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

Henoch-Schönlein purpura

Infectious causes

• Acute rheumatic fever

• Brodie abscess

• Gas gangrene

• Lyme disease

• Necrotizing fasciitis

• Osteochondritis (Pseudomonas)

• Osteomyelitis

• Pyomyositis

• Transient synovitis

Legg-Calvé-Perthes disease

• Acute lymphoblastic leukemia

• Ewing’s sarcoma

• Osteosarcoma

• Rhabdomyosarcoma

Marfan syndrome

Myofascial pain

Osteochondrosis

Osteomyelitis (focal and chronic recurrent multifocal)

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

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