Chapter 162 Musculoskeletal Pain Syndromes
Clinical Manifestations
Diagnosis and Differential Diagnosis
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.
CLINICAL FINDING | BENIGN CAUSE | SERIOUS CAUSE |
---|---|---|
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).
ANATOMIC REGION | PAIN SYNDROME(S) |
---|---|
Shoulder | Impingement syndrome |
Elbow | |
Arm | |
Pelvis and hip | |
Knee | |
Leg | |
Foot | |
Spine |