Growing Pains

Key Points:

  • Lower extremity pain in the afternoon, evening or at night after activity
  • Child may wake at night with pain complaints
  • Most often bilateral
  • Can range from mild ache to severe pain
  • Clinical exam, x-rays and laboratory studies normal
  • Symptoms resolved by morning
  • Observation, local modalities, and occasional over the counter medications as needed
  • Responds to conservative management
  • Resolves with skeletal maturity

Description:

Growing pains is a term that refers to pain in the lower extremities of growing active children. It is accepted as a true clinical entity (Baxter, 1988; Bennie, 1994; Evans, 2004, 2008; Naish, 1951; Oster 1972; Pavone, 2011; Peterson 1986). However, this is a diagnosis of exclusion, therefore, all other potential diagnoses need to be ruled out. Pain can occur in lower extremities without joint involvement. Occurs most often on both sides, but one study demonstrated it to be unilateral in 15% of patients (Pavone, 2011). Most common time for discomfort is in the afternoon and evening, after activity during the day. Pain may also wake patient up at night (Naish, 1951; Oster, 1972; Pavone, 2011; Peterson, 1986).  Pain is relieved by local modalities such as massage, heat or cold application, or over the counter medications. Symptoms routinely resolve by the morning (Oster, 1972; Peterson, 1986), and the child resumes normal activity in between episodes (Naish, 1951; Pavone, 2011). Not associated with constitutional symptoms such as fever, malaise or change in appetite.

Epidemiology:

Most often occurs in children 2-12 years of age (Naish, 1951; Oster, 1972; Pavone, 2011). May come and go for years but resolves with skeletal maturity (Peterson, 1986). A Scandinavian study from 1972 showed prevalence in children 6-19 years of age of 13% for boys and 18% for girls (Oster, 1972).  An Australian study in 4-6 year olds demonstrated prevalence of 36% (Evans, 2004).

Clinical Findings:

No visual change in the appearance of the extremity. No swelling, warmth, erythema, bruising, atrophy, joint contracture or limp (Naish, 1951; Oster, 1972; Pavone, 2011; Peterson, 1986). No associated fever.  Muscles may be tender to palpation while in pain but patient often comforted by massage (Baxter, 1988; Naish, 1951; Pavone, 2011).

Imaging Studies:

Roentgenograms and laboratory values are routinely normal. Therefore imaging or laboratory studies may not be indicated if history and exam are highly consistent with growing pains (Naish, 1951; Oster, 1972; Pavone, 2011; Peterson, 1986). Unilateral growing pain is less common, but may occur (Peterson, 1986); therefore x-rays of the affected areas or screening blood tests to evaluate for inflammatory process may be considered (CBC w/differential, C-reactive protein, erythrocyte sedimentation rate).

Etiology:

The exact etiology is not precisely known. Fatigue of growing muscles may be the source of the pain considering the high activity level in young children (Bennie, 1994) and parental observation of episodes associated with increased activity (Evans, 2008).  The muscular fatigue theory is supported by more rapid resolution of symptoms in children who spend time with muscular stretching prior to activity (Baxter, 1988). An anatomic/mechanical theory was previously considered (Naish,1951) due to ligamentous laxity, planovalgus foot alignment, tibial torsion, and femoral anteversion. The association of these conditions as normal variations in growing children has discounted this theory. Emotional contribution to the etiology has also been considered due to concern for other night time emotional disturbances (Naish, 1951), changes in family dynamics, and association with abdominal pain and headaches. (Oster, 1972).

Treatment:

Education of parents/caregivers is the mainstay of “treatment” (Pavone, 2011). Family and patient can be reassured this is common problem in growing active children. Being alert to a change in the nature of the pain is important. If the pain becomes unilateral or is associated with systemic symptoms, then re-evaluation is needed.

Local modalities such as massage, heat or cold application in the form of heating pad, ice pack, or ointments commonly improve muscle discomfort. If a child has difficulty falling asleep, occasional over-the-counter medication such as acetaminophen or ibuprofen may be utilized (Evans, 2008; Naish, 1951; Noonan, 2004; Pavone, 2011; Peterson, 1986).

Complications:

No long term adult musculoskeletal abnormality has been associated with growing pains as a child. Episodes resolve by skeletal maturity (Evans, 2008; Peterson, 1986).

If the pain characteristics change and the family does not seek medical evaluation, a different etiology of the pain such as inflammatory arthritis, musculoskeletal infection or tumor may be the source. Once the child is seen by a medical provider, prompt evaluation and treatment is appropriate. (Pavone, 2011; Peterson, 1986).

References:

  1. Baxter MP, Dulberg C. “Growing pains” in childhood – a proposal for treatment. J Pediatr Orthop. 1988;8(4):402-406.
  2. Bennie PB. Growing pains.  Arch Pediatr. 1894; 1:337-347.
  3. Evans AM, Scutter SD. Prevalence of “growing pains” in young children. J Pediatr. 2004; 145:255-258.
  4. Evans AM. Growing pains: contemporary knowledge and recommended practice. J Foot Ankle Res. 2008; 1:4: 1-5.
  5. Naish JM, Apley J. ‘Growing pains’: a clinical study f non-arthritic limb pains in children. Arch Dis Child. 1951; 26:134-140.
  6. Noonan KJ, Farnum CE, Leiferman EM, et al. Growing pains: are they due to increased growth during recumency as documented in a lamb model?  J Pediatr Orthop. 2004;24(6):726-731.
  7. Oster J. Recurrent abdominal pain, headaches and limb pains in children and adolescents. Pediatrics 1972; 50:429-436.
  8. Oster J, Nielsen A. Growing pains – a clinical investigation of a school population. Acta Pediatr Scand. 1972; 61:329-334.
  9. Pavone V, Lionetti E, Gargano V et al. Growing pains: a study of 30 cases and a review of the literature. J Pediatr Orthop. 2011;31(5):606-609.
  10. Peterson H. Growing pains. Pediatr Clin N Am. 1986;33(6):1365-1372.

Top Contributors:

Terri Cappello, MD