doi:10.1111/j.1440-1754.2006.00869.

ORIGINAL ARTICLE

Musculoskeletal ndings in obese children

Ana L de S Pinto, Patricia M de Barros Holanda, Ari S Radu, Sandra MF Villares and Fernanda R Lima
Rheumatology Division, School of Medicine, University of So Paulo, So Paulo, Brazil

Aim: A cross-sectional study was conducted to explore osteoarticular alterations in obese children.
Methods: Twenty-ve boys and 24 girls (mean age: 10.8 2.07 years) with a body mass index (BMI) above the 95th percentile were compared
with 28 boys and 19 girls (controls, mean age: 10.4 2.3 years) with a BMI below the 80th percentile.
Results: A higher frequency of at least one osteoarticular manifestation was observed in obese patients (55%) compared with the control
group (23%) (P = 0.001). A statistically signicant association was also found between obesity and lower back pain, genu valgum, genu
recurvatum and tight quadriceps. Fibromyalgia tender points (=11) were present at similar frequency in both groups (obese: 3/38 (9%) vs. control:
1/48 (2%)).
Conclusion: The present data suggest that obesity has a negative impact on osteoarticular health by promoting biomechanical changes in
the lumbar spine and lower extremities.
Key words:

arthralgia; back pain; obesity; physical activity.

The prevalence of obesity has been rapidly increasing in recent

years.1 In children aged 611 years, the prevalence of obesity has
doubled from 5% to 11% and in the group aged 1217 years the
prevalence of obesity has more than doubled for boys (5% to 13%)
and has almost doubled for girls (5% to 9%).1 In Brazil, the latest
national survey (1998) reported that the prevalence of obesity in
children from the South and South-east of Brazil was 6.1% for males
and 5.4% for females.2 A previous study3 provided evidence that the
high prevalence of the childhood obesity might be a result of environmental and cultural changes related to physical inactivity in daily
life.
Obese children and adolescents are at increased risk for adult
obesity and are more likely than their lean counterparts to experience signicant short-term health problems such as hyperlipidemia,
hypertension, glucose intolerance and sleep disturbances.4,5
It is known that obesity involves a risk of musculoskeletal pain in
adults.68 Previous studies have implicated adult obesity as a risk
factor for rheumatological disorders such as back pain, leg pain and
osteoarthritis.68 Yunus studied a possible relationship between BMI
Key Points
1 Obese children present a high frequency of lower limb pain.
2 Low back pain is a common complaint in obese children.
3 Musculoskeletal structural abnormalities, such as genu valgum,
were found in the exam of this sample.
Correspondence: Dr Fernanda R Lima, Rheumatology Department,
School of Medicine, Av. Dr. Arnaldo, 455, 3 andar, 01246-903, So Paulo,
Brazil. Fax: +55 11 3066 7492; email: reumato@edu.usp.br
Accepted for publication 11 January 2006.

Journal of Paediatrics and Child Health 42 (2006) 341344

2006 Paediatrics and Child Health Division (Royal Australasian College of Physicians)

and features of the bromyalgia syndrome.9 Considering this possible relationship, we speculate if the obese children population could
present a higher frequency of tender points, a typical feature of
bromyalgia.10
To our knowledge, no study evaluating the relationship between
BMI and tender points in obese children has been reported. In addition, data on the relationship between BMI and chronic pain and
other signs and symptoms affecting the locomotor system of obese
children, in whom a persistent loading of the musculoskeletal system is present, are limited.
Thus, the purpose of this study was to explore osteoarticular
alterations in obese children.

Materials and Methods

Obese Group
The subjects, 25 boys and 24 girls aged 714 years, were selected
from a Childhood Obesity Clinic performed by the Endocrinolgy Division of the University of So Paulo. They were classied as obese
when their body mass index (BMI) was equal to or greater than the
sex-, race- and age-specic 95th percentile from the rst National
Health and Nutrition Examination Survey.11 Children with some kind
of movement restriction, any long-term treatment, with any systemic disease other than obesity, and who practised any routine
exercise or sport were excluded from the sample.

Control Group
From an initial sample followed by the Sports Medicine Team of the
Department of Rheumatology of the same University and evaluated
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Child obesity and locomotor system

in a pre-participation examination, 28 boys and 19 girls aged 7

14 years, with a BMI below the 85th percentile, were recruited to
serve as a control group. Children who had received any long-term
treatment, who had any systemic disease and who had practised
any routine exercise or sports were excluded from the sample.
As part of a school program, both groups, obese and control,
participated in physical education classes for a total of 100 min a
week.

AL de S Pinto et al.

Results
Baseline Data
Table 1 presents the baseline data. There were no signicant differences between groups regarding age or height. Obese children
were signicantly heavier than controls.

Osteoarticular Symptoms and Signs

Protocol
The protocol was approved by the Ethics Committee of the University of So Paulo School of Medicine, and written consent was
obtained from the parents of each subject.
The childrens mothers and the children completed a questionnaire standardised in our clinic with minor modications12 that
included age, medication, diseases and symptoms of persisting pain
in the locomotor system. To examine the degree of musculoskeletal
pain, the subjects were asked about the frequency of pain. We considered this symptom only if the child answered that the pain was
present at least once a week during the last month.
Height was measured to the nearest 1.0 cm using a stadiometer.
Weight was measured to the nearest 0.2 kg with a standard physicians beam scale. Body mass index (BMI) was calculated as body
weight in kilograms divided by height in meters squared (kg/m2).
All subjects received a complete musculoskeletal examination in
a private setting while dressed in light clothing. All the children were
examined by the same assessor, a paediatric rheumatologist. The
posture examination was conducted with the patient standing up.
The ideal stance occurs when the joints of the lower limbs and feet
are symmetrically aligned, with the weight-bearing line passing
through the anterior superior iliac spine, the patella and the second
metatarsal. The presence of scoliosis, lumbar hyperlordosis, genu
varum, genu valgum and genu recurvatum was observed, according
to the conventional orthopaedic examination,13 from behind and
from the side in the erect posture.
With the patient in the supine position, hamstring exibility was
assessed with the hip positioned at 90 and with the knee extended.
The hamstring was considered tight if the knee extension was inferior to 15.13
With the patient in the prone position, quadriceps exibility was
assessed with the knee fully exed, with the anterior aspect of the
thigh in contact with the supporting surface. The quadriceps was
tight if the calcaneus did not reach the buttock region.13
The tender points, dened by diffuse tenderness at discrete
anatomic locations, were evaluated according to the American
College of Rheumatology 1990 criteria for the classication of
Fibromyalgia.10

Data Analysis
Baseline continuous data (age, height, weight, BMI) were expressed
as mean SD and the two groups were compared by the Students
t-test. The chi-square and Fisher exact tests were applied to compare groups regarding categorical variables (back pain, lower and
upper extremity pain, scoliosis, lumbar hyperlordosis, genu varum,
valgum and recurvatum, tight hamstrings, tight quadriceps). The
level of signicance was set at 0.05.
342

At least one osteoarticular manifestation was observed in 27/49

(55%) of the obese children compared with 11/47(23%) of the control
group (P = 0.001). No difference was found regarding upper extremity pain, scoliosis, genu varum, lumbar hyperlordosis and tight hamstring. A statistically signicant association was found between
obesity and lower back pain, lower extremity pain, genu valgum,
genu recurvatum and tight quadriceps, as shown in Table 2.
Fibromyalgia tender points (11) were present at similar frequency in both groups (obese: 3/38 (9%) vs. control: 1/48(2%))
(P = NS).

Discussion
Obesity signicantly increases the risk of developing numerous medical conditions, including hypertension, stroke, respiratory disease,
type 2 diabetes, gout, osteoarthritis, certain cancers and various
musculoskeletal disorders, particularly of the lower limbs and feet.14
Our ndings are consistent with the hypothesis that obesity is an

Table 1 Baseline characteristics and comparison between the obese

group and control group

Age (years)
Height (m)
Weight (kg)
BMI (kg/cm2)

Obese group
(n = 49)
Mean SD

Control group
(n = 47)
Mean SD

P-values

10.8 2.07
145.57 22.38
67.21 16.93
30.1 4.32

11.1 2.2
142 12.4
35.42 8.55
17.3 1.91

NS
NS
<0.0001
<0.0001

Table 2 Symptoms and signs found in the obese group and the control
group
Obese group
Symptoms
Back pain
Lower extremity pain
Upper extremity pain
Signs
Scoliosis
Genu valgum
Genu recurvatum
Lumbar hyperlordosis
Tight hamstrings
Tight quadriceps

Control group

15 (30.6%)
22 (44,8%)
1 (2%)

1 (2%)
9 (19.1%)
0

0.0002
0.0089
NS

5 (10.2%)
27 (55.1%)
12 (24.2%)
18 (36.7%)
37 (75.5%)
22 (44.9%)

9 (19.1%)
1 (2%)
1 (2%)
13 (27%)
32 (68%)
10 (21.2%)

NS
<0.0001
0.001
NS
NS
0.01

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AL de S Pinto et al.

important factor associated with musculoskeletal pain in children.

Relative to their non-obese similar aged counterparts, obese children exhibited signicantly higher complaints of pain in the locomotor system.
It is suggested that excessive increases in weight-bearing forces
caused by obesity may be detrimental to the lower limbs and feet.15
In the present study, we measured the prevalence of pain, which
was dened as frequent pain during the last month, in the arms,
trunk and legs. The most common pain was found in the legs. Huang
et al.16 reported that BMI was associated with pain at each joint in
the leg, foot, ankle and knee in Japanese-American post-menopausal women.
Back pain is a common complaint, reported to occur in up to 85%
of the adult population.17 For many decades, it was believed to be
relatively rare among children and adolescents, but recent studies
have reported a 2654% prevalence of back pain among school children.18,19 Several factors have been reported to be risk factors for
the development of back pain in a child, among them obesity and
physical inactivity and increased hours of computer and TV use.20,21
In adults, it has been theorised that the abnormal mechanical loads
placed on the spine of the obese patient cause back disorders.
Although the association between low back pain and body weight
has been well studied, little is known about how obesity affects
functional status in spine patients.22
A common cause of leg pain in adults is knee and hip osteoarthritis. Osteoarthritis of these joints is a major cause of morbidity and
disability in the elderly6 and this problem is increasing with the current ageing of the population in Western societies. Evidence is growing for the role of systemic factors, such as genetics, diet, estrogen
use and bone density, and local biomechanical factors, such as muscle weakness, obesity and joint laxity.7 It is possible that the persistence of obesity from childhood and adolescence into adulthood
may result in the development of osteoarthritic symptoms in progressively obese individuals.7 Although chronic leg pain in children
is highly prevalent,21 in our sample, obese children presented a
higher frequency of leg pain complaints than our control group.
Unfortunately, we did not perform a radiological investigation to
compare joint space narrowing of the knee and hip between groups,
what could reect the overall volume of the joint cartilage, which in
adults represents an early nding of osteoarthritis.
Bone remodels in response to the loads exerted on it. During
childhood, the physis tend to compensate for these loads but are
also structurally weaker than bone and, theoretically, may be
deformed.23 This is why obese children, during the phases of major
physiologic varus (1820 months) or valgus (3 years) of the knees,
tend to display a greater extent of these deformities. This may also
be the case in permanent deformities such as Blount disease or
slipped capital femoral epiphysis. Both of these conditions have
been associated with obesity and tend to have bilateral involvement.24 Some authors have suggested that excessive increases in
weight-bearing forces caused by obesity may be detrimental to the
lower limbs and feet.23,25 In our study, we found a higher frequency
of postural changes such as lumbar hyperlordosis, genu valgum and
genu recurvatum in the obese group than in the control group.
Whether these changes in spine and leg structure may develop into
symptoms if excessive weight gain was to continue is speculative
and requires further research. Moreover, investigation of other possible causes, such as spondylolysis and spondylolistesis, will certainly contribute to the understanding of the nature of lower back
Journal of Paediatrics and Child Health 42 (2006) 341344
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Child obesity and locomotor system

pain in child obesity. Data on the relationship between BMI and

chronic pain are limited. In a population-based questionnaire study,
non-specic low back pain was positively correlated with BMI among
persons aged 1241 years.26 A relationship between BMI and other
forms of chronic pain, for example, headaches, has also been
reported after adjustment of data for age, education, exercise and
smoking.27 McKendall and Haier28 found decreased mechanical pain
thresholds in healthy pain-free obese subjects, as assessed by a
constant force applied to the nger. In order to nd any relation
between obesity and pain threshold in our sample, we looked at the
frequency of bromyalgic tender points in both groups, but we
found no difference between them.
In conclusion, these data suggest that obesity has a negative
impact on the osteoarticular health of children by promoting biomechanical changes in the lumbar spine and lower extremities and
sleep disturbances. The cause and effect relationship cannot be
determined from this cross-sectional study, and prospective observational studies will be required to establish such relationship.

Acknowledgements
This study was supported in part by a grant from FAPESP, a So
Paulo State Research Grant Foundation, project number 01/13326-4.

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2006 Paediatrics and Child Health Division (Royal Australasian College of Physicians)