Table 1 Differential diagnosis of pediatric chronic musculoskeletal pain

Complex regional pain syndrome

Localized chronic musculoskeletal limb pain that may be accompanied by allodynia, hyperalgesia, swelling and/or changes in skin color of the affected limb; dry, mottled skin; hyperhidrosis and trophic changes of the nails and hair.

Hypermobility

Common, younger ages (preschool to elementary school); pain more severe toward the end of the day, usually associated with specific activities; evidence of hypermobility on physical examination.

Myofascial pain

Pain arises from sustained contraction of a muscle, especially in the head, jaw or upper back. Presence of a trigger point (tender point) and reproduction of the pain by maneuvers that place stress on proximal structures or nerve roots.

Unrecognized local pathology (fracture, strain, sprain)

Trauma/strain to the affected limb; pain worsens with physical activity and excursive; positive findings in plain radiographs.

Arthritis

Inflammation of one or more joints; pain is constant and localized to the affected joint; positive physical findings.

Spondyloarthropathy

Lumbar spinal pain associated with arthritis. Imaging or other evidence of arthritis affecting the sacroiliac joints and the lumbar spine; response to nonsteroidal anti-inflammatory drugs.

Leukemia

Child appears sick; anorexia and lethargy are present; fever is common; nocturnal pain and bone pain. Abnormal blood count, relative thrombocytopenia, and elevated erythrocyte sedimentation rate.

Spinal cord tumors

Slow progression of pain; pain quality is low with steady intensity; abnormal neurologic examination; pathologic magnetic resonance imaging.

Chronic nonbacterial osteomyelitis

Chronic, noninfectious inflammation in the metaphyses close to the physes of multiple bones. Bony tenderness over the affected sites. Presence of lytic lesions on plain radiographs. Lesions appear on bone scan. Pain usually responds to nonsteroidal anti-inflammatory drugs or corticosteroids.

Raynaud’s disease

Cold or emotional stress causes vasospasms which induce discoloration of the fingers, toes, and occasionally other areas. Episodes are short-lived. Pain, numbness or tingling can be experienced with the episode. Pain can be reproduced with a cold challenge. Digital tip ulcers might occur.

Fabry disease

Deficiency of ceramide trihexoside α-galactosidase, X-linked recessive inheritance. Episodic excruciating burning pain in the hands and feet. Symptoms usually begin in adolescence. Presence of bluish maculopapular hyperkeratotic lesions around the perineum, elevated erythrocyte sedimentation rate.

Erythromelalgia

Rare disorder characterized by burning pain, warmth, and redness of the extremities. Can be familial or secondary to myeloproliferative disorders. Pain alleviated by cold exposure.

Pernio

Episodic inflammatory skin condition, presenting after exposure to cold as pruritic and/or painful erythematous-to-violaceous acral lesions, recurs with cold exposure.

Chronic compartment syndrome

Usually occurs in athletes. Repetitive loading or exertional activities cause exercise-induced pain that is relieved by rest. Onset of symptoms typically occurs at a specific exercise distance, interval or intensity level. Symptoms tend to subside with rest and are minimal during normal daily activities.

Peripheral mononeuropathy

More common among adults. Occurs following injury or infection. Can cause severe burning pain in the distribution of the involved peripheral nerve. Findings on physical examination are limited to the area supplied by the injured nerve.

Progressive diaphyseal dysplasia

Begins in adolescence. Causes severe leg pain, fatigue, headaches, weight loss, weakness, abnormal waddling gait. Diagnosis confirmed via plain radiographs, which demonstrate cortical thickening and sclerosis of the diaphysis of the long bones.

Idiopathic juvenile osteoporosis

Uncommon. Typically occurs just before the onset of puberty, involving pain in the lower back, hips, and feet, often accompanied by difficulty walking. Fractures of the lower extremities can occur. Plain radiographs demonstrate low bone density, fractures of weight-bearing bones, and collapsed or misshapen vertebrae. Bone scans can demonstrate microfractures.

Thyroid disease

Hyperthyroidism/hypothyroidism can cause widespread musculoskeletal pain. History and physical examination reveal signs and symptoms of thyroid disease. Abnormal thyroid function test.

Vitamin D deficiency

Uncommon in developed countries. Causes limb pain. Low levels of vitamin D in laboratory tests.

Juvenile idiopathic arthritis

Joint swelling, morning stiffness, elevated inflammatory markers, elevated anti-nuclear antibodies.

Systemic lupus erythematosus

Rash, systemic inflammation, elevated inflammation markers, decreased complement, and elevated specific antibodies, including anti-nuclear antibodies.

Myositis and myopathies

May occur prior to a recent infection; weakness, elevated muscle enzymes.