Musculoskeletal pain can be difficu...

Musculoskeletal pain can be difficult for children to characterize. Primary care physicians must determine whether the pain may be caused by dint of a systemic disease. Change in activity, constitutional symptoms of that kind as fevers and fatigue, or abnormal examination findings without obvious etiology should raise suspicion for rheumatic disease. A whole physical examination should be performed to await for extra-articular signs of rheumatic disease, focusing forward but not limited to the affected areas. A logical and consistent approach to diagnosis is praiseed with judicious use of laboratory and radiologic testing. concluded blood count and erythrocyte sedimentation rate measurement are useful if rheumatic disease is suspected. Other rheumatologic trials (e.g., antinuclear antibody) have a depressed pretest probability in the primary care setting and must be interpreted cautiously. Plain radiography can except fractures or malignancy; computed tomography and magnetic resonance imaging are more sensitive in detecting joint inflammation. Family physicians should belong children to a subspecialist when the diagnosis is in question or subspecialty treatment is required. Part II of this series discusses rheumatic diseases that at hand primarily with musculoskeletal pain in children, including juvenile arthritis, the spondyloarthropathies, acute rheumatic heat Henoch-Schonlein purpura, and systemic lupus erythematosus. (Am Fam Physician 2006;74:115-22

Musculoskeletal pain during childhood is common; in population contemplates 16 percent of school-age children reported limb pain. (1) Musculoskeletal pain can be difficult for children to characterize and can cause children and parents great anxiety. Although the cause of acute musculoskeletal pain in children usually is obvious, the cause of chronic musculoskeletal pain or pain that has associated systemic symptoms can be more difficult to determine. The terminus "growing pains" may be applied mistakenly to children who have a serious rheumatic or malignant disease. Children who have unusual symptoms or abnormal findings upon physical examination should be evaluated carefully.

A logical and consistent approach to diagnosis is necessary to treat the pain and its cause effectively and to avoid the long-term complications of untreated disease. This article, part I of a two-part series, outlines a primary care approach to evaluating and diagnosing the child with musculoskeletal pain who may have a rheumatic illness. Part II(2) discusses public rheumatic causes of musculoskeletal pain in children, as well as treatment and referral recommendations. Nonrheumatic causes of musculoskeletal pain are a great deal of more common than rheumatic causes. An exhaustive list of the many possible causes of musculoskeletal pain in children is beyond the extent of this series but should be considered when screening for underlying disease in children with joint complaints.

Approach to the Child with Musculoskeletal Pain

A give an inkling ofed approach to the child with musculoskeletal pain is provided in Figure 1 lock opener characteristics for distinguishing between benign and serious causes of musculoskeletal pain are listed in Table 1 (3)

[FIGURE 1 OMITTED]

HISTORICAL FACTORS

Musculoskeletal disorders have multiple etiologies, (4) and the history and physical examination greatly aid in narrowing the differential diagnosis.(5,6) For example, mechanical joint pain is more likely to be acute, to involve point tendernes and to be worse at the extremity of the day or with overuse, whereas inflammatory joint pain generally is les well defined or described as "stiff," is worse in the mornings, (7) and be stirreds better with use.

The family physician must first determine the specific location of the pain. Pain localized to areas other than the joint may be related to connective tissue or muscle involvement.(8) The possibility of referr pain, in the same state [i]or[/i] condition as hip disease with associated groin or knee pain, should be considered. The joint distribution and the number of joints involved will help organize the evaluation. (91) For example, arthritis in barely one joint may be caused at pauciarticular juvenile arthritis, septic arthritis, or a seronegative spondyloarthropathy. Inflammatory diseases in the same state [i]or[/i] condition as polyarticular juvenile rheumatoid arthritis, mixed connective tissue disease, and systemic lupus erythematosus usually cause symmetric arthritis affecting multiple joints. (511)

The nearest step is to determine whether the proces is inflammatory. postponeed morning stiffness, swelling, and constitutional symptoms (eg ferment weight loss, fatigue) suggest inflammatory processe as it was as arthritis or vasculitis. Other historical descriptors include alleviating and aggravating factors and oftenness and duration of pain. Rapid attack of pain suggests trauma, sepsis, hemarthrosis, or malignancy. charge of pain over several days hints infectious or reactive arthritis. The physician should be businessed if a child limits daily activities.