Chronic Musculoskeletal Pain in Children:
Part II. Rheumatic Causes
JENNIFER L. JUNNILA, M.D., M.P.H., Army Medical Department Center and School, San Antonio, Texas
VICTORIA W. CARTWRIGHT, M.D., M.S., Madigan Army Medical Center, Tacoma, Washington
W
hen a rheumatic cause of
musculoskeletal pain in chil-
dren is suspected, the pri-
mary care physician should
develop an appropriate differential diagnosis;
establish the most likely diagnosis, if pos-
sible; and begin initial treatment. Part I of
this series1 outlines a primary care approach
to evaluating and diagnosing the child with
musculoskeletal pain and discusses malig-
nancy, benign nocturnal limb pains of child-
hood, and benign hypermobility syndrome.
This article, part II of the series, addresses
initial treatment of rheumatic disease and
discusses the most common specific rheu-
matic conditions of childhood that manifest
as musculoskeletal pain. Key features of these
conditions are summarized in Table 1.2-5
Nonrheumatic causes of musculoskeletal
pain—including sprains and strains, patello-
femoral pain syndrome, stress fractures, and
osteochondrosis—are much more common
than rheumatic causes. Physicians must also
be alert to the possibility of arthralgias
secondary to malignancy. Dermatomyosi-
tis should be considered in any child with
characteristic rash, arthritis, and weakness.
Inflammation of the intervertebral disks
(diskitis), spondylolysis with or without
spondylolisthesis, and malignancy should
be included in the differential diagnosis
of back pain in children. Many inherited
disorders with nonarticular manifestations
(e.g., hemophilia, sickle cell disease) may
present with arthritis or periarticular pain.
Other rare causes of musculoskeletal pain
in children include myofascial pain and
chronic recurrent multifocal osteomyelitis.6
The American College of Rheumatology
has published a consensus stat