Growing pains: Contemporary knowledge and recommended practice

Abstract

Leg pain in children, described as growing pains, is a frequent clinical presentation seen by an array of health care professionals. Described since 1823, growing pains continues to puzzle practitioners, yet diagnostic criteria and evidence based treatment is available.
The medical literature has been searched exhaustively to access all articles (English language) pertaining to leg pains in children which are ascribed to being 'growing pains'.
The literature, whilst plentiful in quantity and spanning two centuries, is generally replete with reiterated opinion and anecdote and lacking in scientific rigour. The author searched 45 articles for relevance, determined according to title, abstract and full text, resulting in a yield of 22 original studies and 23 review articles. From the original studies, one small (non-blinded) randomised controlled trial that focused on GP treatment with leg muscle stretching was found. Nine prevalence studies were found revealing disparate estimates. Ten cohort (some case-controlled) studies, which investigated pain attribute differences in affected versus unaffected groups, were found. One series of single case experiment designs and one animal model study were found.
Growing pains is prevalent in young children, presents frequently in the health care setting where it is poorly managed and is continuing to be researched. A common childhood complaint, growing pains needs to be acknowledged and better managed in the contemporary medical setting.

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BioMed Central
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Journal of Foot and Ankle Research
Open Access
Review
Growing pains: contemporary knowledge and recommended
practice
Angela M Evans
Address: School of Health Science, Division of Health Science, University of South Australia, City East Campus, North Terrace, Adelaide, 5000,
Australia
Email: Angela M Evans - angela.evans@unisa.edu.au
Abstract
Background: Leg pain in children, described as growing pains, is a frequent clinical presentation
seen by an array of health care professionals. Described since 1823, growing pains continues to
puzzle practitioners, yet diagnostic criteria and evidence based treatment is available.
Methods: The medical literature has been searched exhaustively to access all articles (English
language) pertaining to leg pains in children which are ascribed to being 'growing pains'.
Results: The literature, whilst plentiful in quantity and spanning two centuries, is generally replete
with reiterated opinion and anecdote and lacking in scientific rigour. The author searched 45
articles for relevance, determined according to title, abstract and full text, resulting in a yield of 22
original studies and 23 review articles. From the original studies, one small (non-blinded)
randomised controlled trial that focused on GP treatment with leg muscle stretching was found.
Nine prevalence studies were found revealing disparate estimates. Ten cohort (some case-
controlled) studies, which investigated pain attribute differences in affected versus unaffected
groups, were found. One series of single case experiment designs and one animal model study were
found.
Conclusion: Growing pains is prevalent in young children, presents frequently in the health care
setting where it is poorly managed and is continuing to be researched. A common childhood
complaint, growing pains needs to be acknowledged and better managed in the contemporary
medical setting.
Background
Growing pains first appeared as a described entity in the
medical literature in 1823 following the observations of a
French physician Marcel Duchamp [1]. Although the
topic of many reports since that time [2-11], and despite
being a frequent paediatric clinical presentation, growing
pains remains largely misunderstood [12-14] and as a
result poorly managed [2,15]. The purpose of this article
is to compile a contemporary summary of what is known
about growing pains and to provide a management guide-
line from the currently available scientific evidence.
Methods
The medical literature has been searched exhaustively to
access all articles (English language) pertaining to leg
pains in children which are ascribed to being 'growing
pains'. It is important to note however, that growing pains
(defined in Table 1) are not the same as all non-specific
Published: 28 July 2008
Journal of Foot and Ankle Research 2008, 1:4 doi:10.1186/1757-1146-1-4
Received: 13 May 2008
Accepted: 28 July 2008
This article is available from: http://www.jfootankleres.com/content/1/1/4
© 2008 Evans; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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leg pains. Many previous reviews have utilised the litera-
ture conveniently rather than comprehensively which has
resulted in many incomplete and misleading articles amid
the body of knowledge [16].
The subject search used a combination of controlled
vocabulary, MeSH headings and free text terms based on
the following search strategy for searching MEDLINE:
# 1 growing pain* or leg pain* or leg ache*
# 2 paediatric or pediatric or child*
# 3 #1 and #2
The electronic databases searched were:
1. Cochrane Pain, Palliative & Supportive Care Register
(current issue)
2. The Cochrane Controlled Trials Register: Cochrane
Library (current issue)
3. MEDLINE (1966 – present)
4. EMBASE (1980 – present)
5. CINAHL (1960 – present)
6. AMI (- present)
7. AMED (1985 – present)
8. Current Contents (1993 – present)
In addition, the reference lists of all eligible trials, key text-
books, and previous reviews were searched for additional
studies.
The literature presents with recurring themes which have
formed the basis for the structure of this present review. In
this review, growing pains will be discussed under the fol-
lowing five sub-headings which reflect the body of knowl-
edge found within the scientific literature: definition,
prevalence, aetiology, associations and treatment.
Results
Definition
There is no single diagnostic test for growing pains and as
a result it continues to be diagnosed on the basis of both
inclusion and exclusion criteria [2,15,17,18] (Table 1).
Misdiagnoses of children with less common but poten-
tially more serious conditions including rheumatoid
arthritis (articular pain) or bone tumours (unlikely to be
bilateral and night time occurrence) are unlikely if these
criteria are adhered to and can be investigated further with
blood analyses and imaging if suspected. A recent
matched case-control study concluded that growing pain
remains a clinical diagnosis and if precise inclusion and
exclusion criteria are considered, there is no need for lab-
oratory tests to make a diagnosis [19].
Prevalence
Studies of the prevalence of growing pains have presented
a wide range of estimates from 2.6 to 49.4% [8,11,14,20-
23]. Poor sampling, disparate age ranges and non-
defined, variable criteria account for much of this latitude.
A robust prevalence study established the prevalence of
growing pains in children aged four to six years as 37%
[24].
Aetiology
Growing pains remains enigmatic in terms of its cause.
Three main theories have been traditionally proposed as
follows:
Anatomical
The anatomical theory emerged in the 1950's when the
previously suspected association between growing pains
Table 1: Definition of 'growing pains' – inclusion and exclusion criteria.
Pain factors Inclusion criteria Exclusion criteria
Nature of pain Intermittent
Some pain free days and nights
Persistent
Increasing intensity
Unilateral or bilateral Bilateral Unilateral
Location of pain Anterior thigh, calf, posterior knee – in muscles Joint pain
Onset of pain Late afternoon or evening Pain still present next morning
Physical examination Normal Swelling, erythema, tenderness
Local trauma or infection
Reduced joint range of motion
Limping
Laboratory tests Normal Objective findings eg ESR, x-ray, bone scan abnormalities
Limitation of activity Nil Reduced physical activity

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and rheumatic fever had been overthrown [25]. Scoliosis,
lordosis, genu valgum and flat feet have all been cited but
unsubstantiated associations [20]. The anatomical theory
centred on the premise that a cause of the pain was a pos-
tural or an orthopaedic defect that could induce bad pos-
ture or stance and that treatment of these 'defects' were
clinically observed to give relief. The anatomical theory
has recently been weakened with the research findings
that foot posture and growing pains are uncorrelated [26].
Fatigue
The notion of muscular fatigue as the cause of growing
pains was initiated by Bennie in 1894 from clinical case
observations [4]. This theory has been periodically reiter-
ated, focussing on a surmised accumulation of metabolic
waste products within the leg muscles, but remains
untested [21,27,28]. Parents will often associate episodes
of growing pains with periods of increased physical activ-
ity [15].
Psychological
The emotional or psychological theory was introduced in
1951 [21] and has been further cited and addressed as
possible causative factor by many authors since
[2,22,28,29]. Increased vulnerability to pain has been sus-
pected as has a familial predisposition. There is dissent
regarding gender bias, where girls have historically been
regarded as more susceptible [22]. Oberklaid investigated
children with growing pains as part of a wider tempera-
ment survey and found that parents of affected children
rated them to have a negative or intense mood [23].
Further theories of pathogenesis
Many investigations into the cause of growing pains have
ensued in the last decade. Indeed, it is notable that this
condition has continued to captivate clinicians and
researchers with 185 years of reported history within the
medical literature. Table 2 summarises the four recent
studies which have developed new theory for the aetiol-
ogy of growing pains, as referred to in the following text:
(i) Lower pain threshold: The pain threshold in children
with growing pains has been found to be significantly
reduced in comparison to an age and gender matched
control group [30]. The authors suggest this may indicate
that growing pains is a generalised non-inflammatory
pain syndrome occurring in childhood.
(ii) Decreased bone strength: The speed of sound through
bone was assessed using ultrasound and it was found that
the bone strength density of the tibia in children with
growing pains was significantly less than for normative
data [31]. The authors postulate that bone fatigue with
activity may give rise to the leg pains.
(iii) Altered vascular perfusion: Investigation of the
uptake of technetium-99 during bone scans has been
found not to differ in small samples of children with
growing pains versus unmatched controls [32]. The
authors hence refuted the hypothesis that growing pains
may be induced by altered vascular perfusion in a manner
similar to migraine headaches.
(iv) Joint hypermobility: There is untested clinical impres-
sion that children with growing pains may be hypermo-
bile similarly to children with fibromyalgia [33,34]. As
there is no universally reliable and valid assessment tool
for hypermobility in children, support for this notion
remains pending [35].
Associations
(i) The profile of affected children and the frequency of
pain episodes has been recently reported [15]. Children
with growing pains were found to be approximately 5%
heavier, but not taller than children not reporting growing
pains. A positive family history of growing pains was
reported, with affected children having either a parent or
sibling having experienced growing pains in almost 70%
of cases. Most children were reported to experience grow-
ing pains in spates with frequency of one to three months
[15].
(ii) Previous studies have associated growing pains with
abdominal pain, headache, as part of a pain triad [29,36]
an area which is still somewhat unclear.
Table 2: Summary of the recent studies which have established new aetiological theory for growing pains (GP).
Date First Author Sample
size
Research design Findings New theory
2004 Hashkes, PJ GP group: n = 44
No GP control: n = 46
Case control
Dolorimeter (pressure)
GP group had lower pain
thresholds
GP may be a variant of a non-
inflammatory pain syndrome
2005 Friedland, O GP group: n = 39
No GP control: n =
Case control
Ultrasound bone speed,
tibia and radius
GP group had reduced tibial
bone speed.
GP may represent a local
overuse syndrome.
2005 Hashkes, PJ GP group: n = 11
No GP control: n = 12
Case control
Bone scintigraphy, tibia
GP group did not have altered
vascular perfusion when
compared with control group
GP are not associated with
altered vascular perfusion as
opposed to migraine

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(iii) Growth has been associated [1,5,27,37-39] and disas-
sociated [2,12,13] with growing pains, but little investiga-
tion has ensued. Childhood is, by definition, a time of
growth, but growth per se as a source of pain is uncertain
and contentious [40,41]. Preliminary results found
recumbent posture to be associated with increased tibial
growth in three lambs [37]. Clearly this preliminary find-
ing cannot be validly transposed to human subjects. Par-
ents of children with growing pains associated growing
pains and increased growth in 35% of cases [15].
(iv) Increased levels of lead, zinc and decreased levels of
copper and magnesium have been detected in the hair of
children with growing pains, but the usefulness of the
analysis of elements in hair remains controversial and has
yet to be validated [42].
(v) Flatfeet have been postulated as an aetiological factor
for growing pains for many years [20] with preliminary
support from single case experiments [43]. A recent com-
parative study has however, found no clinically significant
difference in the foot posture of children with or without
growing pains [26].
(vi) Increased activity levels have been found to be associ-
ated by the parents of children with growing pains in 37%
of reports [15]. Opinions over many years lend support to
this preliminary finding [4,23,34,39,44].
(vii) Children's quality of life (QoL) when affected with
growing pains has been little investigated, despite being
such a frequent clinical presentation [2,45]. It has been
reported as a preliminary finding that parents assessed
reduction in their child's QoL due to growing pains in
some 5% of cases [15].
Treatment
There is only one randomised controlled trial which offers
evidence for the treatment of children with growing pains,
summarised in Table 3[46]. This small, non-blinded trial
offers best (if limited) evidence for the management of
growing pains with muscle stretching. Despite this being
the best available evidence, it is not dispensed by health
professionals who when infrequently consulted (only
34% of children were seen by health professionals [15])
dispense paracetamol. In addition, parents practice the
time-honoured methods of rubbing children's legs and
using hot water bottles during periods of distress [15].
Much lower on the evidence hierarchy, single case experi-
ments supported the use of in-shoe wedges and foot
orthoses [43]. In addition to the frequently practiced
parental methods of treatment using paracetamol, leg
rubs and heat, the literature is replete with many
unfounded treatments including: vitamin C, D, magne-
sium, calcium, reassurance [34]. Clearly the first line treat-
ment for growing pains should be that supported by (best
available randomised controlled trial) evidence in the
form of a muscle stretching program for the quadricep,
hamstring and tricep surae groups [46]. Only once muscle
stretching has been instituted should any supplementary
treatments be appended, if needed.
Conclusion
Much has been written about growing pains over many
years. In common with numerous medical conditions,
there is much opinion and a relative paucity of sound sci-
ence to guide clinicians. That being said, the last decade
has seen some clarity and with confidence the contempo-
rary clinician and researcher can be assuaged of the fol-
lowing tenets:
(i) Growing pains is prevalent in children aged four to six
years (37%)
(ii) The diagnosis of growing pains is made clinically uti-
lising both inclusion and exclusion criteria
(iii) Growing pains is familial
(iv) Growing pains is not associated with flat feet
Table 3: Summary of the only randomised controlled trial for treatment of growing pains (GP) (Baxter & Dulberg, 1988).
No. pain episodes per month Group 1 – treatment
Muscle stretching program *
n = 18
Group 2 – control
Reassurance, leg rubs, acetyl-salicylic acid
n = 16
Beginning of trial 10 10
3 months 1 6
9 months 0 3
18 months 0 2
The RCT for management of GP revealed a statistically significant difference between the treatment and control groups of children (aged 5 – 14
years). However the study was biased, with no examiner blinding. Additionally, sample sizes are small and statistical power was not calculated.
* Parents were taught a muscle stretching program for quadriceps, hamstrings and gastroc-soleal groups. All stretches were performed twice daily
(morning and evening) for 10 minutes each time.

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(v) Health professionals are usually not consulted and the
most practiced methods of management are paracetamol,
rubbing legs and heat packs
(vi) The best evidence for management is muscle stretch-
ing of quadriceps, hamstrings and triceps surae groups
Contemporary practice should be informed an influenced
by this current summary and by future research into this
prevalent and frequently presenting childhood com-
plaint.
Competing interests
The author declares that she has no competing interests.
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