PEDIATRIC RHEUMATOLOGY UPDATE
This page is provided by Thomas J. A. Lehman MD
Delivering the best care - with great care
Dr. Lehman is the author
of many textbook chapters and articles on the care of children and young adults
with rheumatic disease. He practices in
Frequent Sprains??? Sports injuries?? Ankylosing Spondylitis??
Do you have a teenager or older child in your practice who is always spraining his/her ankles or knees? Some children are just clumsy, and others too aggressive playing sports. However, this is often the initial story for children with spondyloarthropathies.
Spondyloarthropathies typically present in boys or girls from ages 10 and up. Their characteristic feature is tendon inflammation, usually in the lower extremities. Many of these children initially present to their pediatricians with repeated complaints of knee, ankle, or heel pain associated with activities. It’s almost always thought to be an injury.
There are several key findings which help in making the proper diagnosis. The most important is that these children tend to be tight. Often they cannot bend over and touch their toes. This disease tends to run in families, so don’t be fooled when mom or dad says, "Oh, Don’t worry. I can’t do that either."
The second key finding is that these children often have low back pain or stiffness. Don’t expect them to tell you about it unless you specifically ask. Typical responses are, "Sure, but what’s my back got to do with my ankle pain," or, "Isn’t everybody stiff in their back when they wake up in the morning?" If you think the child might have a spondylo-arthropathy look for the following findings: 1) tender SI joints, 2) heel pain on percussion, - I thump the heel with my fist while the child is lying on their stomach with their knee bent so the foot is up in the air, 3) swollen and/or tender Achilles’ tendons which hurt when you squeeze them.
The final question to ask is whether mom or dad have low back pain. Often the answer is yes, but they have an ‘excuse.’ Few injuries cause persistent back stiffness in the morning. It’s not a definite finding, but it should make you more suspicious. The spondyloarthropathies are actually very common. They have a genetic basis and tend to ‘run in families.’ However, they have highly variable penetrance. Often one family member will have minimal symptoms while another has significant problems.
Is this important? Yes!!. With proper therapy we can make these children and young adults much more comfortable. Often they can resume full activities and go back to being successful athletes, cheerleaders, etc.
Two academic points about spondyloarthropathies: first, many people expect these patients to be HLA-B27 positive. Also many people “improperly” (personal opinion see below) label these children as having juvenile ankylosing spondylitis. About half of these children are HLA-B27 positive. However, about half are not. Don’t make the diagnosis based on the presence or absence of this HLA antigen. The second academic point; all of the childhood rheumatic diseases are going through a period of ‘redefinition.’ The international nomenclature committee has decided that ‘spondyloarthropathy’ is to be replaced by ‘enthesitis associated arthritis.’
If you have a child or young adult whom you suspect might have a spondyloarthropathy or who has been labeled with juvenile ankylosing spondylitis, give us a call. We’ll be glad to help you out. Most get better with NSAIDs, but some children require more aggressive therapy including TNF blocking agents or immunosuppressives. The choice of NSAID is very important as all NSAIDs are not equally effective for this disease.
In many children this tends to be a recurrent disease. Proper counseling, monitoring, and physical therapy are important. A small percentage will go on to develop full fledged ankylosing spondylitis. Although I discuss this subject in much more detail in my book (below), I think it is very important for every parent of a child diagnosed with juvenile ankylosing spondylitis to understand that no one can predict the future with certainty. I’ve been in practice over twenty-five years. During that time the answer has changed from every HLA-B27 child with joint pain will ultimately develop ankylosing spondylitis to maybe very few to ….. No one really knows how often this happens and no one really knows if your child will go on to develop full fledged ankylosing spondylitis. The key is not to lose sleep over what you call it. It must be treated aggressively and appropriately for the problems the child or young adult has. Labeling children with ‘juvenile ankylosing spondylitis’ unnecessarily causes them and their parents great worry about the future and impedes their development into the young adults they should be. Yes some HLA-B27 positive boys will go on to ankylosing spondylitis and they should be watched carefully. But, they should not be labeled prematurely or prevented from reaching their full potential by a premature and often incorrect diagnosis.
For a more detailed discussion of the many forms of spondyloarthropathies and their treatment consider my book below.
Dr. Lehman is the author of many
textbook chapters and articles on the care of children and young adults with
rheumatic diseases including SLE, JRA, dermatomyositis, scleroderma,
“Dr. Tom Lehman’s experience and compassion are evident on every page of this book, and they help guide the reader—child, parent, and healthcare professional alike – through the world of childhood arthritis. This book is an absolute gem written with a single goal in mind: improve the lives of kids with arthritis.” -- Jack Klippel, M.D. President and CEO of the Arthritis Foundation
“Dr. Lehman has given
parents and families of children with arthritis the first book that speaks to
the parent and child as equals. His book
explains the illnesses, the medications, the lab tests, and the disease course
in simple, understandable lay language and givens them valuable insight into
how a pediatric rheumatologist thinks.
Bravo!”-- Charles Spencer, M.D., Professor of
It’s not just
A guide to childhood muscle, bone, and joint pain,
rheumatic diseases and the latest treatments
It has always been a frustration trying to answer the many questions I have received from people over the web. I can’t take the time and give them the detail I would like to. I have to take care of my patients. This book is a distillation of my experience answering questions for parents and health professionals over 25 years of practice. If you want to know about the diseases, the tests, the medications, or how to be sure you are getting the best care– If you are the family member of a child with joint pains, this book will give you the answers. There are chapters on sports injuries, common orthopedic conditions and of course on all the various forms of arthritis. If you are a general physician, a pediatrician, or a nurse who cares for children with these diseases it will answer many of the questions families ask you, and you can recommend it to them. It will also answer many of your questions about what shots to give, what precautions to take, and the other questions families, pediatricians, and other health care providers have asked me over the years.
The Division of Pediatric Rheumatology at HSS continues to grow. We’re adding faculty, and we’ve received grants to expand both our teaching programs and our research into the causes and care of childhood rheumatic disease. Thank you for your continued support!
We’re in White Plains!
If you have patients who don’t want to come into NYC we can see them at the Burke Rehabilitation Center in White Plains. Call our NYC office 212-606-1151 for appointments.
is the author of many textbook chapters and articles on the care of children
and young adults with SLE. He practices
The Arthritis Foundation also works with children with enthesitis.
Click for BOOKS dealing with childhood arthritis.
This site provided by Thomas J. A. Lehman MD
Chief, Division of Pediatric Rheumatology
The Hospital for Special Surgery
535 E 70 St,
212-606-1151, fax 212-606-1938, e-mail email@example.com
Systemic lupus erythematosus, dermatomyositis, Scleroderma, progressive systemic sclerosis, pss, jra, juvenile rheumatoid arthritis, childhood arthritis, growing pains, rheumatism, children with pain, bone pain, pediatric specialists, my child hurts, chronic disease, chronic childhood illness, the best care, Kawasaki disease, mixed connective tissue disease, SLE, JCA, JIA, juvenile chronic arthritis, sports injuries, frequent sports injuries, cyclophosphamide, Methotrexate, diclofenac, voltaren, Relafen, children’s health care, educational materials, pediatric resources, public health education, health education, school nurse materials, help for school nurses.
systemic lupus erythematosus
heel pain and collagen skin disorders
elevated white blood cell count differential
sensitivity specificity "positive predictive" "negative predictive"
juvenile rheumatoid arthritis