Growing Pains

Case

The mother of a four year old girl brings her to the office with the chief complaint that for the past three nights the child has awaken from sleep with pains in her legs. Your exam is normal.. How should you further evaluate this patient?

Introduction

Growing pains are a common pediatric disorder with an incidence of about 15%. It is most common from 3-5 years of age, but may be seen up to 9 years of age. There is a greater incidence in girls.

Symptoms usually are pains that occur at the end of the day or awaken the child from sleep. Most often the pains are bilateral and usually localized to the thighs or calves and do not involve the joints. Rarely, there may be pains in an upper extremity. The symptoms do not interfere with activities during the daytime. The symptoms are intermittent with periods of days or weeks without any pain.

Physical examination is normal without any evidence of trauma, joint swelling, erythema, decreased range of motion, limp, or tenderness. Evaluations, including radiographs and ESR, are normal.

While growing pains may be benign, physicians should be on the lookout for more serious conditions.

Etiology

  1. Multiple theories including fatigue, anatomic or postural abnormalities, and consistent overuse of affected muscles.  A precise etiology has yet to be determined. 
  2. “Growing pains” may be a misnomer, as the pains do not occur primarily during times of rapid growth.  Moreover, children growing rapidly do not appear to suffer from growing pains more than others. 
  3. Growing pains do appear to be associated with other recurrent pain issues, such as headache or abdominal pain.  This may be related to psychosocial factors or issues related to a child’s pain threshold. 

Features

  1. Episodic in nature, occurring monthly for at least three months with pain-free periods.
  2. Children of preschool or elementary school age
  3. Bilateral thigh or calf pain, primarily in lower extremities.  NO joint involvement.
  4. Pain occurs mostly at night with relatively rare daytime events.  The pains may awake children during the night.
  5. Children do not have any limitations of activities.
  6. Physical exam reveals no focal findings or deficits. 

Differential Diagnosis

  1. Trauma – elicit with history
  2. Tumors – no investigation necessary if pain consistent with growing pains.  If pain is unilateral, increasing in severity, or associated with palpable mass, further investigation is warranted.  Focal pain on exam usually present.
  3. Osteomyelitis – would expect fever, infection
  4. Hypermobility Syndrome- pain usually in the joint. 
  5. Nocturnal cramps- parent may feel a tightness in the muscle.
  6. Ostoid osteoma- benign tumor with night time pain in the bone. Radiograph may be normal but bone scan may show abnormality. Focal pain on exam usually present.

Treatment

  1. Treatment should be conservative due to benign nature of condition.
  2. Stretching, massage, or low dose Tylenol or Motrin may help.  One study on stretching found that it resulted in more rapid resolution of symptoms. s
  3. Parents should be reassured that the pains will improve within a year or two of onset. 

Reference

  1. Baxter MP Dulberg C. “Growing pains” in childhood—a proposal for treatment. J Pediatr Orthop 1988; 8:402.
  2. Cassidy JT. Progress in diagnosis and understanding chronic pain syndromes in children and adolescents. Adolesc Med 1998; 9:101.
  3. Evans AM, Scutter SD. Prevalence of “growing pains” in young children. J Pediatr 2004;145:255.
  4. Hashkes PJ, Friedland O, Jaber L, et al. Decreased pain threshold in children with growing pains. J Rheumatol 2004; 31:610.
  5. Oster J. Growing pain. A symptom and its significance. (A review). Dan Med Bull 1972; 19:72.
  6. Szer, Ilona. Are those limb pains "growing" pains. Contemporary Pediatrics. March 1989.

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