What is the appropriate management for a pediatric patient experiencing musculoskeletal pain?

Management of Pediatric Musculoskeletal Pain

Begin with a thorough clinical history and targeted physical examination to identify red flags, then proceed with plain radiographs as first-line imaging only when indicated, reserving advanced imaging for specific clinical scenarios. 1

Initial Clinical Assessment

History Taking - Key Elements

• Timing and onset: Determine if pain is acute versus chronic, constant versus intermittent, and whether it occurs at night (nighttime pain suggests infection or neoplasm) 1
• Location and radiation: Identify if pain is localized or diffuse, and note that hip pathology commonly presents as knee pain in children 2
• Associated symptoms: Screen for fever, weight loss, fatigue, morning stiffness, joint swelling, neurologic deficits, or gait disturbance 1, 3
• Activity history: Document participation in repetitive sports (weightlifting, wrestling, soccer, gymnastics, baseball) which predispose to specific injury patterns 1
• Psychological factors: Assess for anxiety, school avoidance, or lifestyle disruption 4

Physical Examination - Critical Findings

• Neurologic examination: Test motor strength, sensation, reflexes, and gait 1
• Spinal palpation: Check for tenderness over spinous processes, paraspinal muscles, and sacroiliac joints 1
• Range of motion: Document limitations in flexion, extension, and rotation 1
• Skin examination: Look for café-au-lait spots, dimples, hair tufts, or psoriatic lesions 1, 5
• Joint assessment: Evaluate for effusion, warmth, erythema, and dactylitis (sausage digits) 5
• Weight-bearing ability: Inability to bear weight is a critical red flag 2

Red Flags Requiring Urgent Evaluation

The following findings mandate immediate imaging and laboratory workup:

• Persistent nighttime pain refractory to rest (present in 25-30% of children with spinal neoplasm) 1
• Fever with localized tenderness (suggests infection - vertebral osteomyelitis or discitis most common in ages 2-12 years, male:female ratio 3:1) 1
• Neurologic deficits including motor weakness, sensory changes, or bowel/bladder dysfunction 1
• Constitutional symptoms: Weight loss, fatigue, or malaise 3
• Morning stiffness lasting >30 minutes or stiffness at rest (suggests inflammatory arthritis) 5
• Inability to bear weight 2
• Rapid progression of pain intensity over short interval (suggests aggressive tumor) 1

Laboratory Testing - When Indicated

Order laboratory studies only when red flags are present or inflammatory/infectious etiology is suspected:

• Complete blood count: Look for leukocytosis (infection) or cytopenias (malignancy) 1, 3
• Erythrocyte sedimentation rate (ESR): Elevated in infection (typically >40 mm/hour) and inflammatory conditions 1, 3
• C-reactive protein (CRP): More sensitive than ESR for acute infection; >2.0 mg/dL predicts septic arthritis 1
• Blood cultures: When fever and systemic symptoms present 1

Avoid routine rheumatologic panels (ANA, RF) in primary care without specific clinical suspicion, as they have low pretest probability and high false-positive rates. 3

Imaging Algorithm

No Red Flags Present

Do not obtain imaging for isolated musculoskeletal pain with normal physical examination, no trauma history, and no neurologic deficits. Most pediatric musculoskeletal pain is self-limiting and resolves with conservative management. 1

Red Flags Present - Stepwise Approach

Step 1: Plain Radiographs

• First-line imaging for all pediatric musculoskeletal pain requiring evaluation 1, 5, 2
• Include AP and lateral views of the affected area 1
• Can identify fractures, spondylolisthesis, tumors, and gross bony abnormalities 1
• Limitation: Low sensitivity for spondylolysis without spondylolisthesis, stress reactions, and soft tissue pathology 1

Step 2: MRI Without Contrast (Preferred Advanced Imaging)

MRI is the standard of care when advanced imaging is needed after negative or equivocal radiographs. 1

Indications for MRI:

• Red flags present with negative radiographs 1
• Suspected soft tissue pathology (spinal cord, intraspinal contents, paraspinal tissues) 1
• Clinical suspicion for infection, inflammation, or tumor 1
• Detection of marrow edema indicating stress reactions or microtrabecular injuries 1
• Inflammatory spondyloarthropathy evaluation 1

MRI demonstrates definitive diagnosis in an additional 34% of pediatric patients after negative radiographs. 1

Add IV contrast when:

• Suspected infection (osteomyelitis, discitis, epidural abscess) 1
• Suspected tumor (to assess enhancement patterns) 1
• Suspected inflammatory process requiring characterization 1

Step 3: Alternative Advanced Imaging

SPECT/CT (area of interest):

• Very sensitive for detecting spondylolysis when radiographs are negative with high clinical suspicion 1
• Identifies areas of increased bone turnover from stress reactions or fractures 1
• Can be combined with CT for improved anatomic localization 1
• Limitation: Radiation exposure; reserve for specific indications 1

CT without contrast (area of interest):

• Superior for evaluating bony architecture and mineralization 1
• Increased sensitivity for detecting nondisplaced fractures and spondylolysis compared to radiographs 1
• Less sensitive than MRI for stress reactions without frank lysis 1
• Useful for follow-up of known spondylolysis if clinically warranted 1
• Avoid complete spine CT; target the symptomatic area only 1

Ultrasound:

• Limited utility for spinal evaluation; MRI remains standard 1
• May evaluate for enthesitis in spondyloarthropathy when radiographs negative 1
• Useful for peripheral joint assessment with dynamic capability 5
• Limitation: Operator-dependent with high interoperator variability 1

Pharmacological Pain Management

First-Line: NSAIDs

Naproxen is the preferred first-line NSAID over other selective COX-1 or COX-2 inhibitors due to established efficacy and safety profile in children. 5

• Ibuprofen is an acceptable alternative first-line NSAID 5, 6
• Dose based on age, weight, and comorbidities 5, 7
• For inflammatory conditions: Trial for at least 8 weeks, as time to response is approximately 1 month 5
• Adverse effects are rare in children but monitor for gastrointestinal, renal, and antiplatelet effects 7

Second-Line: Acetaminophen

• Acetaminophen alone for mild pain or when NSAIDs contraindicated 8
• Combination therapy with NSAIDs enhances effect for acute or postoperative pain 5
• Dosing (adults and children ≥12 years): 2 caplets every 8 hours, maximum 6 caplets in 24 hours, do not exceed 10 days without physician direction 8
• Children <12 years: Consult physician for appropriate dosing 8

Opioids - Limited Role

• Small titrated doses can be used for severe pain without affecting clinical examination or neurologic assessment 5
• Reserve for acute severe pain only; not appropriate for chronic musculoskeletal pain management 5

Medications to AVOID

Aspirin is NOT recommended for children due to controversial efficacy, safety concerns, and toxicity risks (Reye syndrome). 5

Non-Pharmacological Interventions

These interventions are very effective and should be implemented alongside pharmacological management:

• Cognitive behavioral strategies: Distraction, breathing exercises, and coping mechanisms 5
• Parent coaching: Parents function as "coaches" providing encouragement for coping strategies 5
• Physical modalities: Heat compresses, ice packs, massage, and repositioning 5, 7
• Activity modification: Reduce repetitive activities causing overuse injuries 1

Specific Clinical Scenarios

Overuse/Repetitive Activity Pain (Sports-Related)

Radiographs first, then consider MRI or SPECT/CT if negative with persistent symptoms:

• Spondylolysis is common in weightlifting, wrestling, gymnastics 1
• Multilevel spondylolysis in soccer players (compressive stress from running) 1
• Rotational injuries in baseball players (high torsional forces) 1
• MRI detects stress reactions before frank lysis develops 1
• SPECT very sensitive for early spondylolysis when radiographs negative 1

Suspected Infection

Obtain ESR, CRP, CBC, and blood cultures immediately:

• ESR ≥40 mm/hour and CRP >2.0 mg/dL support diagnosis 1
• MRI with IV contrast is imaging modality of choice 1
• Vertebral osteomyelitis and discitis most common spinal infections 1
• Clinical presentation: Persistent nighttime pain, low-grade fever, decreased range of motion, irritability, localized tenderness, limping 1
• Septic arthritis is an orthopedic emergency requiring arthrocentesis for diagnosis 1

Suspected Inflammatory Arthritis

Screen all patients with psoriasis for arthritis via history and physical examination:

• Dactylitis in younger girls suggests psoriatic arthritis with oligoarticular disease 5
• Enthesitis and axial involvement in older boys suggests psoriatic arthritis 5
• Morning stiffness >30 minutes or stiffness at rest indicates inflammatory process 5
• Immediate referral to pediatric rheumatologist when inflammatory arthritis suspected 5
• Screen for uveitis by history and physical; refer to ophthalmology immediately if eye pain, redness, visual loss, or photophobia develops 5

Suspected Neoplasm

Persistent nighttime pain refractory to conservative management is the hallmark:

• Present in 25-30% of children with spinal neoplasm 1
• Motor/gait disturbance and neurologic symptoms present later 1
• Rapid increase in pain intensity over short interval suggests locally aggressive tumor 1
• MRI with IV contrast for evaluation 1
• Benign tumors: Osteochondroma, osteoblastoma, osteoid osteoma, giant cell tumor, aneurysmal bone cyst 1
• Malignant tumors: Leukemia, lymphoma, rarely metastasis 1

When to Refer to Specialist

Immediate referral to pediatric rheumatologist:

• Signs and symptoms of inflammatory arthritis present 5
• Joint swelling with morning stiffness or stiffness at rest 5
• Dactylitis or enthesitis identified 5

Refer to pediatric specialist when:

• Pain significantly impacts daily functioning or quality of life 5, 7
• Diagnosis remains unclear after initial evaluation 3
• Acute medication provides insufficient pain relief 5
• Red flags present requiring subspecialty management 1

Immediate orthopedic referral:

• Suspected septic arthritis (requires arthrotomy, irrigation, debridement) 1
• Spondylolisthesis with spinal canal or neural foraminal narrowing 1
• Fracture requiring surgical intervention 2

Common Pitfalls to Avoid

• Undertreatment of pain: Proactive use of appropriate analgesic therapy is essential; pain medications make children more comfortable and facilitate examination, they do not mask symptoms or cloud mental status 5, 7
• Obtaining imaging without red flags: Most isolated pediatric musculoskeletal pain is self-limiting and does not require imaging 1
• Ordering rheumatologic panels without clinical suspicion: ANA and other tests have low pretest probability in primary care with high false-positive rates 3
• Inadequate NSAID trial: At least 8 weeks required for inflammatory conditions given time course to response of approximately 1 month 5
• Failing to screen psoriasis patients for arthritis: Joint disease often precedes skin manifestations 5
• Missing referred pain patterns: Hip pathology commonly presents as knee pain in children 2
• Delaying referral for inflammatory arthritis: Immediate rheumatology referral indicated when signs present 5
• Using aspirin in children: Contraindicated due to safety concerns and toxicity risks 5
• Ordering complete spine imaging: Target the symptomatic area only to minimize radiation exposure 1