Orthopaedic Surgery - Growing Pains

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Basics

Growing pains are a common, benign, noninflammatory pain syndrome of childhood characterized by recurrent episodes of lower-extremity discomfort without objective musculoskeletal abnormalities.

Despite the name, the condition has not been shown to result directly from periods of rapid skeletal growth.

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Typical Pattern

The pain usually occurs after active days and is most prominent during the late afternoon, evening, or nighttime.

Children may occasionally awaken from sleep because of the discomfort.

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Resolution of Episodes

Each episode resolves completely.

The child is generally normal and pain free between episodes.

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Location

Symptoms occur predominantly in the lower extremities and may involve one or both legs.

Pain is usually vague rather than sharply localized.

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Frequency

Episodes occur unpredictably.

Pain-free intervals may last days, weeks, or even months.

Some severely affected children may experience symptoms almost daily.

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Physical Findings

Growing pains produce no persistent objective abnormalities.

There should be no focal tenderness, swelling, joint restriction, weakness, or limp.

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Synonyms

Other terms include benign nocturnal limb pains of childhood, leg aches, and night pains.

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Epidemiology

Growing pains are very common.

Approximately 15–36% of children are reported to experience symptoms consistent with this syndrome at some point.

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Age

The condition most commonly affects children between approximately 4 and 14 years of age.

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Sex

Girls may be affected slightly more often than boys.

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Risk Factors

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High Activity Level

Symptoms are frequently reported in otherwise healthy, highly active children.

Episodes may be more noticeable after days involving substantial running, jumping, or sports participation.

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Family History

A positive family history is common.

A parent or sibling has been reported to have experienced similar childhood pains in nearly 70% of cases in some series.

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Etiology

The precise mechanism remains uncertain.

The disorder has been proposed to represent a form of relative musculoskeletal overuse or stress-related pain in otherwise normal children.

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Possible Contributing Factors

Proposed contributors include increased physical activity, relatively reduced bone strength, altered pain perception, and a lower pain threshold.

None of these explanations completely accounts for the syndrome.

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Diagnosis

Growing pains are a clinical diagnosis of exclusion.

The history and examination must be typical, and findings suggesting infection, inflammatory disease, malignancy, neurologic disease, or structural orthopaedic pathology should be absent.

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Signs and Symptoms

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Relationship to Activity

Pain frequently occurs after periods of increased activity.

Symptoms most often develop in the evening or at night.

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Nocturnal Pain

Children may awaken because of discomfort, although they should return to normal function afterward.

Persistent morning pain is not typical.

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Duration

Individual attacks may last from several minutes to several hours.

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Laterality

Pain is commonly bilateral, although episodes may occasionally affect only one leg at a particular time.

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Character

The pain is generally diffuse, vague, and poorly localized, often involving the calves, thighs, shins, or region behind the knees.

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Severity

Pain intensity varies considerably.

Some children describe only mild aching, whereas others experience episodes severe enough to cry or awaken from sleep.

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Episodic Course

A characteristic feature is the presence of completely pain-free intervals.

This episodic pattern helps distinguish growing pains from many inflammatory, infectious, neoplastic, or structural disorders.

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Physical Examination

A careful examination is essential because growing pains should not produce abnormal findings.

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Observation of Gait

The child should be observed walking naturally, preferably before becoming aware that gait is being assessed.

There should be no limp, stiffness, guarding, or reluctance to bear weight.

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Palpation

The lower extremities should be palpated systematically.

Growing pains should not produce focal bony, muscular, or joint-line tenderness.

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Range of Motion

Range of motion of the hips, knees, and ankles should be full and symmetric.

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Hip Examination

Particular attention should be given to the hips because hip disease may initially present as vague thigh or knee pain.

Gentle internal and external rotation of the hip, sometimes called the roll test or log-roll test, should not produce guarding or restriction.

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General Findings

There should be no swelling, erythema, warmth, muscle wasting, weakness, neurologic deficit, or systemic illness.

Any such finding should prompt investigation for another diagnosis.

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Laboratory Tests

Routine laboratory testing is not necessary when the history and physical examination are entirely typical.

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Atypical Presentation

If the history is unusual or concerning, investigations may include a complete blood count and inflammatory markers such as ESR and/or C-reactive protein.

Further testing should be directed toward the suspected alternative diagnosis.

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Imaging

Routine imaging is unnecessary for classic growing pains.

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Plain Radiographs

Radiographs may be obtained when pain is persistently localized, unilateral, associated with trauma, or accompanied by an abnormal examination.

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Advanced Imaging

Bone scintigraphy or other advanced imaging may occasionally help localize an occult source of pain when the clinical picture is atypical.

MRI is often preferred when an occult infection, stress injury, tumor, or inflammatory condition is suspected.

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Differential Diagnosis

Because growing pains are a diagnosis of exclusion, important alternative causes of childhood limb pain include:

Legg-Calvé-Perthes disease, chronic or subacute osteomyelitis, leukemia, sickle cell disease, juvenile idiopathic arthritis, Lyme disease, Osgood-Schlatter disease in older children, restless legs syndrome, and muscle cramps.

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Other Concerning Diagnoses

Depending on the clinical setting, stress fracture, bone tumor, inflammatory arthropathy, infection, trauma, neurologic disease, and referred hip pain should also be considered.

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Red Flags

Findings that are inconsistent with typical growing pains include persistent unilateral pain, focal tenderness, swelling, warmth, morning stiffness, joint restriction, limp, weakness, fever, weight loss, fatigue, night sweats, or progressively worsening symptoms.

These findings require further evaluation.

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Treatment

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Reassurance

Once the diagnosis is reasonably established, the most important treatment is reassurance of the child and family.

The condition is benign and does not damage bones, joints, or muscles.

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Stretching

A regular stretching program may decrease the frequency of symptoms.

Useful stretches target the hamstrings, quadriceps, and calf muscles, particularly before bedtime.

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Home Program

The stretching program can usually be performed with parental supervision and does not require formal physical therapy.

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Activity Modification

Most children can remain active.

If symptoms become frequent or severe, temporary reduction of particularly strenuous activities may help bring discomfort into a tolerable range.

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Orthoses

In selected children with substantial foot pronation or other biomechanical abnormalities, shoe inserts or orthotic devices may be considered.

However, orthoses are not routinely required for children with otherwise typical growing pains.

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Physical Therapy

Formal physical therapy is generally unnecessary.

It may be helpful when flexibility is poor, symptoms persist despite a home stretching program, or another biomechanical problem is present.

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Medication

Simple analgesics may be used occasionally for troublesome episodes.

Examples include acetaminophen or NSAIDs when appropriate.

Continuous routine medication is usually unnecessary.

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Follow-Up

Children with a completely typical presentation generally require only limited follow-up.

Repeated visits may sometimes be useful when the diagnosis remains uncertain or when the evolving pattern of symptoms needs to be observed.

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Prognosis

The prognosis is excellent.

Growing pains almost always resolve spontaneously as the child matures, without permanent musculoskeletal consequences.

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Patient Monitoring

Parents should monitor the character, frequency, location, and timing of pain.

A simple symptom diary may be useful when episodes are frequent.

The stretching program can be continued, and activity may be adjusted according to symptom severity.

Reevaluation is appropriate if the pattern changes or if the child develops persistent focal pain, swelling, limp, fever, morning symptoms, weakness, or other objective abnormalities.