Growing pains are difficult to define

Hallie Palladino’s 9-year-old-daughter had complained on and off about leg pain, which her parents treated with massage and stretching. But then came a period in the spring when the pain intensified so much that the then-second-grader’s school grew concerned. An X-ray at urgent care didn’t reveal any problems. But, one night before bed, Palladino’s daughter told her it was too painful for her to stand or walk.

"We agreed it would be wise to take her to the ER," Palladino said.

She brought her daughter to Lurie’s Children’s Hospital of Chicago, where the child was admitted for a couple of days and had a thorough examination that included a full-body scan. No medical problems were detected, and the physicians told Palladino that the aches in her daughter’s legs were likely just intense growing pains. After two days off her feet in the hospital, the pain subsided, and it hasn’t returned.

“They took my daughter’s pain incredibly seriously, and they made sure to rule out all the very serious stuff,” Palladino said. “They never made us feel like it was an overreaction.”

Growing pains are common: A 2004 survey of children ages 4 to 6 in South Australia estimated that 37 percent of them were affected. But according to a recent study published in the journal Pediatrics, there is confusion about what is meant by the phrase “growing pains,” and no consensus about their cause — in fact, growth might not even be involved at all. Therefore, the study suggests that doctors and researchers avoid using the term.

In an effort to establish agreement about what the condition entails, the authors of the Pediatrics paper, “Defining Growing Pains: A Scoping Review,” looked at 145 studies and two diagnostic systems that mentioned growing pains. “There was extremely poor consensus between studies as to the basis for a diagnosis of growing pains,” they wrote.

For example, only half of the studies mentioned lower limb pain; only 48 percent of the studies reported that the pain came in the evening; and only 42 percent said it was episodic or recurrent. Perhaps most significantly for a condition with the word growing in it, 93 percent of the studies did not refer to the relationship between growth and growing pains. In fact, more than 80 percent of the studies didn’t even specify the age of onset of the pains.

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Just as there is no clear consensus on what constitutes growing pains, the researchers pointed out, there is no agreement on what causes them. Studies have suggested that growing pains may be the result of issues related to anatomy (hypermobility, knock knees or low-bone-mineral density, for example), psychological issues such as stress, vascular issues such as skeletal blood flow and metabolic problems such as low vitamin D levels.

“All of these causes are either unsupported by research, or underpinned by inconsistent evidence,” the authors of the study wrote. “This uncertainty means there is a lack of guidance for clinicians as to when the label growing pains might be appropriate for a patient.”

The absence of agreement on diagnostic criteria and etiology led the researchers to suggest that “growing pains” is a misnomer. Other studies have come to the same conclusion, proposing alternatives such as “recurrent limb pain in childhood,” “benign nocturnal limb pains of childhood,” “benign leg ache in children” and “idiopathic limb pain.”

Mary O’Keeffe, the lead author on the Pediatrics study, said that “the lack of evidence that growth is even related to such pains” is the most interesting aspect of the study. “If we don’t know that growth is a contributing factor,” she said, “I don’t think we should be mentioning growth as a cause to children and their parents.”

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But if clinicians do choose to use this term, they shouldn’t use it in isolation, added O’Keeffe, who is a physical therapist and postdoctoral research fellow at the University of Sydney’s Institute for Musculoskeletal Health. “They should try to communicate what factors might be contributing to the pain, rule out serious disease, suggest some treatments, and monitor improvement.”

Matthew Oetgen, chief of Orthopedic Surgery and Sports Medicine at Children’s National Hospital in Washington, D.C., said that he views the term growing pains as “sort of a colloquial term for pain in younger kids that is otherwise unexplained.”

He said that growing pains affect children who are younger than 12, who have vague areas of pain, often around the knee or down into the legs. “And it can be very variable. It can be both sides. It can be one side one day and the other side the other day. It can be activity related or it can be after.” Often the pain tends to come and go, and get better without requiring medicine.

Oetgen thinks it’s possible the condition does have “some relationship to growth,” and perhaps is a result of tension in the muscles and tendons that aren’t growing at the same rate as bones.

Stacie Grossfeld is an orthopedic surgeon and sport medicine doctor in Louisville who treats children and adults. Grossfeld said that, rather being a misnomer, the term “growing pains” fits a couple of growth-related conditions she sees in young athletes.

One is Osgood-Schlatter disease, a condition that usually occurs during a growth spurt when a tendon tugs on a growth plate in the shinbone, causing pain. “We treat that regularly,” she said. “That’s a very common growing pain disease.”

Another condition, called Severs disease, involves inflammation of the heel bone’s growth plate and is often triggered by increased activity. It is commonly seen in youth soccer players. Both conditions are treated with rest, icing, stretching and pain management, but kids may be advised to take time off from sports if there is too much pain. “Once you quit growing, typically your growing pains go away,” Grossfeld said.

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Oetgen said that if the pain is sporadic, moves around and doesn’t keep a child from their usual activities, you can watch and wait and use a little ibuprofen or acetaminophen for the pain. Parents should be more concerned if the pain is persistent and localized, is accompanied by a fever, prevents a child from engaging in activities they usually enjoy, results in a persistent limp, or is so sharp it wakes them at night, he said. Grossfeld added that pain after trauma that doesn’t resolve after rest, as well as swelling and discoloration, are also red flags.

If a work-up doesn’t find a problem, Oetgen says he will tell parents something along the lines of, “I think this is what people describe as growing pains,” making clear that there is no uniform way to describe the condition.

Although it lacks specificity, “I don't think it's a bad term,” he said. While papers such as the recent Pediatrics study show that no one is talking about exactly the same thing, “I think that at the more 30,000-foot view, most people are talking about the same thing. So, I think it's a good description for a pretty common phenomenon that we don't have a great technical description for.”

Palladino said she found the use of the phrase “legitimizing,” because it acknowledged that her daughter had indeed been feeling pain, but also put the pain in context of something natural. “It closed a loop on that whole experience,” she said.

Her daughter’s hospital visit was positive in another way, she added: “All her doctors believed her and took her seriously. They thoroughly examined her, and they gave her an answer that was reassuring and that legitimized her concern about her own body.”

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