Non-inflammatory Musculoskeletal Pain 4%

Question 1

What is the epidemiology of AMPS?

Sex ratio
Age range

Answer 1

F>M = 4:1
8-16 yo, peaks in older adolescence
- Youngest is 2 yo

Question 2

What is the diagnostic evaluation indicated in AMPS?

Answer 2

No lab testing is required

• Normal CBCd, ESR, CRP
• No benefit in obtaining RF, ANA, etc if low clinical suspicion of autoimmune disease

Imaging should be directed to rule in or out specific diagnoses

• Xray or bone scintigraphy - exclude trauma, tumor
• MRI - exclude spinal cord lesions. Bone edema is frequently seen but cannot be differentiated from trauma

Question 3

A 6-year-old male presents with 3 months of bilateral thigh and calf pain, worse at night or worse after having a busy day with lots of physical activity. Improves with ibuprofen. He’s otherwise healthy except complains of abdominal pain quite frequently. Labs normal. What is the diagnosis?

Answer 3

Benign nocturnal limb pain of childhood (growing pains)

Question 4

What is the treatment of benign nocturnal limb pain of childhood (growing pains)?

Answer 4

Education, reassurance that pain is self-limited and benign

OTC analgesics, passive stretching

Orthotics for children who are hypermobile and have pes planus

Question 5

What are some symptoms that suggest a diagnosis other than growing pains in a child with leg pain at night?

Answer 5

Think other diagnoses if atypical symptoms - articular or unilateral pain, pain in the back or upper extremities, pain present during the day, daily pains (not episodic), systemic symptoms, or abnormal exam

Question 6

What is the epidemiology of children with growing pains?

Age range
Concurrent abnormality

Answer 6

Age 3-12

Italian study showed 94% children had low vitamin D levels with pain improved after supplementation

Question 7

A 13-year-old female presents with hand/wrist pain, paresthesias, numbness, thenar atrophy, positive phalen and tinel sign.

What is the diagnosis?
What underlying group of disorders should be considered?
How is the diagnosis confirmed?

Answer 7

Carpel tunnel syndrome, an overuse syndrome

Consider metabolic disorder since rare in children. Operative treatment is often the only effective treatment in children who have a metabolic disease

Diagnosis is confirmed with bilateral motor and sensory electrophysiological testing

Question 8

A 12-year-old obese Hispanic male presents with bilateral hip/groin pain and new limp. What diagnostic evaluation will reveal the condition?

Answer 8

Slipped capital femoral epiphysis (SCFE)

XR hips (AP, lateral, and frog) showing widening and irregularity of the physis with posterior inferior displacement of the femoral head . Looks like ice cream scoop falling off the cone.

MRI can be helpful in diagnosing a “preslip” and may show physeal widening, synovitis, periphyseal edema, and joint effusion

SCFE is displacement of the proximal femoral epiphysis on the femoral neck

More common in obese, boys, AA, Hispanics, Polynesians, and Native Americans
Bilateral in 20-40%
Second SCFE usually occurs within 1 year of the initial slip
Increase in incidence over the years (due to increasing rates of obesity)
Boys (12.7-13.5 yo)
Girls (11.2-12 yo)

Affected hip is usually held in abduction and external rotation with decreased active and passive internal rotation and adduction

Trendelenburg test may be positive, reflecting gluteus medius weakness

Question 9

A 12-year-old obese AA female presents with bilateral hip pain, left knee pain, and new limp. An XR performed in the ED confirms the diagnosis. What is the management?

Answer 9

Slipped capital femoral epiphysis (SCFE)

SCFE may compromise the vascular supply to the femoral head and lead to AVN

All cases warrant urgent orthopedic referral

Treatment includes non weight-bearing traction and surgery with epiphyseal fixation and osteotomy

Most patients do well after surgical fixation

Complications including AVN, chondrolysis, and femoral acetabular impingement may occur in both treated and untreated children

Patients require long-term follow-up as SCFE may develop in the contralateral hip if prophylactic pinning is not performed

Children under age 10 or over 16 years and thin children who do not fit the typical profile for SCFE should undergo evaluation for endocrinopathies (hypothyroidism, chronic renal insufficiency, growth hormone treatment and renal osteodystrophy)

Question 10

A 7-year-old male presents with chronic left hip and knee pain. On physical exam, he demonstrates left hip pain and limitation with internal rotation and abduction.

What is the diagnosis?

Answer 10

Legg-Calve-Perthes disease

Idiopathic AVN of the femoral epiphyses

Affects 4-10 year olds, peaking between 5-8 year olds
M>F (4-5:1), High prevalence in caucasians
Bilateral in 10-15%
Bilateral LCP is usually asynchronous; apparently synchronous bilateral LCP should raise the suspicion for an alternate diagnosis (epiphyseal dysplasia)

Question 11

What is the treatment of Legg-Calve-Perthes disease?

Answer 11

Treatment - rest, exercises to preserve hip ROM, femoral and/or pelvic surgery

Short-term bracing may be needed but avoid prolonged bracing

Question 12

What is the difference between Osgood-Schlatter disease and Sinding-Larsen-Johansson syndrome?

Answer 12

Osgood Schlatter: Traction apophysitis of growth plate of the TIBIAL TUBEROSITY at the inferior attachment of the patellar tendon

Sinding-Larsen-Johansson: Traction apophysitis of INFERIOR POLE OF THE PATELLA at the superior attachment of the patellar tendon

Question 13

A 13-year-old male who participates in track presents with bilateral heel pain with running and jumping. He demonstrates pain with medial and lateral squeeze of the calcaneal apophysis. What is the diagnosis and treatment?

Answer 13

Sever disease

Calcaneal apophysitis, traction apophysitis of the os calcis at the insertion of the Achilles tendon

Treatment: ice, rest, NSAIDs, activity modification, PT (little evidence); taping, heel lift, heel cups decrease pain (some evidence)

Question 14

A 14-year-old male is referred to rheumatology for chronic back pain worse when she is working out. She points to her thoracic back to indicate where the pain is. She has a reassuring examination. XR reveals hyperlordosis of the lumbar spine, loss of disc space height, Schmorl nodes. What is the diagnosis and treatment?

Answer 14

Scheuermann disease

Most common cause of structural kyphosis in adolescence with incidence of 0.4-10%
M>F

Xrays - anterior wedging of at least 3 adjacent vertebral bodies of 5+ degrees, endplate irregularities, loss of disc space height, Schmorl nodes

Treatment

• Exercise
• Back brace to prevent flexion (20 minutes of home exercises before bracing)
• Schroth therapy - focuses on muscular balance, healthy posture, breathing shows promise in decreasing kyphosis
• Day/night custom back orthotic

Bracing should stop once growth is complete but before bony maturity is reached

Surgery is needed for patients with persistent pain or curve >75 degrees

Question 15

How does congenital indifference to pain present?

Answer 15

Rare autosomal recessive disorder characterized by the complete absence of pain perception typically associated with noxious stimuli

Associated with SCN9A (sodium channel) gene mutation or PMRD12 gene mutation

Question 16

A 3-year-old female with developmental delay presents for evaluation of shoulder tenderness (fussiness when picked up). XR revealed mild effusion and healing spiral humerus fracture. MRI also showed mild effusion but no synovitis. No known trauma though mom reports older sister pushed her off of the sofa a couple weeks ago. What is the next step in evaluation?

Answer 16

Concern for non-accidental trauma

Get skeletal survey

Also consult to social work

Question 17

A teenage female presents with insidious onset of extension-related low back pain worse with physical activity. XR is abnormal. What is on the differential and what percentage of patients with low back pain have one of these conditions?

Answer 17

Spondylolysis is a defect in the pars interarticularis
Spondylolisthesis is bilateral pars defects, forward translation of one vertebrae on the next caudal segment

20% of patients with low back pain will have spondylolysis or spondylolisthesis

Question 18

What is the management of spondylolysis or spondylolisthesis?

Answer 18

Activity restriction until asymptomatic (2-3 months)
PT on core strengthening and hamstring flexibility
Thoracolumbar orthosis to limit extension and rotation is variable
Adolescents return to sports when they are pain free (with or without brace)

Question 19

What are some classic physical exam findings in spondylolysis or spondylolisthesis?

Answer 19

Lumbar hyperlordosis, ipsilateral paraspinal muscle muscle spasms, tight hamstrings, limited forward flexion, straight leg raise, painful spinal extension

Focal tenderness over the site of pars lesion and palpable step-off at the LS junction with spondylolisthesis

Question 20

A 12-year-old patient presents with severe, sharp chest pain that then persist as a dull ache. Sometimes the pai radiates to the anterior ribs and back and is associated with a popping sensation. When the patient stretches by twisting their trunk, the pain comes back.

On exam there is tenderness and worsening pain on direct pressure over the affected ribs.

What maneuver would be positive in this condition?

Answer 20

Slipping rib syndrome

Hooking maneuver: Reproduction of the pain (often with a click) occurs when examiner hooks fingers under the inferior margins of the affected ribs and pulls anteriorly and superiorly

Question 21

A 9-year-old patient presents with moderate-severe chest pain. He is recovering from a URI. The chest pain is reproducible when palpation over 2nd costochondral junction. What is the diagnosis and treatment?

Answer 21

Tietze syndrome

It’s a localized form of costochondritis that affects one costochondral, costosternal or sternoclavicular joint

Treatment is rest, pain control with NSAIDS, PT

Question 22

A 16-year-old female presents with pain that started in her knees but spread to her ankles, hips, fingers, wrists, elbows, shoulders, and entire back. She describes the pain as sharp and stabbing, sometimes burning and tingling in her hands or feet. On physical exam, she has tenderness with range of motion of her joints and even reports that it hurts when you lightly touch her knee. What is the diagnosis?

What would be on the differential if she described the severe burning pain as episodic and she also had bluish maculopapular hyperkeratotic lesions on her lower trunk and her ESR is elevated?

Answer 22

Amplified Musculoskeletal Pain Syndrome

Fabry disease may be on the differential for an adolescent who presents with episodic, excruciating burning pain in the distal extremities with blue maculopapular hyperkeratotic lesions clustered on the lower trunk and perineum. ESR is usually elevated.

Question 23

A 13-year-old female presents with left anterior knee pain with prolonged standing or knee extension. She was kicked in the knee during soccer practice but it didn’t really bother her too much. On exam, she has pain with full knee extension and with palpation to her anterior fat pad. What is the diagnosis and treatment?

Answer 23

Hoffa syndrome - Hoffa fat pad irritation/impingement

Treatment: local cryotherapy, patellar taping, PT

Question 24

A 17-year-old male basketball player presents with bilateral knee pain worse after basketball practice. He points to 6 o’clock on his knee cap when asked where the pain is. On exam, he has tenderness over the proximal patellar tendon but otherwise normal exam. What is the diagnosis and how can you confirm the diagnosis?

Answer 24

Patellar tendinopathy - “jumper’s knee” in skeletally MATURE patient

Dx: Ultrasound

Tx: load reduction, ice, transfriction massage, progressive eccentric strengthening

DDx in skeletally immature individuals: Osgood-Schlatter disease or Sinding-Larsen-Johansson disease

Question 25

A 12-year-old female presents with lateral knee pain and sometimes at the greater trochanter. On exam, there is reproducible pain and snapping with palpation over the lateral femoral condyle with passive flexion, maximal at 30 degrees knee flexion. What is the diagnosis ?

Answer 25

Iliotibial band (IT) syndrome

The IT band starts from the tensor fasciae latae and gluteus medius and maximus muscles and extends laterally as a tight band of fascial tissues.

Question 26

An 11-year-old male presents with shoulder pain. He takes tennis lessons after school and attends tennis and swim camp in the summer time. He has tenderness over his proximal arm. What is the diagnosis and what can you see on x-ray?

Answer 26

Little League Shoulder

Due to excessive rotational and shear forces causing microfractures across proximal humeral physis

XR shows widening, lateral fragmentation, sclerosis, and cystic changes in the proximal humerus physis

Prevention is key

M>F, 11-16

Question 27

What causes tennis elbow?

What are 2 complications of tennis elbow?

Answer 27

Tennis elbow = lateral epicondylitis

95% of patients have tendinosis of origin of extensor carpi radialis. brevis tendon

Due to overuse of arm related to excessive wrist extension

Children are more likely to suffer valgus compressive injuries to the lateral elbow. Such forces may lead to damage to end-arterial blood supply to the capitellum.

May result in Panner osteochondrosis or steochondrosis dissecans of the capitellum

Question 28

A 14-year-old golfer presents with medial elbow pain. On the exam, there is tenderness at or below the medial epicondyle. There is pain on resisted wrist flexion and forearm pronation in elbow flexion. What is the pathology present?

Answer 28

Golfer elbow

Due to tendinosis at the origin of the flexor/pronator muscle in skeletally mature individuals

Rule out ulnar neuropathy

Question 29

An 8-year-old baseball player complains of medial elbow pain. There is mild overlying swelling and tenderness. What is the diagnosis and what can you see on x-ray?

Answer 29

Little league elbow = medial epicondyle apophysitis

X-ray shows irregular ossification followed by enlargement and eventual fragmentation of the medial epicondyle with/without avulsion

Question 30

What conditions are associated with chondrolysis of the hip?

Answer 30

Septic arthritis
inflammatory arthritis
Marfan syndrome
Stickler syndrome
Prolonged immobilization, severe trauma

Chondrolysis of the hip causes hip pain, stiffness, limp, and decreased ROM

Question 31

A 14-year-old female presents with bilateral knee pain worse with activity, going up stairs, or sitting in class for a long time. Sometimes, her knee feels like it gives way. She moves her finger in a circle around her knee cap when asked where the pain is. What is the diagnosis?

Answer 31

Patellofemoral syndrome

Physical exam findings: lower extremity malalignment, leg length discrepancy, femoral anteversion, external tibial torsion, laterally displaced tibial tubercle, pronated subtalar joint, vastus medialis wasting, increased Q-angle, patellar facet tenderness, muscle tightness and/or weakness (quads, hip external rotators/abductors, trunk muscles). Painful quadriceps setting/grind test and patellar compression test.

Question 32

A 14-year-old weight lifter presents with lower leg pain at the start and near the end. On exam, she has tenderness along the posteromedial border of the tibia. She just started practicing again after a relaxing summer. What is the diagnosis?

Answer 32

Posteromedial Tibial Stress Syndrome (shin splints)

Question 33

Slipping rib syndrome is associated with what sports?

Answer 33

swimming, horseback riding, and running.

Slipping rib syndrome can occur spontaneously or after trauma or repetitive trunk motion

Slipping rib syndrome can be a cause of recurrent chest or abdominal pain.
Diagnosis of slipping rib syndrome is made by using the symptom history and physical examination findings, in particular the hooking maneuver.

Symptoms involve the 8th, 9th, or 10th ribs and result from the hypermobility of these ribs with subsequent subluxation of the affected rib under the superior adjacent rib. This causes irritation of the intercostal nerve and muscles, leading to anterior chest wall pain. Slipping rib syndrome presents with pain localized to the anterior lower costal margin and is described as sharp, stabbing, and episodic, usually lasting minutes. Pain can be reproduced by deep breathing, bending over, twisting or turning movements, and raising the arms.

Question 34

How can you differentiate Fabry disease from erythromelalgia?

Answer 34

Fabry disease symptoms do not improve with cold unlike erythromelalgia where cold provides relief

Symptoms of Fabry disease may include acroparesthesias of the hands or feet that is not usually associated with relief on exposure to cold, as was described in the vignette. Symptoms may present early in childhood with worsening manifestations as the patient ages. It is a lysosomal storage disease, which is inherited in an X-linked fashion and thus is more common and more symptomatic in boys. It is important to ask about other potential manifestations of the disease and look for other physical stigmata. Patients may have abdominal pain, proteinuria, cardiac involvement (myocardial hypertrophy, arrhythmias, and valvular disease), angiokeratomas, and corneal changes. Fabry disease is the result of mutations in GLA, which encodes α-galactosidase A. Diagnosis in male patients can be made by measuring the level of α-galactosidase activity, which is less than 1% in affected male patients. Female patients may have near normal levels, so an enzyme assay is not sufficient for diagnosis; rather, molecular genetic studies of GLA are preferred.

Question 35

What gene mutation can be seen in Erythromelalgia?

Answer 35

SCN9A

Erythromelalgia most commonly presents as redness, pain, and heat in the feet.

Symptoms of erythromelalgia often improve with application of cold.

In a few patients with erythromelalgia, mutations in SCN9A, which encodes the sodium channel protein Na(v)1.7 subunit, can be identified, particularly in hereditary cases.

Question 36

How do you differentiate Costochondritis and Tietze syndrome?

Answer 36

Costochondritis and Tietze syndrome are distinguished by the multiple involved costochondral joints in costochondritis vs a single rib in Tietze. Additionally, swelling and warmth occur with Tietze syndrome but not costochondritis.

Costochondritis is a common reason for anterior chest pain that involves multiple levels and has no visible changes.

Tietze syndrome is rare and has associated swelling, erythema, and warmth over the costochondral junction, involving a single rib in the majority of patients.

Question 37

What disease has these MRI findings:

Bone marrow edema and fracture in the L5 pars interarticularis bilaterally

Answer 37

spondylolysis

Spondylolysis is a stress reaction or fracture of the pars interarticularis in the lumbar spine typically resulting from repetitive hyperextension.

Question 38

What disease has these MRI findings:

Anterior wedging of the L1 to L3 vertebral bodies with intraosseous disc herniations of L2 and L3

Answer 38

Scheuermann disease

causes structural kyphotic deformity. Scheuermann disease may affect the thoracic or thoracolumbar spine and leads to structural kyphosis of the thoracic spine with possible nonstructural hyperlordosis of the cervical or lumbar spine, which may increase the risk of associated pain and may predispose to a risk of spondylolysis. Radiologic findings are typically demonstrable on plain radiography.

Question 39

What disease has these MRI findings:

L4 to L5 disc herniation abutting the traversing L5 left and right nerve root

Answer 39

lumbar disc herniation.

Patients with lumbar disc herniation often have limitation in forward flexion, pain with straight-leg raise, and radicular symptoms.

Question 40

What disease has these MRI findings:

Patchy bone marrow edema in the sacrum and iliac bones adjacent to the sacroiliac joints bilaterally

Answer 40

sacroiliitis

Patients with sacroiliitis often have limitation in forward flexion, morning pain or stiffness, and pain after sitting for long periods

Question 41

What should you think of if a patient reports recurrent extremity pain, most often involving the lower leg described as predictable pain during similar times, distances, and intensities of workouts that is relieved with rest?

How would you confirm the diagnosis?

Answer 41

chronic exertional compartment syndrome (CECS)

Diagnosis of chronic exertional compartment syndrome is confirmed with pre- and post-exercise measurements of intracompartmental pressures

The extremity pain associated with CECS is theorized to arise from reversible decreased bloodflow within a closed space leading to decreased tissue perfusion and associated pain. It usually happens in athletes, particularly runners. Patients experience repeated pain with activity that causes tissues to become tight and painful. The pain usually goes away with rest. Although there is typically no permanent tissue injury, infrequently the condition escalates and becomes acute compartment syndrome.

The anterior or lateral lower leg is the most common site affected by CECS, but it can occur in other areas including the upper leg and forearm. Diagnosis is made clinically based on the characteristics of the pain, including its predictable nature related to times, distances, and intensities of workouts and its resolution with rest. Diagnosis is confirmed by measuring compartment pressures with manometry before exercise and at 1 and 5 minutes after exercise.

Question 42

What is the diagnosis if a patient’s knee pain is reproduced by extending the knee against resistance or when squatting with the knee in full flexion?

Answer 42

Osgood-Schlatter disease (OSD)

Osgood-Schlatter disease (OSD), a common cause of anterior knee pain in children and adolescents, is caused by repetitive traction of the patellar tendon on the tibial tuberosity. Symptoms are more common in athletes (particularly during a growth spurt) and those who participate in sports that involve jumping. Patients report an achy pain that is exacerbated by kneeling, jumping, squatting, and stairs. There is tenderness (with or without swelling) along the tibial tubercle. In addition, pain is reproduced by extending the knee against resistance or when squatting with the knee in full flexion.

Question 43

What is the diagnosis of a patient’s knee pain if there is tenderness along the anteromedial joint line with a palpable tender thickened band?

Answer 43

Synovial plica

Synovial plica is a less common cause of anterior knee pain in children and adolescents. Synovial plicae are residual embryonic remnants that persist and may become thickened and inflamed. Patients typically report anterior knee pain associated with a clicking, catching, or locking sensation. Patients may report symptoms that are worsened with activities such as running, kneeling, squatting, and stairs. There is tenderness along the anteromedial joint line with a palpable tender thickened band in some cases. Synovial plica should be considered in patients with patellofemoral pain that does not respond to conventional management.

Question 44

What is the diagnosis of a patient’s knee pain if exam shows suprapatellar resistance while the patient performs quadriceps contraction with the knee in full extension?

Answer 44

patellofemoral pain syndrome (PFS)

A positive patellar inhibition test (suprapatellar resistance while the patient performs quadriceps contraction with the knee in full extension)

Question 45

What is the diagnosis of a patient’s knee pain if exam shows pain and contraction of the quadriceps muscle when the examiner attempts to displace the patella laterally?

Answer 45

patellofemoral instability

Patients with true patellofemoral instability may have similar symptoms as those with PFS. In contrast to PFS, patellofemoral instability is caused by lateral tracking of the patella in the femoral groove during knee flexion and extension, which may result in frank subluxation or dislocation. Similar to PFS, patellofemoral instability is more common in adolescent girls, particularly those who are athletes, hypermobile, or have anatomic variants that may predispose them to malalignment (ie, patella alta, shallow intercondylar groove, lateral attachment of the patellar ligament, or bipartite patella). Patients with patellofemoral instability may similarly experience a sensation of their knee “giving way” and may visualize the patella shifting out of place (a popping sound may also be heard with dislocation). In addition, there may be intermittent joint effusions. A patellar apprehension test positive for patellar instability occurs when there is pain and contraction of the quadriceps muscle when the examiner attempts to displace the patella laterally.

Question 46

What disease has these findings on Xray?

decreased size and flattening of left femoral head epiphysis with increased density compared to the right side

Answer 46

Legg-Calve-Perthes disease (LCPD)

Decreased size of left femoral head epiphysis with increased density compared to right side is a possible radiographic finding in Legg-Calve-Perthes disease (LCPD), pediatric idiopathic avascular necrosis of the hip. However, radiographic findings may also be normal early in LCPD, and magnetic resonance imaging may be required for further evaluation if clinical suspicion is high.

Question 47

What disease has these findings on Xray?

widening and irregularity of the left femoral capital physis with posteromedial slip of the epiphysis

Answer 47

slipped capital femoral epiphysis (SCFE)

Question 48

Vitamin C is needed to synthesize what?

Answer 48

collagen and chondroitin sulfate

vitamin C (ascorbic acid) is necessary for the synthesis of collagen and chondroitin sulfate,

deficiency of vitamin C can lead to poor collagen synthesis, resulting in subperiosteal, gingival, and intradermal hemorrhage. Severe bone pain can result from the subperiosteal hemorrhage. Rarely, hemarthrosis can mimic synovitis. Radiographs show subperiosteal new bone apposition, a characteristic finding in scurvy

Question 49

The bony symptoms of rickets with deficient calcium and/or vitamin D is due to what problem with bones?

Answer 49

defective ossification of the bony matrix.

Question 50

The bone pain from hypervitaminosis A is from what mechanism?

Answer 50

overactivation of retinoid receptors on bone leads to osteoclastogenesis and periosteal bone resorption

Question 51

What syndromes are associated with chondrolysis?

Answer 51

Marfan syndrome

Stickler syndrome