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Growing pains

Growing pains have no relation to growth.

Many children with non-specific aches and pains, including 'growing pains', are often found to have joint hypermobility, although not all hypermobile children are symptomatic.

The cause of growing pains is unknown.

The 'rules' are useful to consider and if the clinical presentation does not fit, then consider other diagnoses.

Growing pains occur in young children with lower leg aches, often in calves, feet and ankles, after periods of activity, and usually end of the day, or evenings and can wake children from sleep.

The term is often used when there is uncertainty about the diagnosis and care must be taken to not miss serious pathology, including malignancy. We suggest that the term is only used when the 'rules', as listed below, apply. Any concerns warrant referral to paediatrics.

Investigations may need to exclude malignancy (leukaemia), infection, inflammatory joint or muscle disease, or rickets.

The ‘rules’ of growing pains (please note - these are reassuring features). If the presentation does not fit the rules, then concern is warranted.

  • Age range 3–12 years.
  • Pains symmetrical in lower limbs and not limited to joints.
  • Pains never present at the start of the day after waking.
  • Child doesn’t limp.
  • Physical activities not limited by symptoms.
  • Physical examination normal (with the exception of joint hypermobility, flat feet).
  • Systemically well.
  • Major motor milestones normal.

Indications for concern and warranting referral (to paediatrics / paediatric rheumatology), include the following:

  • Systemic upset (red flags to suggest sepsis or malignancy – fever, malaise, anorexia, weight loss, raised inflammatory markers, bone pain, persistent or worsening night pain).
  • Abnormal growth (height and weight).
  • Abnormal developmental milestones and in particular:

Delay in milestones (especially major motor skills).
Regression of achieved motor milestones or other milestones.

  • Impaired functional ability (ask about play, sport, schoolwork, ‘clumsiness’).
  • Limping (intermittent or persistent).
  • Morning symptoms (other than tiredness after disturbed sleep).
  • Asymmetric joint pain or swelling that comes and goes, changes site (migratory) and is very responsive to NSAIDs, with evidence of streptococcal infection.
  • Widespread pain (such as upper limbs and back).
  • School absenteeism.

Investigations to consider include:

  • Full [complete] blood count (and film/peripheral smear) to help exclude malignancy or sepsis.
  • Acute phase reactants (ESR, CRP, ferritin). 
  • Streptococcal titres (consider rheumatic fever) in school-aged Maori or Pacific children.
  • Vitamin D and bone chemistry (consider rickets). 
  • Muscle enzymes (consider muscle disease).
  • Thyroid function tests.

Management of growing pains is essentially explanation and reassurance, advice on analgesia, footwear and when to come back and seek health care attention. Advise to use analgesia (paracetamol / acetaminophen) before bed time may help to pre-empt and prevent night waking. If the child does wake then massaging limbs may help. Supportive footwear (such as trainers/sneakers or sports shoes) may help to reduce episodes of pain.

A parent information leaflet for growing pains is available

There is a Top Tips for Growing Pains

The photographs below show flexible flat feet (i.e., with normal arches on tip toe) - a common feature in children with growing pains. Mobile medial arches may be also seen by extending the big toe when the child is standing or sitting.

 More information on growing pains is available.

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