A 4 year old boy who attends the GP with a 6 month history of waking up at night in pain. His mum says that he screams and cries, and says the pain is in both his legs, from his thighs to his shins. He asks his mum to rub his legs, and this sometimes helps to calm him down. He eventually goes back to sleep after up to an hour, and can happen any night, but they tend to have runs of good weeks and bad weeks. Sometimes mum can predict that he will wake up - if he has had a particularly busy day or has had lots of PE, but usually there seems to be no reason for it.
Mum is exhausted as she also has a 3 month old baby and she is not sure if he is ‘playing up' as a result of the attention she is giving his sister.
He wakes up in the morning feeling absolutely fine. The local doctor asks about limping, which his mum says has never been a problem. He is very active and likes running and climbing. He never has pain throughout the day, and his mum has not noticed any joint swelling. There is no morning stiffness. He reached all his milestones at the appropriate age, and there have been no concerns about regression of milestones.
He has a past medical history of glue ear and asthma. He lives with his mum, stepdad and baby sister. He is due to start school in September.
Examination – the local dcotor performs a pGALS musculoskeletal examination, which shows hypermobility and flat feet, but normal arches on tip toe. There are no other abnormalities.
The photograph below shows flat feet on standing but normal arches on tip toe - these changes are normal for a child of his age.
Useful Links and Resources:
A parent information leaflet is available: Growing Pains Information Sheet.
Pain waking the child at night is usually a concern, but can be due to growing pains if there are no other red flags and criteria for growing pains are met (see rules of growing pains).
The GP diagnoses growing pains. She reassures the boy and his Mum of the diagnosis, explains that no further investigations are needed, and directs them towards Arthritis Research UK resources, which are available on their website. The diagnosis can be confidently made as the boy has a typical history, which includes no daytime symptoms, no other red flags and a normal examination. The 'rules of growing pains' must be met and any atypical features should prompt referral to the appropriate specialist.
The rules of growing pains can be found here.
Limitation and pain on hip rotation is always a concern. In this age group, consider Perthes disease and arrange an urgent hip Xray. Infection, inflammation and malignancy must also be considered (See red flags).
Arrange urgent review by appropriate specialist, with urgent xray and bloods if indicated.
Likely none. Consider arranging a review and discussing with mother reasons for concern/return.
Gross motor – walking, climbing and managing stairs.
Fine motor and vision – holding pen with appropriate grip. Starting to manage zips and buttons independently. No visual concerns.
Flat feet and hypermobililty are common in this age group. The majority will resolve and not require any intervention. If significant pain, consider referral to a paediatric musculoskeletal specialist and physiotherapy.