Table 1.

Differential diagnosis of pediatric chronic muscular pain

Diagnosis	Distinguishing charateristics
Fibromyalgia	Diffuse chronic musculoskeletal pain with multiple predictable tender points
Hypermobilty	Common, younger age (preschool to elmentary school age), pain more sever towards the end of the day, usually associated with specific activities, evidence of hypermobility in physcal examination
Myofascial pain	Pain arises from sustained contraction of a muscle, especially in the head, jaw, and upper back. Presence of a trigger point (tender point) and reproduction of the pain by maneuvers which place stress upon proximal structures or nerve roots.
Unrecognized local pathology (fracture, strain, sprain)	Trauma/strain to the affected limb, pain worsens with physical activity and excersice, positive findings in plain radiographs.
Arthritis	Inflamation of one or more joints, pain is constant, 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 vertebral column, response to nonsteroidal anti-inflammatory medications.
Leukemia	Child appears sick, presence of anorexia and lethargia, fever is common, nucturnal pain and bone pain. Abnormal blood count, relative thrombocytopenia, and elevated erythrocytes sedimentation rate.
Spinal cord tumors	Slow progression of pain, pain quality – low and steady intesity, abnormal neurologic examination, pathologic MRI.
Chronic recurrent multifocal 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 enduces 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.
Farby disease	Deficiency of ceramide trihexoside α-galactosidase, X-linked recessive inheritance. Episodic excruciating burning pain in the hands and feet. Symptomes usuall begin in adolescence. Presence of bluish maculopapular hyperkeratotic lesions around the perineum, elevated erythrocytes 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, recures 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 or time 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 an injury or infection. Can cause severe burning pain in the distribution of the involved peripheral nerve. Findings in a 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, 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 reveals signs and symptomes of thyroid disease. Abnormal thyroid function tests.
Vitamin D deficiency	Uncommon in developed countries. Causes limb pain. Low levels of vitamin D in laboratory tests.