Most pediatricians and general practitioners – in
their day-to-day office practice – often come across children
complaining of pain in their legs. These pains may sometimes point to
serious underlying conditions such as malignancies, infections or
injuries. However, majority of the cases may be due to ‘growing pains’,
that have a benign and self-limiting course .
Growing pains, though considered benign, can cause
considerable anxiety in the parents. Sometimes, the child wakes up in
the middle of night with extreme agony, complaining of severe pain in
the legs. There are no symptoms in the morning and pediatrician finds no
abnormality on physical examination . The pediatrician may be in a
dilemma; should parents be simply reassured or the child has to be
This article reviews the current knowledge regarding
the diagnosis, etio-pathogenesis and management of this fairly common
but perturbing condition.
Growing pains are typically intermittent, nocturnal
and poorly localized, usually occurring once or twice per week - though
there is never a regular pattern. Children suffering from ‘growing
pains’ are characteristically well without any physical problems,
despite severe pain experienced in the night. Night awakenings are
common but not an essential feature. The usual age group is 4-14 years
with equal gender preponderance [1-3]. The diagnostic criteria given by
Naish and Apley  are: intermittent lower limb pains for at least 3
months duration, not specifically located in the joints, and of
sufficient severity to interrupt sleep. The definition provided by
Peterson  guides clinicians better, and has several inclusion as well
as exclusion criteria (Table I). Growing pains is
essentially a clinical diagnosis and laboratory investigations or X-rays
are unnecessary [2,6,7].
TABLE I Diagnostic Criteria for Growing Pains
Characteristics of pain
Intermittent pains once or twice per
Pain, that is persisting or increasing in
rarely daily, totally pain free in
episodes; individual episodes lasting for
min to 2 hours
Usually in the muscles of calf, sometimes
a) Pain involving joints
anterior thigh muscles, shins and
b) Pain occurring only in one limb
fossa and affecs both limbs
In the evening and nights
Daytime pain and Nocturnal pain that
persists till next morning
Signs of Inflammation
Though diagnosis of growing pain seems easy; there
may be a danger of over-diagnosis, if leg pains due to other conditions
are not kept in mind [5,7,8]. Entities mimicking growing pains may be
grouped under five broad headings (Box I) as follows:
BOX I Differential Diagnosis of Growing
Inflammation of Soft-tissue or bone due to
sports injuries or accidental injuries or battered child
syndrome, Osgood-Schlatter disease, Chondromalacia Patella
Osteomyelitis, Septic arthritis, Cellultis
and soft tissue abscess
Benign: Osteoid osteoma, Unicameral cyst,
Fibrous dysplasia, Aneurismal bone cyst, Gaint cell tumor,
Histiocytosis X and Osteochondroma,
Malignant: Osteosarcoma, Ewing’s sarcoma,
Leukemia and neuroblastoma
Developmental and Congenital
Slipped capital femoral epiphysis,
Hypermobile joints, Limb deformities such as genu valgum, flat
foot, Discoid lateral meniscus, Patellar subluxation
Legg-Calve-Perthes disease, Osteochondritis
dissecans, Sickle cell crisis, Amplified musculoskeletal pain
syndromes, Restless leg syndrome, Juvenile idiopathic arthritis
Injury related leg pains: History is obvious, if
there is any trauma, and usually the pain is localized. However, history
may not be that obvious in cases of non-accidental trauma or Battered
child syndrome; presence of injuries of different ages and their
inappropriate explanation may be the clue. Osgood-Schlatter disease is
characterized by pain over the tibial tubercle, usually in athletes and
more common in boys between ages 10-15 years. Chondromalacia Patella or
idiopathic adolescent anterior knee pain syndrome (also known as
Runner’s knee), on the other hand, commonly affects adolescent girl
athletes doing a lots of running .
Infections: There are usually systemic features
such as fever and toxicity. Localized tenderness, swelling and erythema
at the site of pain may be found on examination.
Tumors: Benign tumors, which produce pains in
leg, are usually associated with swelling and are well localized. Pain
in Osteoid osteoma can cause night awakening, but it is persistent and
gradually increasing in severity as opposed to intermittent painful
nights in growing pains .
Malignant tumors that can cause leg pain are
associated with systemic features such as fever and weight loss.
Osteosarcoma can present with deep bone pain with night awakening, but
there is usually a palpable mass .
Slipped capital femoral epiphysis may present as knee
pain due to referred pain along the course of obturator nerve. Usually,
patients with this disorder have some limp and have externally rotated
lower limb and restriction of movements at hip .
Hypermobile joints can produce knee pain, that is
worse after activity and relieved by rest. Hypermobile joints have
abnormally increased range of motions and may be assessed with the
Beighton scale .
Legg-Calve-Perthes disease may present as referred
pain in knee, but there is usually associated limp and restriction of
movements in hip. Osteochondritis dissecans often presents with vague
knee pain. However, localized tenderness over medial femoral condyle may
be elicited on careful examination. The leg pain in sickle cell anemia
is persistent in nature. Other characteristic features of sickle cell
anemia will be difficult to miss by careful history and physical
There are two major forms of Amplified
Musculoskeletal Pain Syndromes (AMPS); Diffuse AMPS and Localized AMPS
. Diffuse AMPS, also known as Juvenile primary fibromyalgia syndrome
(JPFS), reveals well defined tender points, and usually affects older
child or adolescent with a female preponderance. These children look
debilitated; have disturbed personality and daytime symptoms .
Localized AMPS, also known as Complex regional pain syndrome (CRPS), is
characterized by ongoing burning pain in leg subsequent to an injury or
other noxious event. Other characteristic features include allodynia,
hyperalgesia and autonomic dysfunction .
Restless leg syndrome (RLL) may sometimes be confused
with growing pains as both these conditions tend to manifest during the
evening hours and are related to discomfort in the legs. However, the
uncomfortable feeling in the legs in RLL is associated with an
irresistible urge to move the legs, worsened by rest and relieved by
movements such as walking or stretching (only as long as motion
continues) [10,11]. Juvenile Idiopathic Arthritis may present as leg
pains initially, where minimal joint involvement may be missed. The key
here is the persistent nature of pain and morning symptoms .
Presence of following Red flag signs in a child with
leg pain should alert a clinician for further investigations [8,9]: (i)
involvement of joints, (ii) systemic involvement, (iii)
persistent pain or daytime pain or pain that is localized, and (iv)
Prevalence And Natural History
It is believed that growing pains affect about 10-20%
of children . Estimated prevalence ranges from 2.6% to 36.9%. This is
mainly due to different and unspecified sample sizes, different age
ranges in the literature, and lack of objective diagnostic criteria
adopted in different studies [4,12,13].
Abu-Arafeh and Russell determined the prevalence rate
to be 2.6%, among school children aged 5-15 years . Evans, et al.
 estimated the prevalence of growing pains among children aged
4-6 years to be 36.9%, in a well-designed sample using a validated
questionnaire. A relatively recent study by Kaspiris and Zafiropoulou
 reported a prevalence of 24.5% among 532 children of age 4-12 years.
Growing pains is the most common cause of recurrent
musculoskeletal pain in children . Two recent studies reported that
most of cases of unexplained recurrent limb pains in children could be
classified as growing pains [16,17].
Usually, there is a gradual decline in the frequency
of pain episodes over a period of 1 to 2 years and most cases of growing
pains resolve by adolescence . Uziel, et al.  reported
persistence of growing pains in 18 out of 35 cases in 5-year follow up,
though the episodes became less frequent and milder. However, more
recently, Pavone, et al.  reported resolution of all pain
episodes of growing pains after 1 year, in all 30 cases.
The terminology growing pains is being used since
1823, since the condition was first described in medical literature by
French physician Marcel Duchamp as Maladies de la Croissance
(pains of growth) . Many authors have raised objections and
questioned the validity and rationale of the term . Clearly,
these pains cannot be attributed to growth. Peak age for growing pains
(4-8 years) corresponds to the relatively slower growth period of
childhood. Moreover, the sites of pain (diaphyses) do not match the site
of maximal growth (epiphyses) . Besides, no difference of rate is
seen between the children with and without growing pains . Thus the
term growing pains appears to be a misnomer; there is no evidence that
growth per se can cause pain. Alternative terms such as
‘paroxysmal nocturnal pains’  and ‘recurrent limb pains in childhood’
 have been suggested. However these terms are non-specific and
describe the disorder incompletely. The terminology Benign idiopathic
paroxysmal nocturnal limb pains of childhood  perhaps describes
the condition properly, but sounds too long and inconvenient for general
use. On the other hand, the term growing pains has the advantage of
emphasizing the benign nature of the disease and indicates that the pain
occurs in the growing children, and not after growth is complete .
Thus, despite the controversy, the term growing pains enjoys wide
acceptance and popularity .
In the 19th century, at the time when the term
Growing pain was coined, growth was considered to be the causative agent
of nearly all pains during the childhood . By early 20th century,
medical community believed that growing pains were actually a sub-acute
form of rheumatic fever, [7,23]. Studies of Sheldon in 1936 and
thereafter Hawksley in 1939 proved that growing pains are not associated
with rheumatic fever [24,25].
The exact mechanisms, by which these pains occur, are
still poorly understood. Some of the theories, put forward to explain
the etiology of ‘growing pains’, are summarized below [2,3]:
Anatomical/mechanical theory: Hawksley observed
that growing pains were often associated with postural or orthopedic
defects such as flat foot, knock-knee, scoliosis or bad stance .
Mechanical instability such as flexible flat feet with hind foot valgus
had been suggested as a cause of growing pains . A small controlled
study reported that shoe inserts were effective in reducing the
frequency and severity of growing pains . However, subsequent study
by the same author did not found any association between foot posture
and growing pains . A cross sectional study  reported a
statistically significant association between joint hyper-mobility and
growing pains. Some cases of growing pains occurring after increased
activity may be explained by hypermobile joints. However, due to absence
of universally reliable and valid assessment tool for hyper-mobility in
children, the notion of hyper-mobility causing growing pains remains
largely unproved .
Fatigue theory: It was observed that bone
strength (based on speed of ultrasound in tibia), in children with
growing pains, was significantly lesser than in controls .Often
episodes of growing pains are reported on days of increased activity and
during the latter part of a day. These observations probably signify
that growing pains represent, a local overuse syndrome leading to
bone fatigue .
Psychological theory: John Apley (1951) found
emotional disturbance and family stress to be associated with ‘growing
pains’ . His famous saying "physical growth is not painful, but
emotional growth can hurt like hell" often gets quoted . Oster
(1972) also showed that psychogenic abdominal pains and nervous
headaches are more often found in children with growing pains than in
otherwise healthy children .
Lower pain threshold: Haskes, et al. 
have recently shown that children with growing pain have decreased pain
threshold when compared with the age- and sex- matched controls. They
suggested that ‘growing pains’ may represent a form of non-inflammatory
pain amplification syndrome. This was further supported by the findings
of Uziel, et al.  in a 5-year follow-up study of growing
pains. They found a correlation between persistence of symptoms and
lower pain threshold. Pathirana, et al.  also demonstrated a
lower threshold of pain response to cold, vibration and deep pressure in
cases of growing pains than in controls.
Other associations: A positive family history
associated in some cases of growing pains suggests that there may be a
genetic component playing role in the pathogenesis . Some cases of
growing pain may be actually having childhood onset e.g.,
Restless leg syndrome . Children with growing pains may also
represent a parasomnia such as sleep walking and sleep terrors . A
study found hair of children with growing pain contained increased
levels of lead and zinc and decreased levels of copper and magnesium
. However, the usefulness of the analysis in the pathogenesis is not
validated . In a recent study – Golding, et al.  could not
find any role of dietary omega-3 fatty acids in the development of
growing pains .
Thus growing pains may be caused by lower extremity
overuse, in children having lower pain threshold or decreased bone
strength [2,20]. The negative psychosocial environment may also be a
The most important component of management is proper
explanation regarding the benign nature of growing pains. The family may
be reassured that these pains will be resolved in time and will not
progress to any serious organic disease . The parents may be advised
to use analgesics as well as non-pharmacologic measures to relieve pain
such as leg massages, rubbing, and hot fomentation. But it remains
unclear whether these interventions actually help to resolve the attack,
as the pain episodes are self-limiting. Considering the intermittent
nature of pain, use of analgesics on regular or long-term basis can be
harmful, and should not be advised .
In this era of evidence-based medicine, treatment
modalities proven with randomized controlled trials are the gold
standards for management. A randomized controlled trial  involving
treatment of growing pains described efficacy of a muscle stretching
program (involving the quadriceps, hamstrings, and gastrosoleus muscle
groups) in faster decline of pain episodes. These exercises may be
taught to the parents and done at home twice-a-day for 10 minutes in the
morning and at night. This treatment modality has further advantage of
providing an extra attention of the parent, fulfilling the psychological
needs of the children .
Evans  reported use of in-shoe devices such as
tri-plane wedges and orthoses was effective in children with pronated
foot posture. However, the study involved single-case experimental
design, which is much lower in evidence hierarchy . These in-shoe
devices may be helpful in selected cases with postural defect.
Widespread vitamin D deficiency is being reported
among population at large, and vitamin D may affect body’s endocrine
system, immune system, cardiovascular system, neuro-psychological
functioning and neuromuscular performance . Thus, it is interesting
to know whether vitamin D has any role in management of growing pains. A
recent study reported insufficient vitamin D levels in majority of cases
with growing pains . However, the study does not mention, if the
children without growing pains had different vitamin D levels. Efficacy
of vitamin D supplementation in growing pains has not been studied.
Currently, there is insufficient evidence to use vitamin D for the
management of growing pains. Use of vitamin C, calcium or magnesium etc
have no scientific basis and should not be advocated.
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