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Dr. Edilson Forlin, MSc., PhD
Pediatric Orthopedic Surgeon

Limb pain is one of the most common complaints from children and reasons to visit a Pediatric Orthopedic Surgeon. Usually, the parent’s concern is that the pain could indicate some important health problems. Fortunately, the so-called growing pain (GP) represents the majority of these cases. Some studies have shown a frequency of up to 50% of GP in children from the age of 3 to 6 years old. When seeing a child with pain in the limbs the main concern for physicians is to rule out any other more serious conditions. The good news is that the diagnosis of growing pain is clinical and categorized as follow:

  • The age range for patients with GP is from 3 to 12 years old but, most concentrated at the age of 3 to 6 years.
  • Intermittent pain with frequency ranging from almost every day to one every 2-3 months.
  • Common time is late afternoon or during the night (sometimes can wake the child) and pain could last few minutes up to one hour or more with complete remission after.
  • It can affect one or both lower limbs, usually alternately.
  • Site of the pain is not precise, mostly localized in the legs or thighs.
  • No swelling, redness or any external signs.
  • Pain can subside completely with some massaging and/or warming with rarely using analgesics.
  • Usually, the child is very active with no complain when doing any physical activities. The child has no limping and has normal health.

What are the causes of GP?
The aetiology of GP remains unknown as well as the mechanism of the pain. There is controversy about the origin of the pain, whether it is from the muscles, bone or other structures. Some authors believe it’s from bone stress. Many theories were suggested about the cause of the pain. Genetic predisposition, family history, non-inflammatory syndrome, vascular syndrome, joint hypermobility, conditions of birth, breastfeeding, psychological disturbance, low threshold for pain, foot position, muscles shortening and bone weakness have been associated with GP. Another factor pointed out is the deficiency/insufficiency of vitamin D and some studies found that increasing vitamin D levels seem to reduce the pain severity.

What is the differential diagnosis?
There are dozens of circumstances that cause limb pain and can be initially misdiagnosed with GP. Some conditions are; trauma, chronical inflammations as a stress fracture, transient synovitis of the hip, so-called osteochondritis (Legg Perthes –hip, OsgoodSchlater –joelho, Sever and Kohler disease – foot) as well as some subacute osteomyelitis, arthritis and tendinitis of the infancy. Most of these entities can be recognized/suspected with a careful clinical evaluation.

What complementary exams are necessary?
The main goal is to rule out any orthopedic problems. If the clinical history is typical and the physical examination is normal then usually no lab test or x-ray is necessary. Any unexpected complain as localized, progressive and distressed pain, swelling, limp, muscle atrophy or limitation of motion can be investigated. For patients with frequent pain, the evaluation of vitamin B levels and other bone markers can be ordered.

How the GP should be treated?
When the GP is characterized the parents should be oriented and reassured regarding the aspects of the condition. No specific treatment is needed as there is no preventative measure. The following are advised to relieve the pain: massage, warm the limb (usually with hot gel pack) and support and reassure the child. In a minor number of cases, when pain is more intense and lasting, a pain killer, such as ibuprofen, can be administrated. We recommend parents to create a “pain chart”, marking the days and duration of the pain as well as the measures taken. That way we will have a better understanding of the pain pattern that can facilitate our assessment and guidance.

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