The patient’s unmet needs (PUN)
A young mother presents her six-year-old boy with the complaint that, for many weeks now, he has been waking regularly at night, complaining of pains in his calves and thighs. These usually ease-up enough for him to sleep once either parent has gently rubbed his muscles, but on occasion they have resorted to settling him down with a painkiller. He is fine in the day and he is otherwise fit and well. Examination reveals no abnormality, and you confidently diagnose ‘growing pains’. ‘That’s what my friend’s GP said about her little boy,’ interrupts the mum. ‘And he turned out to have leukaemia. So I’d like him tested.’
The doctor’s educational needs (DENs)
What are the key features of growing pains and how common are they? What is thought to be the cause?
Growing pains usually occur in younger children, and are equally predominant in girls and boys. They are characterised by aches and pains which are poorly localised in the lower limbs, usually the calves.1 There is usually no swelling or bruising. The pains typically occur at night and can disturb the child and indeed the whole household for nights on end. Parents are usually at the end of their tether by the time they reach the GP.
Growing pains is a historical term and these pains really have nothing to do with growing. Musculoskeletal pain in childhood is common – 16% of school-age children report limb pain.
The cause of acute musculoskeletal pain in children may be obvious, such as trauma, but more chronic disease is often harder to characterise and diagnose. In a child presenting with growing pains, it is important to exclude a more serious condition. A lot of symptoms will be non-specific, but some will be associated with serious systemic disease and distinguishing the serious cases from the rest of the growing pains demands skill and expertise from the GP.
Sometimes, the parent will give all the history, but older children can often describe their symptoms.
What are the important differential diagnoses?
As a general rule, mechanical joint pain is more likely to be acute and to be worse at the end of the day or after sporting activities. For example, Osgood-Schlatters disease is a mechanical enthesitis of the tibial tubercle and is usually much worse after exercise, such as running, and rarely causes night pain.
Inflammatory musculoskeletal pain will often be more nebulous and is worse in the mornings when the child gets out of bed. The joints will be stiff and feel better after use. Prolonged morning stiffness, swelling and constitutional symptoms such as fever, weight loss and fatigue will indicate an inflammatory condition.
More serious conditions to be considered and ruled out in preschool children are:
- neurological disease such as cerebral palsy
- juvenile idiopathic arthritis (JIA)
More serious conditions to be ruled out in young school-age children – five to 10 years – are:
- malignancy such as leukaemia
- irritable hip
- Perthes’ disease
- muscle diseases such as dermatomyositis.
More serious conditions to be ruled out in older children and adolescents are:
- slipped capital femoral epiphysis
- malignancy such as sarcoma
- osteochondritis dissecans (common in the knee)
What are the red flags that might alert the GP to one of the differential diagnoses?
Getting a description of the nature and time of the pain is a good start to the assessment of a child presenting with musculoskeletal pain.
- Red flags in a child with musculoskeletal pain include:
- Malignancy – ask about weight loss, fever and unremitting pain present day and night
- Infection such as osteomyelitis – there will be systemic symptoms and the child may be ill and limping or unable to walk
- Trauma – ask about injuries or whether they have fallen
- Systemic illness such as new onset diabetes can cause joint pain
- Unilateral, constant and very well localised pain
If any red flags are discovered, immediate referral is necessary.
Once you’ve taken a history and ruled out red flags, the assessment will search for identifiable and treatable causes of joint and muscle pains. A physical examination should be undertaken to assess the musculoskeletal system. Paediatric GALS (gait, arms, legs and spine) is a quick screening tool to assess the musculoskeletal system in children and is very useful in primary care.3
If any abnormalities are discovered using pGALS, then a more detailed regional examination of the child should be conducted. A general systemic examination might be necessary depending on the level of clinical suspicion and concern.
The diagnosis of growing pains is reached after more serious conditions have been ruled out. Generally, growing pains:
- Are not present at the start of the day
- Do not make the child unwell
- Tend to occur in the age range three to 12 years
- Do not cause the child to limp
- Do not limit their physical activities
- Do not affect the child’s motor system development or cause them to regress in their developmental milestones
- Are classically felt in the lower limbs, around the shins and ankles
- Do not cause any abnormalities on physical examination
Are investigations needed? What tests might the GP consider?
Investigation in primary care is usually not necessary – using the assessment described above, and with experience, it is possible to rule out serious disease and diagnose growing pains without any investigations. But, as in this case, some parents will find it hard to be reassured by their GP without some baseline investigations.
Baseline investigations which will rule out most serious diseases are:
- ESR and CRP
- U&E, liver function tests and bone enzymes
- Thyroid function
- Muscle enzymes including creatine kinase (which, if raised, suggests dermatomyositis)
- X-ray of any affected joints, although this is usually reserved for specialist care investigation because of the risks of radiation
If you have any doubt at all that the child may have a serious condition, promptreferral to a paediatrician or orthopaedic surgeon with an interest in paediatric conditions should be undertaken.
Has any specific treatment been shown to help or prevent growing pains? What is the prognosis for this condition?
The condition is self-limiting. Reassurance and explanation are important and the parent should understand that the condition can resolve without treatment, but this it can have a waxing and waning history with symptoms fluctuating over months or even years before settling. Clear instructions should be given to the parents to return to the GP if symptoms change. Simple analgesia and massage is also effective.
A useful information sheet on this can be downloaded here. 4
Dr Louise Warburton is a GPSI in rheumatology musculoskeletal medicine in Shropshire and a senior lecturer at Keele University.
1. Peterson HA. Leg aches. Pediatr clinc North Am 1977:24(4); 731-6
2. Sherry DD, Malleson PN. Nonrheumatic musculoskeletal pain, and idiopathic musculoskeletal pain syndromes. In: Cassidy JT, Petty RE, eds. Textbook of Pediatric Rheumatology. 4th ed. Philadelphia, Pa.: Saunders, 2001: 362-81
3. Foster HE, Kay LJ, Friswell M et al. Musculoskeletal screening examination (pGALS) for school-age children based on the adult GALS screen. Arthritis Rheuma, 2006; 55(5):709-16
4. Foster HE, Boyd D and Jandial S. Hands on: Practical advice on management of rheumatic disease. Growing pains. Autumn 2008. No 1. www.arthritisresearchuk.org. Accessed 15/03/13
Arthritis Research UK. www.arthritisresearchuk.org. Accessed 15/03/13.
Warburton L (ed). Musculoskeletal Problems in Primary Care; RCGP Publications. March 2012.