What is the workup for a 12-year-old male with joint clicking and intermittent pain?

From the Guidelines

For a 12-year-old male with joint clicking and occasional pain, a comprehensive evaluation starting with a detailed history and physical examination is crucial to determine the underlying cause of his symptoms. This approach is supported by the 2019 American College of Rheumatology guideline for the treatment of juvenile idiopathic arthritis, which emphasizes the importance of prompt initiation of appropriate therapy to prevent permanent damage and improve outcomes 1. The evaluation should include asking about the specific joints affected, timing of symptoms, relationship to activity, family history of joint disorders, and any associated symptoms like swelling, redness, or limited range of motion.

Physical examination should include assessment of all major joints for range of motion, stability, and reproduction of clicking. Initial laboratory tests should include complete blood count, erythrocyte sedimentation rate, C-reactive protein, and rheumatoid factor to screen for inflammatory conditions, as recommended by the American College of Rheumatology guideline 1. Imaging studies should begin with plain radiographs of the affected joints, with consideration of MRI for persistent symptoms without clear diagnosis, as MRI has been shown to be sensitive and specific for detecting joint abnormalities 1.

This approach helps distinguish between benign joint hypermobility syndrome (common in adolescents), growing pains, early osteoarthritis, or inflammatory conditions like juvenile idiopathic arthritis. Joint clicking alone is often benign, especially without pain or functional limitation, but persistent pain warrants thorough investigation. Treatment depends on the diagnosis but may include activity modification, physical therapy for strengthening exercises, and occasional NSAIDs like ibuprofen (10mg/kg/dose) for pain relief, as recommended by the American College of Rheumatology guideline 1. Referral to pediatric rheumatology or orthopedics is indicated if symptoms persist despite initial management or if inflammatory markers are elevated.

Some key points to consider in the evaluation and management of this patient include:

• The importance of a thorough history and physical examination to determine the underlying cause of joint clicking and pain
• The use of laboratory tests and imaging studies to screen for inflammatory conditions and detect joint abnormalities
• The consideration of benign joint hypermobility syndrome, growing pains, early osteoarthritis, and inflammatory conditions like juvenile idiopathic arthritis in the differential diagnosis
• The use of activity modification, physical therapy, and NSAIDs for pain relief in the management of joint clicking and pain
• The importance of referral to pediatric rheumatology or orthopedics if symptoms persist despite initial management or if inflammatory markers are elevated.

From the Research

Initial Assessment

The patient is a 12-year-old male presenting with complaints of joints that click and sometimes hurt. The first step in the workup would be to take a detailed clinical history, including family history, and perform a complete physical examination to provide vital clues to the underlying condition 2.

Differential Diagnoses

Based on the age and symptoms of the patient, several differential diagnoses can be considered:

• Slipped capital femoral epiphysis (SCFE), which typically occurs in adolescents and may present with hip, thigh, or knee pain 3
• Osgood-Schlatter disease, a common osteochondritis of the lower limb in sport-practicing children and adolescents 4
• Juvenile spondyloarthropathy, a group of inflammatory conditions that can present with peripheral arthritis and enthesitis 5
• Osteochondritis dissecans and other musculoskeletal conditions associated with Stickler syndrome, a genetic disorder that can affect the joints and other systems 6

Physical Examination

A structured screening examination of the musculoskeletal system, such as the pGALS (pediatric Gait, Arms, Legs, and Spine) examination, can help identify any abnormalities or patterns of joint involvement 2. The examination should include an assessment of the hip, knee, and other joints to look for signs of inflammation, instability, or other abnormalities.

Imaging Studies

Imaging studies, such as X-rays or MRI, may be necessary to confirm the diagnosis and evaluate the extent of any joint or bone abnormalities. For example, X-rays can help diagnose SCFE, while MRI can help evaluate the sacroiliac joints and other areas of concern in juvenile spondyloarthropathy 3, 5.

Laboratory Tests

Laboratory tests, such as rheumatoid factor and HLA-B27, may be ordered to help diagnose or rule out certain conditions, such as juvenile spondyloarthropathy 5.

Further Evaluation

Based on the results of the initial evaluation, further testing or referral to a specialist, such as an orthopedic surgeon or rheumatologist, may be necessary to confirm the diagnosis and develop a treatment plan.