Musculoskeletal Pain Syndromes

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Chapter 162 Musculoskeletal Pain Syndromes

Musculoskeletal pain is a frequent complaint of children presenting to general pediatricians and is the most common presenting problem of children referred to pediatric rheumatology clinics. Prevalence estimates of persistent musculoskeletal pain in community samples range from roughly 10% to 30%. Although diseases such as juvenile idiopathic arthritis and systemic lupus erythematosus (SLE) may manifest as persistent musculoskeletal pain, the majority of musculoskeletal pain complaints in children are benign in nature and attributable to trauma, overuse, and normal variations in skeletal growth. There is a subset of children in whom chronic pain complaints develop that persist in the absence of physical and laboratory abnormalities. Children with idiopathic musculoskeletal pain syndromes also typically have marked subjective distress and functional impairment. The treatment of children with musculoskeletal pain syndromes optimally includes both pharmacologic and nonpharmacologic interventions.

Clinical Manifestations

All chronic musculoskeletal pain syndromes involve pain complaints of at least 3 mo in duration in the absence of objective abnormalities on physical examination and laboratory screening. Additionally, children and adolescents with musculoskeletal pain syndromes often complain of persistent pain despite previous treatment with nonsteroidal anti-inflammatory drugs and analgesic agents. The location varies, with pain complaints either localized to a single extremity or more diffuse and involving multiple extremities. The prevalence of musculoskeletal pain syndromes increases with age and is higher in females, thus rendering adolescent girls at highest risk.

The pain complaints of children and adolescents with musculoskeletal pain syndromes are commonly accompanied by psychologic distress, sleep difficulties, and functional impairment throughout home, school, and peer domains. Psychologic distress can include symptoms of anxiety and depression, such as frequent crying spells, fatigue, sleep disturbance, feelings of worthlessness, poor concentration, and frequent worry. Indeed, a substantial number of children with musculoskeletal pain syndromes display the full range of psychologic symptoms, warranting an additional diagnosis of a comorbid mood or anxiety disorder (e.g., major depressive episode, generalized anxiety disorder). Sleep disturbance in children with musculoskeletal pain syndromes may include difficulty falling asleep, multiple night awakenings, disrupted sleep-wake cycles with increased daytime sleeping, nonrestorative sleep, and fatigue.

For children and adolescents with musculoskeletal pain syndromes, the constellation of pain, psychologic distress, and sleep disturbance often leads to a high degree of functional impairment. Poor school attendance is common, and children may struggle to complete other daily activities relating to self-care and participation in household chores. Peer relationships may also be disrupted because of decreased opportunities for social interaction due to pain. Therefore, children and adolescents with musculoskeletal pain syndromes often report loneliness and social isolation, characterized by having few friends and lack of participation in extracurricular activities.

Diagnosis and Differential Diagnosis

The diagnosis of a musculoskeletal pain syndrome is typically one of exclusion when careful, repeated physical examinations and laboratory testing do not reveal an etiology. At initial presentation, all children with pain complaints require a thorough clinical history and a complete physical examination to look for an obvious etiology (e.g., sprains, strains, or fractures), characteristics of the pain (localized or diffuse), and evidence of systemic involvement. A comprehensive history can be particularly useful in providing clues to the possibility of underlying illness or systemic disease. The presence of current or recent fever can be indicative of an inflammatory or neoplastic process if the pain is also accompanied by worsening symptoms over time or weight loss.

Subsequent, repeated physical examinations of children with musculoskeletal pain complaints may reveal eventual development and manifestations of rheumatic or other diseases. The need for additional testing should be individualized, depending on the specific symptoms and physical findings. Laboratory screening and/or radiographs should be pursued if there is suspicion of certain underlying disease processes. Possible indicators of a serious, as opposed to a benign, cause of musculoskeletal pain include pain present at rest and relieved by activity, objective evidence of joint swelling on physical examination, stiffness or limited range of motion in joints, bony tenderness, muscle weakness, poor growth and/or weight loss, and constitutional symptoms (e.g., fever, malaise) (Table 162-1). Results of complete blood count and erythrocyte sedimentation rate (ESR) measurement are likely to be abnormal in children whose pain is secondary to a bone or joint infection, SLE, or a malignancy. Bone tumors, fractures, and other focal pathology resulting from infection, malignancy, or trauma can often be indentified through imaging studies, including plain radiographs, MRI, and technetium Tc 99m bone scans.


Effects of rest vs activity on pain Relieved by rest and worsened by activity Relieved by activity and present at rest
Time of day pain occurs End of the day and nights Morning*
Objective joint swelling No Yes
Joint characteristics Hypermobile/normal Stiffness, limited range of motion
Bony tenderness No Yes
Muscle strength Normal Diminished
Growth Normal growth pattern or weight gain Poor growth and/or weight loss
Constitutional symptoms (e.g., fever, malaise) Fatigue without other constitutional symptoms Yes
Laboratory findings Normal CBC, ESR, CRP Abnormal CBC, raised ESR and CRP
Radiographic findings Normal Effusion, osteopenia, radiolucent metaphyseal lines, joint space loss, bony destruction

CBC, complete blood count; CRP, C-reactive protein level; ESR, erythrocyte sedimentation rate.

* Cancer pain is often severe and worst at night.

Adapted from Malleson PN, Beauchamp RD: Diagnosing musculoskeletal pain in children, Can Med Assoc J 165:183–188, 2001.

The presence of persistent pain accompanied by psychologic distress, sleep disturbances, and/or functional impairment and in the absence of objective abnormal laboratory or physical findings suggests the diagnosis of a musculoskeletal pain syndrome. All pediatric musculoskeletal pain syndromes share this general constellation of symptoms at presentation. Several more specific pain syndromes routinely seen by pediatric practitioners can be differentiated by anatomic region and associated symptoms. A comprehensive list of pediatric musculoskeletal pain syndromes is provided in Table 162-2; they include growing pains (Chapter 147), fibromyalgia (Chapter 162.1), complex regional pain syndrome (Chapter 162.2), localized pain syndromes, low back pain, and chronic sports-related pain syndromes (e.g., Osgood-Schlatter disease).


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