence for screening feasibility is comparatively encouraging. Brief self-report instruments have been administered successfully in pediatric orthopedic, sports medicine, rheumatology, prosthetics, and MSK clinics, with generally high completion and acceptability rates. These findings support the practical capacity of clinical services to identify patients who may require further assessment. Screening performance and feasibility, however, should not be interpreted as evidence of clinical effectiveness.
Evidence that psychological screening itself, or referral following a positive screen, improves orthopedic outcomes remains limited. Screening may facilitate recognition and access to care, but its downstream benefit depends on accurate interpretation, confirmatory clinical assessment, referral capacity, intervention availability, and longitudinal follow-up. Accordingly, the proposed clinical recommendations should be understood as evidence-informed and adaptable rather than as established standards supported by definitive comparative trials. To facilitate interpretation of the heterogeneous literature, Table 2 summarizes the principal evidence domains relevant to adolescent MSK care[12-31,35-41,44-46,49-52,56-60,65-75,77,85,88,94,98-100,113,115-124]. The table distinguishes associations, prognostic findings, screening feasibility, and intervention efficacy, while also indicating whether the supporting evidence is derived directly from adolescent orthopedic populations, from adjacent pediatric settings, or indirectly from adult or other-specialty populations.
| Evidence domain | Predominant design/context | Principal finding | Interpretation | Ref. |
| Association: Scoliosis | Cross-sectional studies and reviews in adolescents with idiopathic scoliosis | Body image dissatisfaction and psychological distress are frequently associated with poorer self-reported quality of life | Direct adolescent evidence; associations are repeatedly reported, but causality and temporal direction remain uncertain | Feddema et al[12], Al Hajaj et al[13], Balboni et al[14], Bertuccelli et al[15], Gallant et al[21], Belli et al[22], Wang et al[23], Schwieger et al[24], Sanders et al[25], Kaya et al[26], Auerbach et al[45], Bertuccelli et al[46] |
| Association: Chronic MSK pain | Cross-sectional, cohort, and review evidence in adolescents with chronic MSK pain | Anxiety, depressive symptoms, catastrophizing, sleep disturbance, and pain interference frequently coexist with disability | Predominantly direct or adjacent pediatric evidence; findings vary across populations, measures, and study designs | Andias and Silva[35], Harte et al[36], Ocay et al[37], Phillips et al[38], Owiredua et al[39], Groenewald et al[40], Sherwood et al[41], Wolock et al[49], Forgeron et al[50], Jahre et al[51], Bateman et al[52], Feinstein et al[57], Miller et al[58], Guite et al[59] |
| Association: Sports injury | Observational studies and reviews involving adolescent athletes | Injury may be accompanied by poorer mental health, while pre-existing psychological difficulties may also be associated with injury vulnerability or recovery | Direct and adjacent adolescent evidence supporting a potentially reciprocal relationship rather than a single causal pathway | Putukian et al[27], Chow et al[28], Park et al[29], Nyland and Pyle[30], Brewer and Chatterton[31], Piussi et al[44] |
| Prognostic value | Prospective studies of adolescents undergoing surgery, rehabilitation, or recovery from MSK pain | Selected psychological factors may predict pain, disability, adherence, recovery, or return to sport | Direct evidence is limited and heterogeneous; prognostic associations do not demonstrate that modifying the factor will improve outcomes | Holley et al[56], Ramo et al[60], Hooten[65], Li et al[66], Pagé et al[67], Rabbitts et al[68], Fisher et al[69], Sapienza et al[70], Flanigan et al[71], Gennarelli et al[72], Richard et al[73], Li et al[74], Thorsell Cederberg et al[75] |
| Screening feasibility in orthopedic care | Implementation studies in pediatric orthopedic and sports clinics | Brief self-report or electronic screening can be completed during routine encounters and may identify previously unrecognized risk | Direct adolescent orthopedic evidence supporting feasibility and case identification, but not improved orthopedic outcomes | Colon-Morillo et al[17], Iturralde et al[88], Catanzano et al[94], Matthews et al[117] |
| Screening feasibility in adjacent pediatric care | Implementation studies in rheumatology, prosthetics, primary care, and chronic-disease services | Screening is generally acceptable and can be incorporated into outpatient workflows when response pathways are available | Adjacent pediatric evidence that informs implementation but cannot be treated as orthopedic outcome-effectiveness evidence | Milatz et al[16], James et al[18], Marshall et al[19], Marshall et al[20], Wissow et al[85], Martel et al[98], Quittner et al[99], Patel et al[100] |
| Psychological intervention | Trials and reviews in pediatric chronic pain populations | Psychological interventions may improve selected pain, disability, or coping outcomes, whereas effects on anxiety and depression are variable | Adjacent pediatric evidence; results should not be generalized automatically to all adolescent orthopedic populations | Palermo[77], Harrison et al[113], Maynard et al[115], Salerno et al[116], Birnie et al[122], Fisher et al[123], Palermo et al[124] |
| Integrated care | Pilot studies, implementation research, and evidence from pediatric chronic illness, trauma, rehabilitation, and adult MSK care | Coordinated models may improve access, engagement, and continuity of psychosocial care | Mostly adjacent or indirect evidence; direct evidence for improved adolescent orthopedic outcomes remains limited | Marshall et al[20], Reichman et al[106], Yonek et al[107], Teixeira et al[108], American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Collaborative and Integrated Care and AACAP Committee on Quality Issues and American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Collaborative and Integrated Care and AACAP Committee on Quality Issues[118], Alsulami et al[119], Davidson et al[120], Marani et al[121] |
The timing and frequency of psychological screening in adolescent MSK care have not yet been established as universal orthopedic standards. Available studies nevertheless provide examples of feasible approaches in specific clinical settings. Colon-Morillo et al[17] recommended a brief mental health assessment for adolescents older than 12 years attending an orthopedic sports clinic, whereas Catanzano et al[94] described a protocol in which patients aged 12-21 years were screened at three-month intervals. These protocols demonstrate feasibility within their respective institutional contexts but should not be generalized automatically to all orthopedic populations or clinical encounters. A pragmatic approach may include screening at the initial evaluation, at major changes in treatment or function, before and after surgery, during prolonged rehabilitation, or when pain, adherence difficulties, emotional distress, or safety concerns emerge. The optimal interval should be determined by the patient’s clinical course, the instrument used, local workflow, available referral resources, and institutional policy.
Regarding the choice of instrument, the studies reviewed suggest that a stepped or sequential approach offers the best balance between brevity and diagnostic depth. Colon-Morillo et al[17] and Catanzano et al[94] both describe a two-stage protocol beginning with the PHQ-2 as a first-line screen; when a patient scores 3 or above, the longer nine-item version (PHQ-9) is administered to assess depression severity more comprehensively. The ninth item of the PHQ-9, which directly addresses thoughts of self-harm, triggers an automatic social work referral when answered affirmatively, independent of the total score[17]. This procedure reflects the protocol adopted in the cited institution and should not be interpreted as the only acceptable response model. Any affirmative response to an item concerning death or self-harm requires prompt clinical clarification of intent, plan, means, immediacy, protective factors, and current safety, followed by activation of locally approved emergency or safeguarding procedures when indicated.
This tiered structure mirrors the logic described by Stearns et al[125] in the context of yellow flag screening in orthopedic physical therapy, where a multidimensional first-line instrument such as the OSPRO-YF is followed by more targeted unidimensional questionnaires when initial findings are positive. For settings in which Patient-Reported Outcomes Measurement Information System (PROMIS) measures are already embedded in the clinical workflow, Cheng et al[95] provide guidance on score interpretation. In a cross-sectional study of 50 adult patients with MSK conditions evaluated by a board-certified clinical psychologist, a PROMIS Depression score of 53 or above was identified as the optimal cutoff for predicting a DSM-5 depressive disorder, with adequate specificity (86%) though not sufficient sensitivity (79%) to serve as a stand-alone diagnostic tool. The authors therefore advocate using PROMIS Depression scores as a screening instrument rather than a diagnostic one, noting that even modestly elevated scores should prompt further discussion and potential referral. By contrast, PROMIS Anxiety scores demonstrated weaker discriminant ability, and the authors caution against over-interpreting mild to moderate elevations on that domain. For suicide risk specifically, Matthews et al[117] describe the successful implementation of the PSS-3 Suicide Risk Assessment in a pediatric orthopedic specialty clinic, where universal administration to all presenting patients achieved a completion rate of 83% and identified a 3% positivity rate among those screened. A single affirmative response on any item triggered an immediate social work consultation, a protocol facilitated by the permanent availability of social workers within the clinic. The authors note that patients were not informed in advance that a positive response would result in a social work visit, an intentional design choice aimed at eliciting more candid answers. Crucially, approximately 23% of patients with a positive screen were subsequently admitted to inpatient psychiatric facilities, underscoring that timely identification within the orthopedic visit can directly translate into life-altering interventions for patients who would not otherwise have been referred for mental health evaluation. Stearns et al[125] further articulate a three-step framework for integrating yellow flag screening into routine physical therapy practice that has broader relevance for orthopedic settings generally. Step one involves establishing a standardised screening process, including the selection of an appropriate tool, definition of the patient population, stakeholder engagement, electronic medical record integration, and staff training. Step two concerns the interpretation of screening results through shared decision making, in which the clinician and patient collaboratively determine the most appropriate care pathway, ranging from standard physical therapy to immediate referral, based on the screening outcome and clinical context. Step three involves longitudinal monitoring, with reassessment intervals determined by clinical need, treatment phase, instrument characteristics, and local protocol. The approximately two-week interval proposed by Stearns et al[125] represents one context-specific model rather than a universal standard for orthopedic practice. This framework explicitly acknowledges that screening decisions are not based on tool scores alone but must integrate clinical judgement and patient preferences, and that the goal is not to have orthopedic providers treat mental health conditions but to ensure that patients are efficiently connected to the appropriate resources. The evidence reviewed in the preceding chapters supports the adoption of a structured, three-tiered stepped-care model for psychological screening and intervention in orthopedic settings, in which the intensity of support is calibrated to the level of identified risk (Figure 2).
At the first level, brief screening may be offered at clinically appropriate time points, such as the initial assessment, major treatment transitions, perioperative evaluations, prolonged rehabilitation, or visits in which psychological or behavioral concerns emerge. A positive or concerning screening result should lead to a focused clinical assessment rather than automatic diagnostic labeling. Patients with mild or context-dependent difficulties may require monitoring, psy
The key psychological risk and protective factors that inform patient stratification across these levels of care are summarized in Table 3[29,51,52,56,75,78,123,126,127].
| 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 |
Psychological screening should be introduced only within a clearly defined clinical pathway. Depending on local organization, questionnaires may be distributed electronically or on paper by trained nursing staff, medical assistants, physiotherapists, or other designated team members and scored automatically or by appropriately trained personnel. Responsibility for reviewing the result and initiating the subsequent clinical response should be assigned explicitly rather than left to informal discretion.
Adolescents should be informed, in developmentally appropriate language, about the purpose of screening, how the results will be used, who will have access to them, and the limits of confidentiality. Whenever feasible and consistent with local legislation, at least part of the assessment should be completed privately, without parents or caregivers present, because the disclosure of depression, self-harm, interpersonal violence, substance use, or other sensitive concerns may be inhibited by parental presence. Parental involvement remains important but should be balanced with the adolescent’s evolving autonomy and confidentiality rights. Confidentiality may need to be breached when there is an immediate risk of harm, abuse, or another legally defined safeguarding concern.
Screening scores and subsequent clinical decisions should be documented in the medical record in accordance with institutional privacy policies. Positive findings require interpretation in relation to age, developmental level, clinical context, language, culture, pain severity, medication effects, and functional impairment. False-positive results may occur, particularly when somatic symptoms of depression or anxiety overlap with pain, sleep disruption, fatigue, or post
Before implementation, services should establish referral thresholds, named referral contacts, procedures for routine and urgent assessment, and mechanisms for confirming that follow-up has occurred. Screening without adequate capacity for interpretation and referral may identify distress without providing an effective response. Where specialist resources are limited, stepped-care pathways, tele-mental health consultation, liaison with primary care, or designated behavioral health coordinators may help match the intensity of support to clinical need.
Risk stratification in adolescent MSK care should be multidimensional because no single psychological, clinical, or family factor reliably identifies all patients likely to experience persistent pain, disability, or poor recovery. Relevant domains include pain severity and distribution, functional impairment, mood symptoms, sleep quality, pain-related cognitions, family responses, and protective psychological resources.
Longitudinal pediatric evidence identifies pain intensity, multisite pain, anxiety symptoms, and poor sleep as potential markers of less favorable long-term outcomes. Murray et al[78] found that these factors during adolescence were associated with greater pain interference, emotional symptoms, sleep difficulties, and poorer psychosocial functioning in young adulthood. Because participants were recruited from tertiary pain clinics, the findings may be most applicable to adolescents with complex or persistent pain rather than to all orthopedic patients.
In youth with new-onset MSK pain, Holley et al[56] found that impaired endogenous pain inhibition and female sex predicted pain persistence, whereas depressive symptoms were associated more strongly with later disability and poorer quality of life. This distinction suggests that risk factors for persistent pain may differ from those predicting functional consequences.
Direct orthopedic evidence is available from adolescents undergoing spinal fusion for idiopathic scoliosis. Presurgical pain intensity and pain catastrophizing were associated with poorer pain, function, and health-related quality of life at follow-up, while parental catastrophizing was associated with greater later pain[75]. Psychological flexibility and pain acceptance in adolescents and parents emerged as possible resilience factors, indicating that assessment should consider protective resources as well as vulnerabilities[75].
Adult orthopedic studies provide indirect support for composite risk assessment. Castillo et al[126] identified distinct profiles based on combinations of pain, depression, post-traumatic symptoms, substance use, resilience, social support, and self-efficacy. Multivariate profiles predicted later outcomes more effectively than individual factors considered separately[126]. However, these findings arose from adults with severe orthopedic trauma and cannot be transferred directly to adolescent elective or outpatient care.
Verma and Juneja[128] evaluated a preoperative risk-stratification model in adults undergoing arthroplasty or spinal fusion. Patients with elevations across multiple psychological domains who received targeted psychiatric intervention showed greater functional improvement than high-risk patients receiving standard care. Although this study supports the potential value of multidomain assessment, its adult population, intervention design, and surgical context limit direct applicability to adolescents.
High-risk status should therefore not be defined by a single score or universal cutoff. Greater concern may be warranted when several factors coexist, such as persistent or multisite pain, functional decline, depression or anxiety, poor sleep, catastrophizing, fear avoidance, limited family support, previous psychiatric history, or urgent safety concerns. Conversely, self-efficacy, psychological flexibility, pain acceptance, supportive relationships, and constructive coping may reduce vulnerability. Risk classification should guide focused assessment and follow-up rather than function as a psychiatric diagnosis or an automatic determinant of treatment[56,75,78,126,128].
Psychological screening has limited clinical value unless positive or concerning findings lead to appropriate assessment, referral, and follow-up. Traditional referral models based solely on directing families to an external mental health service may be ineffective because appointments may be delayed or never completed owing to limited specialist availability, communication failures, insurance or transportation barriers, stigma, and uncertainty about how to access care[118].
Pediatric integrated-care literature describes a continuum ranging from coordinated referral to co-located and fully integrated care[118]. In coordinated models, medical and mental health professionals remain in separate services but communicate through defined referral and information-sharing procedures. Co-located models place behavioral-health professionals within or near the medical setting, while integrated models use shared workflows, treatment plans, and follow-up responsibilities[118]. Although integrated approaches may improve access and engagement, most supporting evidence comes from pediatric primary care rather than adolescent orthopedic services.
Referral intensity should be proportionate to clinical need. Mild or transient concerns may initially require supportive communication, monitoring, psychoeducation, or coordination with the primary care clinician. Persistent depressive or anxiety symptoms, marked functional impairment, disordered eating, severe pain-related fear, or significant family difficulties may warrant formal psychological or psychiatric assessment. Suicidal ideation, self-harm, acute behavioral dysregulation, abuse, or other immediate safety concerns require urgent evaluation and activation of local emergency or safeguarding procedures.
Warm hand-offs may reduce loss between identification and treatment by introducing the mental health professional directly, explaining the purpose of referral, addressing concerns about stigma, and assisting the family with practical access barriers[119]. Pediatric integrated-care studies suggest that co-location, stepped-care models, and active referral support can shorten waiting times and improve service utilization, although these findings should not be interpreted as direct evidence of improved orthopedic outcomes[119].
The Trauma Resilience and Recovery Program provides a relevant adolescent example after traumatic injury. Its stepped pathway combines early psychoeducation and risk assessment, remote symptom monitoring after discharge, subsequent clinical screening, and facilitated referral for patients with persistent symptoms[120]. This model illustrates how referral can be linked to longitudinal monitoring rather than treated as a single administrative event. However, it was developed for hospitalized trauma populations and may require substantial adaptation for elective orthopedic or outpatient settings.
Care coordination also includes communication among orthopedic clinicians, rehabilitation teams, primary care professionals, mental health services, schools, and community resources. Responsibilities should be explicitly assigned for reviewing screening results, initiating referrals, documenting clinical decisions, monitoring attendance and response, and confirming that follow-up has occurred[118-120].
Transition to adult care represents an additional coordination challenge for adolescents with persistent MSK conditions. Structured transition programs may include assessment of readiness, a written clinical summary, identification of adult providers, transfer of psychological and rehabilitation goals, and confirmation of the first adult-care appointment[121]. Evidence for these models is heterogeneous, but their organizational principles may help reduce fragmented care during a vulnerable developmental period[121].
Referral should therefore be understood as an active, supported, and documented process rather than the simple provision of contact details. The most appropriate model will depend on symptom severity, urgency, family preferences, service availability, confidentiality requirements, and local resources[118-121].
Patient-centered MSK care requires attention to the adolescent’s symptoms, functional goals, values, preferences, developmental stage, family context, and daily experience. Effective communication is central to this approach and should include clear information, active listening, empathy, recognition of verbal and non-verbal distress, and opportunities for the adolescent to express concerns that may not emerge during a purely biomechanical assessment[129].
Shared decision-making provides a practical framework for integrating clinical evidence with the patient’s goals and preferences. Clinicians contribute knowledge regarding the benefits, limitations, and risks of available options, while adolescents and families contribute information about treatment burden, school and sport participation, appearance-related concerns, expectations, and acceptable trade-offs[130]. The adolescent’s degree of involvement should be adapted to developmental capacity while preserving meaningful participation and avoiding unnecessary paternalism.
Patient preferences may concern the desired level of involvement in decisions, the characteristics of healthcare professionals, and the acceptability of specific treatments[131]. These preferences may influence satisfaction, adherence, and engagement, but they should be considered within the limits of clinically appropriate and evidence-informed care[131].
Decision aids may improve understanding of treatment options and support deliberation, but they cannot replace skilled communication or individualized assessment[132]. In adolescent MSK care, shared decisions should also account for parental involvement, confidentiality, evolving autonomy, and possible differences between the adolescent’s and caregivers’ priorities.
Patient-centered care should therefore be understood not as a separate intervention, but as the manner in which assessment, screening, rehabilitation, and referral are conducted. Its implementation requires developmentally app
The current evidence base is limited by four closely related methodological and clinical problems: (1) The absence of standardized screening protocols, marked heterogeneity in outcome measurement, insufficient longitudinal research; and (2) The scarcity of adequately designed multidisciplinary trials.
Psychological difficulties are frequently underestimated when clinicians rely exclusively on clinical impression. In MSK and spinal populations, clinician judgment has shown low sensitivity for detecting depression, anxiety, and psychological distress, indicating that substantial morbidity may remain unrecognized without structured assessment[133]. The available screening literature is itself highly fragmented. Park et al[29] identified numerous psychological and physical-health instruments across a relatively small number of studies involving pediatric athletes, while Furie et al[134] documented comparable heterogeneity in adult sports-injury research. The diversity of constructs, versions, thresholds, and administration methods limits comparison across studies and prevents the definition of a single evidence-based screening protocol.
Multidimensional instruments may help reduce assessment burden. Lentz et al[135] developed shorter versions of the Optimal Screening for Prediction of Referral and Outcome Yellow Flag tool to capture negative mood, fear avoidance, and positive coping across MSK conditions. Nevertheless, this instrument was developed primarily in orthopedic physical-therapy populations and cannot be regarded as a universally validated tool for adolescent orthopedic care. Current evidence therefore supports the use of brief, developmentally appropriate measures selected according to the clinical question rather than a single standardized battery.
Outcome heterogeneity further limits interpretation. Definitions of chronic postsurgical pain vary widely in pain threshold, timing, and inclusion of functional or psychological criteria, producing markedly different prevalence estimates across studies[136]. Pediatric patient-reported outcome measures also differ in psychometric quality. Noel et al[137] found that only a limited number of Pediatric Patient-Reported Outcomes Measurement Information System short forms met criteria for recommendation in clinical trials, while several widely used measures required further evidence concerning reliability, responsiveness, cross-cultural validity, or content validity. Widespread use should therefore not be interpreted automatically as adequate validation in the target population.
The problem is compounded by clinical heterogeneity. Adolescents with chronic MSK pain show distinct psychosocial, somatosensory, and pain-modulation profiles, indicating that patients with similar diagnoses may have substantially different mechanisms, vulnerabilities, and treatment needs[37]. At the same time, outcome reporting remains heavily centered on pain intensity, whereas emotional functioning, role participation, sleep, quality of life, economic burden, and patient-identified priorities are assessed less consistently[122]. Standardization should therefore not mean reducing all patients to a uniform outcome set, but rather establishing a core outcome framework supplemented by condition- and phenotype-specific measures.
Longitudinal evidence remains limited. Noel et al[137] found that adolescent chronic pain was associated with higher rates of anxiety and depressive disorders in adulthood, but the study could not establish the temporal ordering of pain and mental-health symptoms or determine whether pain persisted into adulthood. The ongoing Longitudinal Resilience and Risk Factors in Pediatric Postoperative Pain study is designed to assess emotional, parental, sleep, and quality-of-life trajectories before and after pediatric orthopedic surgery, but it has not yet produced outcome data[127]. These limitations prevent firm conclusions regarding causality, developmental trajectories, and the optimal timing of psychological assessment.
Intervention research is similarly heterogeneous. Elbers et al[138] reported substantial variability in treatment content, duration, outcome measures, follow-up, and methodological quality across interdisciplinary multimodal pain programs, making it difficult to determine which components produce sustained benefit. More importantly, Fisher et al[123] found predominantly low- or very-low-certainty evidence across many pharmacological, physical, and psychological treatment outcomes, but high-certainty evidence that psychological therapies did not improve depression or anxiety at post-treatment or follow-up. Benefits for quality of life and broader functioning were also not established consistently[123]. These findings require a more cautious interpretation of multidisciplinary and psychologically informed care: Such models may improve access, participation, or selected pain-related outcomes, but their effects on emotional symptoms and long-term orthopedic recovery remain uncertain.
Direct multidisciplinary evidence in adolescent orthopedic populations is particularly sparse. The van Niekerk et al[139] identified only a small number of psychosocial intervention studies in pediatric scoliosis, most of which tested brief or isolated interventions rather than integrated models of care. Meta-analytic evidence on psychological therapies for pediatric chronic pain has also shown limited or inconsistent effects on disability and emotional functioning[124]. Perioperative research is not more definitive: Nadinda et al[140] found no trials specifically conducted in pediatric orthopedic surgery and substantial variability in intervention type, timing, provider, and comparator conditions. Broader chronic-pain literature further suggests that protocol-driven interventions often provide limited individual tailoring despite marked patient heterogeneity[141].
Future research should therefore prioritize prospectively registered, adequately powered, multicenter studies conducted specifically in adolescent orthopedic and MSK populations. Such studies should use developmentally validated measures, prespecified core outcomes, clinically meaningful follow-up periods, active comparators, transparent reporting of intervention components, and assessment of both benefits and harms. Trials should distinguish screening feasibility from diagnostic accuracy and intervention effectiveness and should evaluate whether treatment effects vary according to psychological, functional, or pain-related phenotype. Until such evidence becomes available, screening pathways and multidisciplinary care models should be viewed as adaptable, evidence-informed approaches rather than universally validated standards in sixteen articles[29,37,96,122-124,127,133-141].
Future research should address specific methodological and implementation questions in adolescent orthopedic and MSK care. Priorities include longitudinal studies, adolescent-specific clinical guidance, rigorous evaluation of digital tools, and prospective testing of stratified interventions.
Longitudinal research is needed to clarify the temporal and reciprocal relationships among psychological symptoms, sleep, pain, disability, family factors, and treatment trajectories. Psychological symptoms in early adolescence have been associated with subsequent MSK pain, while repeated assessments have identified reciprocal relationships among insomnia, mood symptoms, and pain across adolescence[142,143]. Longer-term studies have similarly linked adolescent pain intensity, anxiety, poor sleep, and family dysfunction with less favorable outcomes in young adulthood[78]. Prospective injury studies suggest that adolescent and parental psychological factors may contribute differently to later pain and disability[69].
Future cohorts should therefore include repeated assessments at clinically meaningful points, such as initial evaluation, treatment initiation, early rehabilitation, return to school or sport, and follow-up at 6 months and 12 months. The Longitudinal Resilience and Risk Factors in Pediatric Postoperative Pain study provides a useful multicenter model for repeated perioperative assessment[127]. Studies should include diverse adolescent populations and prespecify psychological, functional, and MSK outcomes, including mood and anxiety symptoms, catastrophizing, fear avoidance, sleep, pain interference, physical function, adherence, school attendance, return to sport, social participation, family responses, healthcare use, and safety outcomes[69,78,127,142,143].
Adolescent-specific clinical guidance is also needed. Existing recommendations concerning psychological assessment after pediatric injury remain heterogeneous, and evidence supporting screening and implementation is less developed than evidence concerning treatment of established mental disorders[144]. Future guidance should specify which patients should be assessed, at which clinical stages, with which instruments, and how positive findings should be interpreted. It should also define responsibility for administration, score review, clinical clarification, confidentiality, parental invol
Oncology provides an organizational example of how psychosocial assessment can be incorporated into specialty guidance through systematic evidence appraisal and explicit implementation pathways[145]. However, it should not be regarded as direct evidence for orthopedic care. Adolescent orthopedic studies should compare structured screening linked to assessment, referral, and follow-up with usual care and evaluate not only case identification, but also treatment engagement, patient acceptability, emotional symptoms, pain interference, function, school and sport participation, safety, and healthcare use.
Digital tools may facilitate screening, monitoring, education, and remote support, especially during prolonged rehabilitation or when access to care is limited. Selected digital mental health interventions may benefit children and ado
Engagement remains a major limitation. In the real-world implementation of WebMAP Mobile, only a minority of adolescent–parent dyads completed the full program, although greater completion was associated with better pain-related outcomes[148]. Similar variability has been reported across mobile health interventions for adolescents with chronic disease[149]. Future studies should therefore assess uptake, adherence, dropout, usability, accessibility, privacy, digital literacy, and procedures for responding to concerning data. Digital interventions should be co-designed with adolescents and should complement rather than replace professional assessment and referral pathways[146-149].
Smartphones and wearable devices may eventually support low-burden monitoring of mobility, sleep, activity, and social participation[150]. However, current evidence derives largely from psychiatric and adult populations. Before routine orthopedic use, studies should establish clinical validity, incremental predictive value, acceptable false-alert rates, informed-consent procedures, privacy protections, data ownership, equity of access, and responsibility for responding to clinically significant signals[150].
Personalized approaches should be evaluated prospectively rather than inferred from exploratory subgroup analyses. Future adolescent studies could test whether a limited set of clinically accessible characteristics, such as psychological distress, catastrophizing, fear avoidance, sleep disturbance, and functional disability, helps identify patients who benefit from different rehabilitation or psychological-support strategies[37,151-154]. Such studies should use prespecified phenotypes, active comparators, clinically meaningful functional outcomes, and adequate sample sizes to test treatment-by-phenotype interactions. Complex biomarkers, neuroimaging, or psychophysical measures should be included only when they provide incremental value beyond accessible clinical assessment. Until such approaches are prospectively validated, phenotype-based care should remain investigational.
Future studies should be multicenter, prospectively registered, adequately powered, and conducted directly in adolescent orthopedic and MSK populations. They should use developmentally validated measures, active comparators, clinically meaningful follow-up, and prespecified procedures for missing data, treatment fidelity, adverse events, and interaction analyses. Screening and phenotype-based care should not be recommended routinely until their incremental clinical utility has been demonstrated and externally validated.
Adolescents with orthopedic and MSK conditions may experience anxiety, depressive symptoms, body image concerns, pain-related fear, catastrophizing, social difficulties, and reduced quality of life. These factors are clinically relevant because they may coexist with pain, functional limitation, treatment burden, and rehabilitation difficulties. The available evidence is heterogeneous and remains predominantly observational, with substantial variation across conditions, age groups, settings, and outcome measures.
Brief validated psychological measures may support the identification of adolescents requiring further assessment, particularly at clinically appropriate points such as the initial evaluation, major treatment transitions, prolonged rehabilitation, or the emergence of emotional, behavioral, or safety concerns. A positive screening result should not be interpreted as a psychiatric diagnosis but should prompt proportionate clinical assessment.
Psychological screening should be integrated only where systems exist for interpretation, confidentiality management, urgent safety assessment, referral, documentation, and follow-up. The appropriate instrument and screening frequency should be adapted to the clinical context, patient needs, and local resources. At present, the optimal frequency of screening and its incremental effectiveness in improving orthopedic, functional, and psychosocial outcomes remain uncertain.
Prospective adolescent-specific studies are needed to determine which patients benefit most, when assessment should occur, and whether screening linked to targeted intervention improves outcomes beyond usual MSK care.
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