Understand | diagnose | change

Whether you are looking to learn more about paediatric musculoskeletal problems, or are involved in the care of children, then PMM and PMM-Nursing will help you change your clinical practice for the better. PMM is free and open to all !

Night Pains

Daniel is a 4 year old boy who attends the GP with a 6 month history of waking up at night in pain. His mother says that he screams and cries, and says the pain is in both his legs, from his thighs to his shins. He asks his mother to rub his legs and this sometimes helps to calm him down. He eventually goes back to sleep after up to an hour. Sometimes his mother can predict that Daniel will wake up (e.g., if he has had a particularly active busy day). His mother is exhausted as she also has a 3 month old baby and she is not sure if Daniel is ‘playing up’ because of the attention she is giving his sister.

Daniel is reported to wake up in the morning seemingly well. There has been no observation of limp.  Daniel is very active and likes running. He never has pain throughout the day, and his mother has not noticed any joint swelling. There is no morning stiffness. He reached all his milestones at the appropriate age, and there have been no concerns about regression of milestones.  

He has a past medical history of otitis media and asthma. He lives with his mother, stepdad and baby sister. He is due to start school in September.

Examination – the GP performs a pGALS musculoskeletal examination, which shows hypermobility and flat feet, but normal arches on tip toe. There are no other abnormalities.

Are there any red flags or concerns from the history?

Pain waking the child at night is usually a concern, but can be due to growing pains if there are no other red flags and criteria for growing pains are met (see rules of growing pains).  

What is the diagnosis? What leads you to this conclusion?

Pain waking the child at night is usually a concern, but can be due to growing pains if there are no other red flags and criteria for growing pains are met (see rules of growing pains).  

The GP reassures Daniel and his mother, explains that no further investigations are needed.

The diagnosis of growing pains can be confidently made as Daniel has a typical history of symmetrical pains in the lower legs, no daytime symptoms, no limp, no red flags and a normal examination.

However, caution is needed and the 'rules of growing pains' must be met.  Any atypical features should warrant investigation and prompt referral to the appropriate specialist.

The family should be advised if Daniel becomes unwell, develops a limp, day time symptoms or the pains are asymmetrical. 

What are the rules of growing pains?

The rules of growing pains can be found here.

How would your differential have changed if Daniel had been stiff in the mornings and had been asking to be carried down to breakfast?

You would be concerned about inflammatory symptoms, and should consider Juvenile Idiopathic Arthritis (JIA) as a likely differential.

If he had restricted hip movement, what would be your differential diagnosis?

Limitation and pain on hip rotation is always a concern. In this age group, consider Perthes disease and arrange an urgent hip X-ray. Infection, inflammation and malignancy must also be considered (See red flags). 

What tests would be appropriate with morning stiffness, joint swelling & joint pain

Arrange urgent review by appropriate specialist, with urgent x-ray and blood tests to exclude infection, malignancy and inflammatory arthritis.

What motor milestones would you expect at the age of 4?

Gross motor – walking, climbing and managing stairs.

Fine motor and vision – holding pen with appropriate grip. Starting to manage zips and buttons independently. No visual concerns.

Are Daniel’s flat feet and hypermobility relevant? Are they normal? Would a referral be beneficial, and if so, who to?

Flat feet and hypermobility are common in this age group. The majority will resolve and not require any intervention. If there is significant pain, then consider referral to paediatric physiotherapy.

Well fitting, supportive shoes can be helpful. 

What analgesia would be appropriate ?

Simple analgesia such as paracetamol (acetaminophen) or Ibuprofen. 

Leg massaging can also be helpful as well as heat packs.

Growing pains are often predictable after times of being physically active. Sometimes a warm bath in the evening and analgesia before bedtime, after especially physically active days, can help to prevent night waking.  

Advice for parents to manage growing pains is available.