Previous sections in this text clearly demonstrate the large percentage of healthcare visits that are attributable to musculoskeletal conditions. Most of the data used to establish these estimates concern adult patients. Unfortunately, there is significantly less information regarding the burden of these conditions in young patients.

Studies, however, do support that pediatric musculoskeletal conditions similarly account for a significant portion of visits to medical providers. For instance, de Inocencio reported that greater than 6% of total visits to pediatric clinics were for musculoskeletal pain.1 Schwend reported that approximately one third of pediatric medical problems are related to the musculoskeletal system.2 In a population-based study in Ontario, Canada, Gunz reported that 1 in 10 children made a healthcare visit for a musculoskeletal problem and that 13.5% of all visits for musculoskeletal disease were made by patient’s age 0 to 19 years.3 Four in 1,000 children are reported by parents as having difficulty with activities of daily living due to musculoskeletal conditions. A search of the National Health Interview Survey (NHIS) child sample revealed that musculoskeletal conditions accounted for 1.6% of parent-reported health conditions in 73.5 million healthcare visits for children and adolescents age 0 to 17 years in the US from 2013 to 2015. This proportion was greatest at 2.4% in the 14- to 17-year-old age group. (Reference Table 7C.0 PDF CSV)

The evaluation and treatment of these pediatric musculoskeletal conditions resulted in approximately 94.8 million missed school days per year from 2013 to 2015, accounting for 27.5% of all missed school days. Musculoskeletal conditions are surpassed only by respiratory infections and developmental delay as a cause of missed school days. Children aged 5 to 9 years old missed the highest number of school days due to musculoskeletal pain. (Reference Table 7C.0.1 PDF CSV)

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Children with musculoskeletal conditions also commonly have other medical problems. According to the National Health Interview Survey from 2013 to 2015, these are most commonly respiratory conditions followed by developmental delay. Of children with musculoskeletal conditions, 48% also have a diagnosed respiratory condition and 36% have developmental delay. (Reference Table 7C.0.2 PDF CSV)

Despite the significant contribution made by musculoskeletal conditions in the total US healthcare burden, research for pediatric musculoskeletal conditions is grossly underfunded. Of the $3.25 billion in National Institutes of Health (NIH) research funding for all pediatric conditions in 2013, only $46.8 million, or 1.4% of total pediatric medical research funding, went toward pediatric musculoskeletal research. Even under the umbrella of funding specifically for musculoskeletal research, pediatric-specific research is under-represented. Of the $424.4 million in funding for the National Institute of Arthritis and Musculoskeletal and Skin Disease (NIAMS) in 2013, this same $46.8 million represented only 11% of total musculoskeletal research dollars.4 

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CONDITIONS

In order to perform a comprehensive review of the burden of musculoskeletal disease in children and adolescents, all conditions that are direct musculoskeletal diagnoses or have musculoskeletal implications were considered for this section. This chapter was divided into separate clinically relevant sections to better understand the burden of each. These sections include musculoskeletal infections, deformity, trauma, neuromuscular conditions, syndromes with musculoskeletal implications, sports injuries, neoplasms, skeletal dysplasias, rheumatologic conditions, medical problems with musculoskeletal implications, and pain syndromes.

DATA

Healthcare visits and hospitalization data are derived from diagnostic codes for each of the conditions presented. These codes are available in the ICD-9-CM Codes section of this topic. Total healthcare visits are the sum of cases seen in physicians’ offices (National Ambulatory Medical Care Survey), outpatient clinics (National Hospital Ambulatory Medical Care Survey), emergency departments (Nationwide Emergency Department Sample), and hospital discharges (Nationwide Inpatient Sample). The largest database used is the Healthcare Cost and Utilization Project (HCUP) Nationwide Emergency Department Sample (NEDS), which estimates approximately 32.5 million weighted visits of children and adolescents through the age of 20 years. These four databases were analyzed for the ages 0 through 20 years, with subsets of data by age groups under 1 year, ages 1 to 4 years, 5 to 9 years, 10 to 13 years, 14 to 17 years, and 18 to 20 years.

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Each database includes multiple variables to define diagnoses, ranging from three possible diagnoses in the physicians’ office and outpatient clinic data sets to 25 possible diagnoses in the HCUP National Inpatient Sample (NIS) database. If a diagnosis code is listed in any of the possible diagnosis variables, the record is coded as presenting with that condition. If the diagnosis code is listed in the first diagnosis variable, it is coded as the primary diagnosis. However, the databases do not permit diagnostic verification. The first diagnosis listed may not be the primary reason for the visit, but a contributing cause. Further, there is the potential for overlap in diagnosis of related conditions. It is also possible diagnoses codes used for reimbursement purposes may be inaccurate. Therefore, these numbers provide only a guide to the impact of major childhood musculoskeletal conditions.

Injuries include two categories: sports injuries and injuries due to a traumatic event. Sports injuries are identified by type of sports activity using the United States Consumer Product Safety Commission’s National Electronic Injury Surveillance System (NEISS), with annual injuries averaged across the years of 2014 to 2016. Because sports injuries cases are not analyzed by ICD-9-CM codes, they may duplicate trauma injury cases cited from the previously discussed databases.

• 1. de Inocencio J: Musculoskeletal pain in primary pediatric care: Analysis of 1,000 consecutive general pediatric clinic visits. Pediatrics 1998;102(6):E63.
• 2. Schwend RM, Geiger J: Outpatient pediatric orthopedics: Common and important conditions. Pediatric Clinics 1998;45(4):943-971.
• 3. Gunz AC, Canizares M, Mackay C, Badley EM: Magnitude of impact and healthcare use for musculoskeletal disorders in the pediatric: A population-based study. BMC Musculoskeletal Disorders 2013;13:98.
• 4. US Department of Health and Human Services, National Institutes of Health (NIH) Research Portfolio Online Reporting Tools (RePORT). http://report.nih.gov/fundingfacts/fundingfacts.aspx  Accessed January 5, 2015.