Definition and characterization of musculoskeletal pain and associated diseases

Definição e caraterização de dor musculoesquelética e doenças associadas

Marco António Fernandes^I, Inês de Melo^I, Flávio Campos Costa^II, Manuel Salgado^I

^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.

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

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

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.

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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).

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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}

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.

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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.

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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