Musculoskeletal pain

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Chapter 31 MUSCULOSKELETAL PAIN

Theodore X. O’Connell

General Discussion

Musculoskeletal pain during childhood can be difficult for children to characterize. Most causes of acute musculoskeletal pain in children are easy to identify, but the cause of chronic musculoskeletal pain or pain that has associated systemic symptoms can be more difficult to diagnose (see Figure 31-1). Nonrheumatic causes of musculoskeletal pain are much more common than rheumatic causes.

Figure 31-1 Evaluation and diagnosis of the child with musculoskeletal pain.

The initial step in obtaining a history is to determine the specific location of the pain. The joint distribution and the number of joints involved should be determined. It should be determined whether the pain is localized to soft tissues rather than the joint. The possibility of referred pain should be considered.

The next step is to determine whether the cause of musculoskeletal pain may be an inflammatory process. Constitutional symptoms (fevers, fatigue, or rash), joint swelling, and prolonged morning stiffness suggest an inflammatory process. A limitation in the child’s daily activities is of greater concern for an inflammatory process or malignancy. Rapid onset of pain suggests trauma, sepsis, hemarthrosis, or malignancy. Onset of pain over several days suggests an infectious or reactive arthritis.

A complete history and physical examination should be performed to help evaluate for extra articular signs of infection, rheumatic disease, or malignancy. Laboratory tests and radiologic studies may help to support a diagnosis in a child with a high likelihood of an inflammatory process and may exclude worrisome diagnoses such as infection and malignancy. Laboratory tests and radiologic studies should be used judiciously as many have a low pretest probability in the primary care setting.

Many rheumatic processes tend to develop over weeks or months. As such, close follow-up and reexamination is helpful to determine the child’s clinical course. Resolution of symptoms and absence of worrisome features are reassuring. Additional signs and symptoms present at a follow-up visit may direct additional evaluation or referrals.

Causes of Musculoskeletal Pain

Arthritides of inflammatory bowel disease

Benign hypermobility syndrome

Benign nocturnal limb pains of childhood (growing pains)

Compartment syndrome

Deep vein thrombosis

Ehlers-Danlos syndrome

Hemarthrosis

Hemophilia

Henoch-Schönlein purpura

Hernia

Infectious causes

• Acute rheumatic fever

• Necrotizing fasciitis

• Orchitis

• Osteochondritis (Pseudomonas)

• Osteomyelitis

• Pyomyositis

• Transient synovitis

Legg-Calvé-Perthes disease

Malignancy

• Acute lymphoblastic leukemia

Osteomyelitis (focal and chronic recurrent multifocal)

Osteonecrosis

Patellofemoral pain syndrome

Rheumatic causes

• Ankylosing spondylitis

• Arthritis with enthesitis

• Dermatomyositis

• Juvenile dermatomyositis

• Juvenile rheumatoid arthritis (RA; pauciarticular and polyarticular)

• Mixed connective tissue disease

• Psoriatic arthritis

• Reactive arthritis (Reiter syndrome)

• Septic arthritis

• Seronegative spondyloarthropathies

• Sjögren’s syndrome

• Systemic lupus erythematosus (SLE)

• Wegener’s granulomatosis

Sickle cell disease

Slipped capital femoral epiphysis

Suggested Work-up

Laboratory studies are used primarily for screening when the differential diagnosis includes infectious, inflammatory, or neoplastic processes. Laboratory tests and radiologic studies should be used judiciously as many have a low pretest probability in the primary care setting.

Complete blood count (CBC)	To evaluate for leukocytosis (infection, leukemia, or inflammatory conditions). White blood cells (WBCs) may be normal in up to 66% of children with leukemia in the initial evaluation of chronic joint pain.
Erythrocyte sedimentation rate (ESR) or C-reactive protein	To evaluate for inflammation or infection. May be normal or elevated with arthritis. A discordant ESR and platelet count is worrisome for malignancy.
Antinuclear antibodies (ANA)	To evaluate for SLE, juvenile RA, and vasculitis. May be positive in up to 40% of healthy children. Titers greater than 1:320 are more likely to represent inflammatory diseases.
Rheumatoid factor	To evaluate for juvenile RA. 70% sensitivity and 82% specificity for RA, but has low positive predictive value in the primary care setting
Plain radiographs	May be helpful in diagnosing fractures, bone tumors, and chronic osteomyelitis
Blood culture	If an infectious etiology is suspected
Joint aspiration and examination of the synovial fluid (cell count and differential, gram stain, glucose, protein, aerobic and anaerobic cultures)	For a child with monoarthritis, who should be considered to have septic arthritis until it is ruled out

Additional Work-up

Lactate dehydrogenase	May be helpful when malignancy is suspected as elevated levels may indicate malignancy
Antistreptolysin-O (ASO) titer	If a recent streptococcal infection is suspected as the cause of arthritis
Lyme antibody titer	If Lyme disease is suspected
Anti-double-stranded DNA	To evaluate for SLE
HLA-B27 genotype	May be useful in the diagnosis of spondyloarthropathy. Should be considered if there is a family history of inflammatory bowel disease, psoriasis, or spondyloarthropathy.
cANCA (antineutrophil cytoplasmic antibody)	To confirm a diagnosis of Wegener granulomatosis
Urinalysis and creatinine	If Henoch-Schönlein purpura is suspected
Synovial biopsy	May be necessary for the child with chronic monoarticular joint pain in whom a definitive diagnosis cannot be made after a thorough evaluation
Computed tomography (CT) scan or magnetic resonance imaging (MRI)	May be helpful in diagnosing malignancy, inflammatory conditions, and cartilage abnormalities
Technetium bone scan	May be helpful in differentiating septic arthritis from osteomyelitis. May also be useful when the source of the patient’s pain is not clear after the clinical examination and initial evaluation.
Ultrasonography	May be useful in identifying and quantifying a joint effusion, especially in deeper joints such as the hips. Also may be used to guide needle aspiration of these joints.
Echocardiography	If pericarditis or carditis is suspected