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  • Pain related to the musculoskeletal system is common in the pediatric age range. The differential diagnosis list is long; etiologies range from inflammatory and oncologic to primary muscular, hypermobility, overuse, and trauma.

  • Physical therapy is the cornerstone of treatment of all types of musculoskeletal pain, with appropriate modifications needed for patients with hypermobility disorders.

  • Trigger point injections are the most frequently performed interventions for myofascial pain and are of low complexity and morbidity. More invasive procedures, such as epidural steroid injections, sacroiliac joint injections, and facet injections, are indicated for specific diagnoses, and patients should be referred to those specially trained to perform them.


Pain related to the musculoskeletal (MSK) system is frequent in the pediatric age range. A longitudinal study within the Prevention and Incidence of Asthma and Mite Allergy (PIAMA) birth cohort study of nearly 4000 adolescents found that the prevalence of MSK pain from age 11 to 20 years ranged from 17.4% to 37.9% in girls and 14.2% to 22.1% in boys.1 Persistent pain, defined as pain lasting longer than 1 month, was found among 16.5% of girls and 5.1% of boys.1 Although it is not uncommon for pain to start in a localized area, among the various types of MSK pain, diffuse idiopathic pain syndromes, including juvenile fibromyalgia2 and benign hypermobility syndrome,3 are the most common diagnoses, with the most frequent area of pain being the neck and back.4,5 In this chapter, we review the clinical findings, pathogenesis, differential diagnoses, and approach to treatment of MSK pain.


Symptoms and Signs

Diffuse idiopathic MSK pain, a diagnosis of exclusion, is the most common diagnosis of noninflammatory MSK pain. As such, a well-explored pain history is paramount in delineating potential causes, focusing the physical exam, and identifying red flags to determine indicated testing/imaging or further consultations (Box 17–1). Often the pain will develop insidiously in a localized area with no definable injury or illness. As discomfort and pain intensify, pain will become constant with periods of exacerbations. Pain is described in a multitude of ways, including deep, dull, aching, or sharp and shooting in nature. The patient may have radicular pain with electric shock–like pains or numbness and tingling in their extremities, often not in a dermatomal pattern. Patients may report intermittent joint swelling, erythema, color changes, or stiffness, especially of the hands. Various factors will exacerbate the pain, including excessive physical activity or prolonged immobility, psychosocial stressors, changes in mood, poor sleep, and illness.

Box 17–1. Red flag symptoms and physical exam findings of musculoskeletal pain that may indicate further evaluation with laboratory studies or imaging or referral to additional providers.

Red Flags

Unexplained fever

Weight loss

History of neoplasm

Chronic steroid ...

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