• Inflammatory and noninflammatory conditions can cause joint pain in adolescents.
  
• Appropriate therapy for adolescents with arthritis requires not only treatment of the disease, but also attention to developmental needs and discussion of school and vocational issues.

There are many causes of joint pain occurring in childhood and adolescence (Table 5–1). Diagnostic accuracy is very important to ensure that the patient receives appropriate treatment.

The first step in evaluating a young patient who complains of musculoskeletal discomfort is to distinguish arthritis (true synovitis and joint swelling) from arthralgia (pain in and around joints). Pain in and around the joints without synovitis or swelling is usually caused by trauma, mechanical factors, or soft tissue syndromes. Excruciating joint pain and swelling, often with erythema, may indicate malignancy. A careful history of recent infections and exposures, as well as immunizations, can highlight possible infection-related causes of joint swelling and pain in the adolescent age group. Chronic childhood arthritis is one of the five most common chronic diseases of childhood, occurring with a frequency greater than diabetes or cystic fibrosis. Juvenile idiopathic arthritis (JIA), including psoriatic arthritis and the spondyloarthropathies of childhood, is the most common cause of chronic arthritis in childhood and adolescence.

The initial evaluation of an adolescent with a possible rheumatic disease includes a complete history and physical examination. In this age group, special attention should be paid to the following issues:

• Age at menarche.
  
• Is the patient skeletally mature? (A rough guide: is shoe size changing with every new pair?)
  
• Is the patient sexually active?
  
• Have there been prolonged or recurrent school absences?
  
• Are there barriers at school that make participation or attendance difficult?
  
• Has there been uninterrupted participation in physical education?
  
• Is there a history of participation in athletics?
  
• In what way does the patient make accommodations to compensate for arthritis symptoms (eg, wearing elastic waist sweat pants instead of jeans with buttons and zippers, avoiding going to the bathroom at school because of difficulty getting on and off the toilet).
  
• Does the patient have a best friend with whom she or he can discuss arthritis issues?
  
• Is there a receptive teacher or school counselor to contact if a Section 504 or Individualized Education Plan (IEP) is needed?
  
• Have vocational and career goals been identified?
  
• Has a disability application been filed?

Rubella, mononucleosis, hepatitis B and C, and varicella infections have all been associated with transient joint swelling (<6 weeks) and should be considered in the differential diagnosis of arthritis in this age group (Table 5–1). Immunization for varicella and the vaccine for MMR (measles, mumps, rubella) may be given to teenagers who did not receive their full complement of vaccinations as children. Vaccination with these attenuated viruses has also been associated with transient arthritis symptoms.

Erythrovirus (parvovirus B19) infection in the older child can cause fever and large and small joint polyarthritis with a morbilliform rash. Lyme disease, caused by Borrelia burgdorferi, can initially present with a rash followed by migratory, large joint arthritis, particularly the knee. A significant number of patients do not recall a tick bite or rash, so it is important to test patients who reside in or who have visited a Lyme endemic area. It is important to distinguish Lyme disease from JIA so that proper antibiotic therapy can be given. Rheumatic fever is now rare, but the syndrome of poststreptococcal arthritis is not uncommon. True synovitis can develop within 7–10 days in adolescents with antecedent streptococcal infection as a result of the molecular mimicry involved in the immune response to the streptococcal infection. In streptococcal-associated arthritis, the chorea and carditis of rheumatic fever are absent, and joint symptoms resolve completely but can recur with subsequent streptococcal infections (see Chapter 52).

Bloody diarrheal illnesses caused by Campylobacter, Salmonella, Shigella, Yersinia, and toxigenic Escherichia coli can be associated with postinfectious reactive arthritis in teenagers, particularly those who are HLA-B27 positive. Sexually active teenagers may contract chlamydia, which is associated with reactive arthritis, or gonococcal infection, which can disseminate and produce a characteristic dermatitis-arthritis syndrome (see Chapter 46).

Noninflammatory conditions can cause joint pain and swelling in the adolescent patient, which can mimic arthritis and be confusing diagnostically. The hallmark of this group of disorders is pain that worsens with activity in the absence of signs and symptoms of inflammation. Chondromalacia patellae, osteochondritis dessicans, Osgood-Schlatter, Sever syndrome, hypermobility syndromes, slipped capital femoral epiphysis, Legg-Calvé-Perthes disease, and Scheuermann disease, represent the most common causes of noninflammatory joint pain in this age group.

Chondromalacia patellae, or patellofemoral syndrome, is commonly seen in teenage girls and presents as unilateral or bilateral knee pain that worsens with activity. Any activity that involves weight bearing on a bent knee can aggravate the pain of this condition. Climbing stairs, using the clutch in a car, standing up after prolonged sitting, participation in gym class, and competitive athletic activities can be particularly troublesome. A minority of girls with chondromalacia patellae (approximately 10%) have knee swelling in addition to knee pain, and even fewer of these patients have persistent knee effusion lasting more than 6 weeks. When this does occur, chondromalacia patellae is easily confused with JIA.

The diagnosis of chondromalacia patellae is confirmed by crepitus and a positive patellar inhibition test on examination, together with a history of knee pain that worsens with activity, the absence of morning stiffness, and the absence of other affected joints, even in patients with prolonged knee swelling. Isometric quadriceps strengthening exercises (Figure 5–1

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