SciELO - Scientific Electronic Library Online

 
vol.28 issue4Fever and clinical thermometry: what do physicians and nurses really know?Case of swyer-james-macleod syndrome diagnosed in adolescence author indexsubject indexarticles search
Home Pagealphabetic serial listing  

Services on Demand

Journal

Article

Indicators

Related links

  • Have no similar articlesSimilars in SciELO

Share


Nascer e Crescer

Print version ISSN 0872-0754On-line version ISSN 2183-9417

Nascer e Crescer vol.28 no.4 Porto Dec. 2019

https://doi.org/10.25753/BirthGrowthMJ.v28.i4.15457 

REVIEW ARTICLES | ARTIGOS DE REVISÃO

Definition and characterization of musculoskeletal pain and associated diseases

Definição e caraterização de dor musculoesquelética e doenças associadas

Marco António FernandesI, Inês de MeloI, Flávio Campos CostaII, Manuel SalgadoI

I Paediatric Rheumatology Unit, Centro Hospitalar Universitário de Coimbra. 3000-602 Coimbra, Portugal. marco@marcofernandes.pt; inesdemelosa@gmail.com; mbsalgado27@gmail.com

II Department of Rheumatology, Centro Hospitalar Universitário de Coimbra. 3004-561 Coimbra, Portugal. flavioaccosta@gmail.com

Endereço para correspondência | Dirección para correspondencia | Correspondence


 

ABSTRACT

Musculoskeletal pain is a frequent reason for seeking health care at any age, including pediatric. Semiological accuracy, with a careful anamnesis plus a systematic and detailed physical examination, is mandatory. Only the use of an accurate and standardized language will allow correct communication so as not to incur ambiguities of definition and interpretation and consequent omissions or overvaluations of clinical manifestations, culminating in diagnostic errors.

This manuscript intends to gather and define the multiple concepts of musculoskeletal pain with the aim of standardizing and clarifying medical terminology. Taking into account general concepts, time progression, and location of musculoskeletal pain, the authors gathered 85 concepts, mostly of painful manifestations, that are described in a succinct and practical way.

Keywords: acute; arthralgia; arthritis; chronic; definitions; musculoskeletal pain, polyarthritis; semiology; subacute


 

RESUMO

A dor musculoesquelética é um motivo frequente de procura de cuidados de saúde em qualquer idade, incluindo a pediátrica. O rigor semiológico, com uma anamnese cuidada e um exame objetivo sistemático e pormenorizado, é obrigatório. Somente a utilização de uma linguagem rigorosa e padronizada permitirá a comunicação correta, evitando incorrer em ambiguidades de definição e interpretação e em consequentes omissões ou sobrevalorização de manifestações clínicas, culminando em erros de diagnóstico.

O presente artigo compila e define os múltiplos conceitos de dor musculoesquelética, com o objetivo de uniformizar e clarificar a linguagem médica. Considerando conceitos gerais, a evolução temporal e a localização da dor musculoesquelética, os autores reúnem 85 conceitos, maioritariamente de manifestações dolorosas, e descrevem-nos de forma sucinta e prática.

Palavras-Chave: aguda; artralgia; artrite; crónica; definições; dor musculoesquelética; poliartrite; semiologia; subaguda


 

Introduction

Musculoskeletal pain (MSP) is very common in pediatric populations, reported in approximately 7% of office visits in primary health care and corresponding to 18% of complaints in emergency services.1-3 Most complaints are benign and attributable to trauma, “growing pains”, development variants, and overuse.1,2 However, serious conditions as musculoskeletal infections, bone tumors, or malignant diseases can involve bones, muscles, and joints, justifying careful anamnesis and a detailed physical examination.1,2

Multiple concepts are associated with MSP. Surprisingly, they are not assembled nor always accurately defined in the literature, as happens with arthritis and arthralgia.4,6,7 Even in medical dictionaries, including rheumatology-specific, surprising omissions are found in these commonly used terms.8

Definitions of the several inflammatory clinical conditions are very different depending on their acute, subacute, or chronic evolution.6-11 The definition of “chronic pain” itself is different depending on whether it has an infectious or inflammatory etiology, requiring three months or six weeks’ duration since onset, respectively, as is the case of juvenile idiopathic arthritis (JIA).6,9-11

Confusingly, the same condition can have more than one name and the same name can refer to different conditions. “Growing pains”, or “leg aches”, a benign condition that affects more than 10% of children, is synonymous of idiopathic bilateral leg pains for pediatricians, with no relationship with growth.1,2,12-14 However, in a reference textbook with 2481 pages written for orthopedists, “growing pains” or “leg aches” were never mentioned.15 Therefore, for many orthopedists “growing pains” mean any of several osteochondrosis or osteochondritis.14-16 These are a large group of heterogeneous conditions characterized by enchondral ossification variations occurring in the epiphysis during growth, involving cartilage and bone.2,14-16 Over 50 eponymic conditions have been described, the most common being Legg-Perthes disease, Osgood-Schlatter disease, Sever disease, Köhler disease, and Freiberg disease.2,14-16

Also, many practitioners are not aware that the definition of arthritis does not require the presence of all the classic signs described by Cornelius Celsus.10,17

We have recently conducted an online inquiry to clinicians regarding some MSP definitions: arthralgia, arthritis, myalgia, allodynia, and hyperesthesia. Each concept had five to seven options, with only one correct answer. The results are presented in Table 1.

 

 

The high percentage of wrong answers (80.8% for arthritis) supports the notion that most clinicians do not evaluate the musculoskeletal system on a routine basis.18 Additionally, most clinicians are not able to perform an adequate musculoskeletal physical exam at any age, despite the availability of screening tools as the pGALS (Pediatric Gait, Arms, Legs, Spine), a valuable resource in the evaluation of MSP children that can be executed in a few minutes.18-20 The main reason for this is that all stages of medical education lack specific training in musculoskeletal system.18

Objectives

The present manuscript aims to define concepts associated with MSP, enabling terminology standardization, greater diagnostic accuracy, and improved communication between health professionals.

I - Causes of musculoskeletal pain

MSP is present in a number of medical conditions, some of which benign − as “growing pains”, myofascial syndromes, and osteochondroses −, but others potentially serious − as malignancies (leukemia, lymphoma, bone sarcoma, neuroblastoma) and several rheumatic diseases.1,7,12-14,16-18,20,23-25

Table 2 depicts the classification of MSP in 24 etiological groups, with some examples and respective severity.

 


(clique para ampliar ! click to enlarge)

 

II - Musculoskeletal pain and associated conditions

A total of 85 concepts associated with MSP were assembled. Despite having referred to a wide bibliography, exact definitions of a number of concepts were not found. In those cases, the authors chose to provide their own definitions. Examples include “continuous pain” and “continuous pain in crescendo” (Figure 1).

 


(clique para ampliar ! click to enlarge)

 

Definition of ‘polyarticular’ differs according to disease: only two joints are considered in acute rheumatism and acute or chronic infections, while five joints are considered in other chronic conditions.7,10,11,17,18,24,27-29

Some concepts correspond to somewhat unique entities with particular characteristics. They are easily identified through a detailed anamnesis and careful observation. In those cases, diagnosis can be established without the need for diagnostic tests. Examples include myofascial syndrome (which can occur in any muscle) and neuropathic pain in the context of complex regional pain syndrome.21,26,30,31

Myofascial pain involving single or multiple muscle groups is the most common cause of back pain in the otherwise healthy pediatric population, especially in adolescent and early-adult years.30

An accurate characterization of different concepts allows:

1. Standardization of use, avoiding interpretation ambiguities and clinical evaluation asymmetries. Examples: difference between arthralgia and arthritis; misinterpretation of the concept of polyarthritis in acute (≥ two affected joints) or chronic (≥ five affected joints) clinical situations.1,7,10,11,17,23,27,28

2. Improved diagnostic acuity, as different MSP concepts are associated with different etiologies. Examples: trigger points are almost exclusively associated with myofascial syndrome or fibromyalgia; neuropathic pain has a limited number of etiologies (as complex regional pain and sensitive neuropathies of toxic, primary and/or secondary vasculitis); migratory polyarthritis is typical of rheumatic fever and also frequent in leukemia; the palindromic pattern suggests arthropathy of inflammatory bowel disease, arthropathy of celiac disease, or autoinflammatory syndromes as familial Mediterranean fever in presence of fever.9,17,30,32-37

III - Characterization of musculoskeletal pain and associated conditions

The different MSP types and associated conditions are listed in Table 3 to 8. If the patient presents with more than one MSP type, it should be investigated and the type associated with the most serious condition should be studied first.

 


(clique para ampliar ! click to enlarge)

 


(clique para ampliar ! click to enlarge)

 


(clique para ampliar ! click to enlarge)

 


(clique para ampliar ! click to enlarge)

 


(clique para ampliar ! click to enlarge)

 


(clique para ampliar ! click to enlarge)

 

Conclusions

The complexity of MSP and underlying conditions compel the clinician for a careful approach, well beyond exhaustive and non-targeted diagnostic tests.

Limb pain is usually benign and self-limited, not requiring medical intervention.1,2,17 The correct diagnosis can often be established only based on clinical history and physical examination.1,2 Diagnostic tests (laboratory and/or imagiological) can be avoided in most cases and do not preclude the need for careful clinical history and a systematic and detailed physical examination.

Likewise, due to the simplicity and sensitivity of pGALS screening examination, this method should be known to all clinicians evaluating children in the clinical practice.

The use of a correct and uniform vocabulary allows accurate communication and prevents ambiguities and diagnostic errors, making the use of standard terminology key among health professionals.

 

REFERENCES

1. Connelly MA, Schamberg LE. Evaluating and managing pediatric musculoskeletal pain in primary care. In: Walco GA, Goldschneider KR, Pain in Children. A Practical Guide for Primary Care. Totowa, Humana Press; 2008:185-99.         [ Links ]

2. Burke MG. Extremity pain. In: Hoekelmann RA, Friedman SB, Nelson NM, Seidel H, Weitzman ML. Primary Pediatric Care, 3th ed. St. Louis, Mosby; 1997:940-5.         [ Links ]

3. De Inocencio J, Carro MA, Flores M, Carpio C, Mesa S, Marín M. Epidemiology of musculoskeletal pain in a pediatric emergency department. Rheumatol Int 2016; 36:83-9.         [ Links ]

4. Guimarães CV, Pedroso H, Conde M. Artralgia. In: Pedroso H, Martins S. Abordagem em consulta de pediatria, da criança ao adolescente. Lisbon, Bene Farmacêutica, 2015:96-9.         [ Links ]

5. Sawyer SS. Examination of the musculoskeletal system. In: Sawyer SS. Pediatric Physical Examination & Health Assessment. Sudbury, Jones & Bartlett Learning; 2012:421-501.         [ Links ]

6. Lehman TJA. In: Juvenile Arthritis. Lehman TJA. A Clinician’s Guide to Rheumatic Diseases in Children. New York, Oxford University Press; 2009:90-124.

7. Melo Gomes JA. A criança com Doença Reumática. In: Palminha JM, Carrilho EM. Orientação Diagnóstica em Pediatria. Dos sinais e sintomas ao diagnóstico diferencial. Lisbon, Lidel; 2003:84990.         [ Links ]

8. Rovenský J, Payer J. Dictionary of Rheumatology. Vienna, Springer; 2009.         [ Links ]

9. Laxer RM, Wright J, Lindsley CB. Infectious Arthritis and Osteomyelitis. In: Petty R, Laxer R, Lindsley C, Wedderburn L. Textbook of Pediatric Rheumatology. 7th ed. Philadelphia, Elsevier; 2016:533-50.         [ Links ]

10. Petty R, Laxer R, Wedderburn L. Juvenile Idiopathic Arthritis. In: Petty R, Laxer R, Lindsley C, Wedderburn L. Textbook of Pediatric Rheumatology, 7th ed. Philadelphia, Elsevier; 2016:188-204.         [ Links ]

11. Laxer RM, Sherry DD, Hashkes PJ. Juvenile Idiopathic Arthritis (JIA). In: Laxer RM, Sherry DD, Hashkes PJ. Pediatric Rheumatology in Clinical Practice. 2nd ed. Toronto, Springer; 2016:31-62.         [ Links ]

12. Salgado M. As “Dores de crescimento” na criança. In: Pedroso H, Martins S. Abordagem em consulta de pediatria, da criança ao adolescente. Lisboa, Bene Farmacêutica; 2015:93-5.         [ Links ]

13. Mohanta MP. Growing pains: Pratitioners’ dilemma. Indian Peditr 2014; 51:379-83.         [ Links ]

14. Staheli LT. Fundamentals of Pediatric Orthopedics. 5th ed. Seatle, Wolters Kluwer; 2016.         [ Links ]

15. Herring JA. Tachdjian’s Pediatric Orthopaedics. From the Texas Scottish Rite Hospital for Children. 5th ed. Philadelphia, Elsevier Saunders; 2014.         [ Links ]

16. Seabra JF. Ortopedia Infantil - O Fundamental. Coimbra, ASIC; 2016.         [ Links ]

17. Jacobs JC. Differential Diagnosis of Arthritis in Childhood. In: Jacobs JC. Pediatric Rheumatology for the Practitioner, 2nd ed. New York, Springer-Verlag; 1993:25-230.         [ Links ]

18. Spencer CH, Patwardhan A. Pediatric rheumatology for the primary care clinicians-recognizing patterns of disease. Curr Probl Pediatr Adolesc Heath Care 2015; 45:185-206.         [ Links ]

19. Foster H, Jandial S. Clinical Examination of the Child with a Rheumatic Disease. In: Sawhney S, Aggarwal A. Pediatric Rheumatology. A Clinical Viewpoint. Singapore, Springer; 2017:89-105.         [ Links ]

20. Haines KA. The approach to the child with joint complaints. Ped Clin N Amer 2018; 65:623-38.         [ Links ]

21. Weiss JE, Stinson JN. Pediatric pain syndromes and noninflammatory musculoskeletal pain. Ped Clin N Amer 2018; 65:801-26.         [ Links ]

22. Davies K, Coperman A. The spectrum of paediatric and adolescent rheumatology. Best Pract Res Clin Rheumatol 2006; 20:179-200.         [ Links ]

23. da Silva JA, Woolf AD. Rheumatology in Practice. London, Springer-Verlag; 2010.         [ Links ]

24. Murias Loza S, Remesal Camba A, Alcobendas Rueda R. Artritis. In: Guerrero-Fenández J, Cartón Sánchez AJ, Borreda Bonis AC, Menéndez Suso JJ, Ruiz Domínguez JA. Manual de Diagnóstico y Terapéutica en Pediatria. Buenos Aires, Editorial Medica Panamericana; 2018:2081-9.         [ Links ]

25. del Moral OM, Salvat IS, Ibarra JM, Cuenca JM. El síndrome de dolor miofascial y los puntos gatillo miofasciais. In: del Moral OM, Salvat IS. Fisioterapia Invasiva del Síndrome de Dolor Miofascial. Manual de punción seca de puntos gatillo. Buenos Aires, Editorial Médica Panamericana; 2017:3-25.         [ Links ]

26. Angus-Leppan H, Guiloff RJ. Familial limb pain and migraine: 8-year follow-up of four generations. Cephalagia 2016; 36:1086-93.         [ Links ]

27. Carapetis JR, Currie BJ. Rheumatic fever in a high incidence population: the importance of monoarthritis and low grade fever. Arch Dis Child 2001; 85:223-7.         [ Links ]

28. Mistry RM, Lennon D, Boyle MJ, et al. Septic arthritis arthritis and acute rheumatic fever in children. J Pediatr Orthop 2014; 35:318-22.         [ Links ]

29. Ferguson PJ, Laxer RM. Autoinflammatory bone disorders. In: Petty R, Laxer R, Lindsley C, Wedderburn L. Textbook of Pediatric Rheumatology. 7th ed. Philadelphia, Elsevier; 2016:627-41.         [ Links ]

30. Weisman SJ. Multidisciplinary approaches to chronic pain. In: Walco GA, Goldschneider KR, Pain in Children. A Practical Guide for Primary Care. Totowa, Humana Press; 2008:133-43.         [ Links ]

31. Schmidt RF, Gebhart GF. Encyclopedia of Pain, 2nd ed. Heidelberg, Springer; 2013.         [ Links ]

32. 32. Fernández-de-las-Peñas C, Arendt-Nielsen L. Myofascial pain and fibromyalgia: two different but overlapping disorders. Pain Manag 2016; 6:401-8.         [ Links ]

33. Simpson DM, McArthur JC, Dworkin RH. Neuropathic Pain: Mechanisms, Diagnosis and Treatment. Oxford, Oxford University Press; 2012.         [ Links ]

34. Prashanth GP, Bhandankar M, Patil VD. Migratory polyarthritis as a paraneoplastic syndrome in childhood leukemia. Rheumatol Int 2013; 33:1647-8.         [ Links ]

35. Gewitz MH, Baltimore RS, Tani LY, Sable CA, Shulman ST, Carapetis J, et al. Revision of the Jones criteria for the diagnosis of acute rheumatic fever in the era of Doppler echocardiography: a scientific statement from the american heart association. Circulation 2015; 131:1806-18.         [ Links ]

36. Sanmarti R, Salvador G. Palindromic rheumatism and other relapsing arthritis. Best Pract Res Clin Rheumatol 2004; 18:64761.         [ Links ]

37. Cabrera-Villalba S, Sanmarti R. Palindromic rheumatism: a reppraisal. Int J Clin Rheumatol 2013; 8:569-77.         [ Links ]

38. Merskey H, Bogduk, N. Part III: Pain Terms: A Current List with Definitions and Notes on Usage. In: IASP Task Force on Taxonomy. Classification of Chronic Pain, Second Edition (Revised). Washington, International Association for the Study of Pain; 2012.         [ Links ]

39. Rodrigues AC, Kang PB. Neuropathic and myopathic pain. Sem Pediatr Neurol 2016;23:242-7.         [ Links ]

40. Terreri MTRA, Len CA, Hilário MO, Ishida A, Pinto JA, Kuwajima SS. Locomotor. In: Puccini RF, Hilário MO. Semiologia da Criança e do Adolescente. Rio de Janeiro, Guanabara Koogan, 2008:220-38.         [ Links ]

41. Sherry DD, Bohnsack J, Salmonson K, Wallace CA, Mellins E. Painless juvenile rheumatoid arthritis. J Pediatr 1990; 116:921-3.         [ Links ]

42. Foster HE, Eltringham MS, Kay LJ, Friswell M, Abinun M, Myers A. Delay in acess to appropriate care for children presenting with musculoskeletal symptoms and ultimately diagnosed with juvenile idiopathic arthritis. Arthr Rheum 2007; 57:921-7.

43. McGhee JL, Burks FN, Sheckels JL, Jarvis JN. Identifying children with chronic arthritis based on chief complaints: absence of predictive value for musculoskeletal pain as an indicator of rheumatic disease in children. Pediatrics 2002; 110:354-9.         [ Links ]

44. Leet AI, Skaggs DL. Evaluation of the acutely limping child. Am Fam Physician 2000; 61:1011-8.         [ Links ]

45. Naranje S, Kelly DM, Sawyer JR. A systematic approach to the evaluation of a limping child. Am Fam Physician 2015; 92:90816.         [ Links ]

46. Hills BA, Thomas K. Joint stiffness and “articular gelling”: inhibition of the fusion of articular surfaces by surfactant. Br J Rheumatol 1998; 37:532-8.         [ Links ]

47. Leung AKC, Wong BE, Chang PY, Cho HY. Nocturnal leg cramps in children: incidence and clinical characteristics. J Natl Med Assoc 1999; 91:329-32.         [ Links ]

48. Leung AKC, Wong BE. Leg cramps in children. Clin Pediatr (Phila) 1997; 36:69-73.         [ Links ]

49. Matthews E, Silwal A, Sud R, Hanna MG, Manzur AY, Muntoni F, et al. Skeletal muscle channelopaties: rare disorders of common pediatric syymptoms. J Pediatr 2017; 188:181-5e6.         [ Links ]

50. Quinlivan R, Jungbluth H. Myopathic causes of exercise intolerance with rhabdomyolysis. Dev Med Child Neurol 2012; 54:886-91.         [ Links ]

51. Scott DL, Khoshaba B, Choy EH, Kingsley GH. Limited correlation between the health assessment questionnaire (HAQ) and EuroQol in rheumatoid arthritis: questionable validity of deriving quality adjusted life years from HAQ. Ann Rheum Dis 2007; 66:1534-7.         [ Links ]

52. Mosek A. The Medical Evaluation of Pain. In: Kreitler S, Beltrutti D. The Handbook of Chronic Pain. New York, Nova Science Publishers; 2007:145-51.         [ Links ]

53. Arendt-Nielsen L, Svensson P. Referred muscle pain: basic and clinical findings. Clin J Pain 2001; 17:11-9.         [ Links ]

54. Madden S, Kelly L. Update on acute rheumatic fever: it still exists in remote communities. Can Fam Physician 2009; 55:475-8.         [ Links ]

55. Butbul-Aviel Y, Uziel Y, Hezkelo N, Brik R, Amarilyo G. Is palindromic rheumatism amongst children a benign disease? Pediatr Rheumatol Online J 2018; 16:12.         [ Links ]

56. Sreenivas T, Nataraj AR, Meno J, Patro DK. Acute multifocal haematogenous osteomyelitis in children. J Child Orthop 2011; 5:231-5.         [ Links ]

57. Perlman MH, Patazakis MJ, Kumar PJ, Holtom P. The incidence of joint involvement with adjacent osteomyelitis in pediatric patients. J Pediatr Orthop 2000; 20:40-3.         [ Links ]

58. Bahk Y-W. Diseases of Joints and Soft-Tissue Infections. In: Bahk Y-W. Combined Scintigraphic and Radiologic Diagnosis of Bone and Joint Diseases. Including Gamma Correction Interpretation, 4th Revised and Enlarged Edition. Seoul, Springer; 2013:119-39.         [ Links ]

59. Weissmann R, Uziel Y. Pediatric complex regional pain syndrome: a review. Pediatric Rheumatol 2016; 14:29.         [ Links ]

60. Goldenberg DL, Burckhardt C, Crofford L. Management of fibromyalgia syndrome. JAMA 2004; 292:2388-95.         [ Links ]

61. Manchikanti L, Hirsch JA. Clinical management of radicular pain. Expert Rev Neurother 2015; 15:681-93.         [ Links ]

62. Sherry DD. Pain syndromes. In: Isenberg DA, Miller III JJ. Adolescent Rheumatology. London, Martin Dunitz, 1999:197227.         [ Links ]

 

Endereço para correspondência | Dirección para correspondencia | Correspondence

Manuel Salgado
Pediatric Rheumatology Unit
Hospital Pediátrico de Coimbra
Centro Hospitalar Universitário de Coimbra
Rua Dr. Afonso Romão
3000-602 Coimbra
Email: mbsalgado27@gmail.com

 

Received for publication: 12.11.2018

Accepted in revised form: 13.11.2019

Creative Commons License All the contents of this journal, except where otherwise noted, is licensed under a Creative Commons Attribution License