Musculoskeletal Pain in Primary Pediatric Care: Analysis of 1000 Consecutive General Pediatric Clinic Visits

Objectives. 1) To determine the number of primary care clinic visits attributable to musculoskeletal pain (MSP) in children >3 and <15 years of age. 2) To describe the demographic characteristics of this population assessed for limb/back pain. 3) To characterize the etiology of musculoskeletal pain in an urban general pediatric clinic in Madrid, Spain. Methods. Prospective evaluation of 1000 consecutive clinic visits to an urban general pediatric clinic. Inclusion criteria were 1) age >3 and <15 years and 2) musculoskeletal evaluation requested by the family or patient. All consultations related to MSP were recorded via standard protocol and data record form. Results. During the study period, 61 of 1000 (6.1%; confidence interval: 4.6–7.5) clinic visits for children >3 and <15 years were related to MSP. Patients’ age, mean 6 SD, was 9.7 6 3.3 years. Musculoskeletal complaints were more frequent in boys (57.4%), although there was no statistical difference. The presenting complaints included knee arthralgias in 33%; other joint (eg, ankles, wrists, elbows) arthralgias in 28%; soft tissue pain in 18%; heel pain in 8%; hip pain in 6%; and back pain in 6%. Symptoms were attributable to trauma in 30%; overuse syndromes in 28% (eg, chondromalacia patellae, mechanical plantar fasciitis, overuse muscle pain); and normal skeletal growth variants (eg, Osgood–Schlatter syndrome, hypermobility, Sever’s disease) in 18% of patients. Conclusion. MSP represents a frequent presenting complaint in general pediatric practice. A new heightened awareness of the frequent occurrence of MSP should be adopted when designing pediatrics continuing medical education and training programs. Pediatrics 1998;102(6). URL: http://www.pediatrics.org/cgi/content/ full/102/6/e63; musculoskeletal pain, limb pain, arthralgia, children, general pediatrics, pediatric primary care. ABBREVIATIONS. MSP, musculoskeletal pain; NHS, National Health Service; MECH, mechanical/overuse; TRAU, trauma; NVAR, normal skeletal growth variants; NS, nonspecific (pain); GP, growing pains; VIR, viral infection; TS, transient synovitis; CI, confidence interval. Musculoskeletal pain (MSP) is a frequent complaint in childhood, affecting 7% to 15% of school children.1–4 Limb or back pain are extremely uncommon in children younger than 3 years, increasing its frequency with age until reaching a plateau during early adolescence. Despite the high prevalence of MSP in pediatrics, to date no study has focused on the number of general pediatric clinic visits attributable to this complaint. This observation might be explained by the profile of pediatric practice recorded in the United States and some European countries,5–8 where .70% of the visits were a result of healthy-child/adolescent check-ups; upper respiratory or ear, nose and throat infections; gastroenteritis; and skin diseases. Although musculoskeletal complaints represent a low percentage of clinic visits, experience indicates that they usually carry a significant economic burden because of the diagnostic procedures performed (such as complete blood count, erythrocyte sedimentation rate, streptococcal serology, radiography) or referral to other health care providers (orthopedic surgeons, rheumatologists). This study was undertaken to determine the number of general pediatric clinic visits attributable to MSP in children and adolescents 3 to 14 years old and to describe their demographic characteristics and the diagnosis reached. PATIENTS AND METHODS The study was performed prospectively, recording all clinic visits to an urban National Health Service (NHS) general pediatric clinic located in Madrid, Spain. The study period was 41⁄2 months, from October 30, 1996, to March 17, 1997. Inclusion criteria were 1) age between 3 and 14 years and 2) musculoskeletal evaluation because of pain requested by the family or the patient. Children who received routine pediatric care at the clinic but who were initially evaluated for MSP elsewhere (eg, in the emergency room) were not included in the study. The Spanish health care system, including pediatric care, is offered to families free of charge in clinics located no more than 30 minutes from family residences. To facilitate access of care, parents can choose among pediatricians working morning/afternoon (8 AM to 3 PM) or afternoon/evening (2 PM to 9 PM) schedules. Routine pediatric care at these clinics is received by 80% to 90% of all children. Unlike those in the United States, families living in urban areas of Spain have a higher socioeconomic status than do suburban populations. Patient assignment to clinics is based on residential geographic location. At the urban general clinic, 859 children are followed routinely, having a nearly equal boy:girl distribution (50.2% to 49.8%). Of the clinic population, 80% were age-eligible for this study. The mean 6 SD and median age of patients 3 to 14 years old were 8.6 6 3.2 and 8.5 years, respectively. To record accurately the number of consultations related to limb or back pain, the visits were classified as either primary (defined as visits for children who attended the clinic for evaluation of MSP) or secondary (defined as visits for children who attended the clinic for other reasons, usually check-ups, but for whom parents requested musculoskeletal evaluation for MSP during the visit). Both type of visits were included in these study results. Data were recorded via standard protocol and data record form. Only unduplicated visits were included in the study. The From the Centro de Salud “Benita de Avila,” Insalud Area 4, Madrid, Spain. Received for publication May 7, 1998; accepted Jul 20, 1998. Reprint requests to (J.d.I.) C/Cantalejo 13, 5°H, 28035 Madrid, Spain. PEDIATRICS (ISSN 0031 4005). Copyright © 1998 by the American Acad-