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Background A 14 year-old boy was referred by an orthopaedic colleague at the district hospital for evaluation of ankylosing spondylitis. The child was previously fit and well. His symptoms reported at the referral was back pain and also possibility of foot drop on the right ankle. His dad had ankylosing spondylitis and was on biologic treatment. Also, there was significant history of autoimmunity in other family members. Methods During the initial consultation, we revisited the history. The boy reported that main symptoms were recurrent popping sensation of his right side shoulder associated with pain and burning sensation on the shoulder which usually settles after an hour. He is sporty boy and plays regular rugby, football and used to throw discus. He denied any history of injury or illnesses preceding his symptoms. There was past history of fracture of right ankle on two occasions managed conservatively. There were no other systemic symptoms. On examination, the child was afebrile and systemically looked well. There was no lymphadenopathy, mouth ulcers or clubbing. His cardio respiratory examination was normal. Abdomen was soft with no organomegaly. He was noted to have winging of scapula on the right side and weakness of the abductor muscles on the right side shoulder. There was wasting of muscles around the right ankle. He was noticed to have bilateral cavovarus and high arched feet. There was scoliosis at the thoracic and lumbar level. His muscle tone, power and reflexes were all normal. Results With his clinical presentation of winging of scapula, long thoracic nerve palsy was considered and he was referred to local physiotherapy. MRI spine done at local hospital was reviewed in the MSK radiology meeting and this showed no evidence of ankylosing spondylitis and confirmed scoliosis. His blood tests showed normal full blood count, liver and kidney function, raised creatinine kinase of 358 and HLA B27 positive. The repeat creatinine kinase was normal (153).The nerve conduction study of both the upper and lower limbs were normal. He was also seen by the neurology team. Further discussion with sport medicine colleagues and advised to continue physiotherapy. On the review 3 months later, his symptoms were much improved. Conclusion The presentation of a teenage boy with back pain and family history of ankylosing spondylitis warrants further evaluation. Thorough history, examination and early referral to specialist centre is beneficial for appropriate management of complex situations like this. Conflicts of Interest The authors declare no conflicts of interest. [ABSTRACT FROM AUTHOR]