Growing Pains

Growing Pains

“Growing pains” (GP) is a term frequently used to describe real events related to growth. But it may also be used to explain problems that have not yet been placed in a recognizable clinical category. This article will suggest that when investigation to rule out major pathologies has been completed, many growing pains will fall under the category of treatable structural abnormalities.

Background
Since it was first coined 150 years ago, the term “growing pains” has come to mean many things and to explain a wide range of complaints in children and young adolescents. In a recent e-mail, Dr. Myles Clough, an orthopedic surgeon from Kamloops, B.C., wrote, “It is actually a term many orthopaedic surgeons try to avoid because it is so nebulous. In my own practice I equate ‘growing pains’ with ‘I don’t know what is wrong with your child!’ and avoid it in favour of saying that I don’t know. When I was in training, the commonest association was rheumatic fever!”

Indeed, the causes of growing pains have been attributed to psychological and nutritional factors, as well as puberty, overexertion, recovery from an infectious disease, fever, strained or relaxed joints, inadequate sleep, and genetics, to name a few.

Despite the vague nature of the term “growing pains,” it has remained. What we do know is that the majority of complaints occur in children three to twelve years old, which is not the most rapid growth period in childhood. In fact, the majority of children grow without complaints, even during growth spurts, so growth is not necessarily even a primary factor.

The nature of GP

The majority of complaints involve intermittent bilateral ache, pain, or cramps of the lower legs or feet, often in the evening or during sleep. Parents instinctively provide relief by massaging or stretching the lower leg muscles. Children may appear to fatigue easily or avoid weight-bearing activities that most children enjoy.

A thorough assessment must be emphasized since some conditions that may mimic GP include pathologies such as juvenile leukemia (causing lower leg bone pain at night), slipped capital epiphysis (causing knee or hip pain) and systemic conditions, such as juvenile rheumatoid arthritis. After the possibility of serious pathology has been eliminated, treatable structural causes often remain the culprit.

Growth vs. structure
Sever’s disease is the most common cause of heel pain in boys aged nine to twelve. This apophysitis at the calcaneal epiphyseal growth plate is thought to be related to the traction of the Achilles tendon and therefore cannot be entirely separated from the growth process. The idea that the bones grow too fast for the muscles, thus producing this traction, may be true. However, it may be that the gastroc/soleus (GS) complex is simply too tight to avoid this traction.

In patellofemoral syndrome (PFS), increased Q-angle, quadriceps weakness, patellar laxity, patella alta, and hyperpronation of the feet can all produce symptoms. PFS may be related in part to an increased Q-angle as a result of pelvic widening during female puberty, a structural result of growth as opposed to growth itself.

Lower leg GP

Soft tissue stresses in the lower leg and foot that produce complaints are compensatory in nature. Hyperpronation alone may produce arch or ankle pain, but night cramping and lower leg pain is more often a function of a tight gastroc/soleus complex. A tight GS complex that reduces the amount of dorsiflexion at the ankle is known as a functional ankle equinus—a very mild version of a true ankle equinus. The foot must hyperpronate in order to gain a few more degrees of motion. While adequate ankle dorsiflexion for walking is usually available, running and playing are more demanding. The tremendous stretching forces on the GS complex during activity may produce symptoms for months or years until the GS becomes flexible and/or, hyperpronation compensates. Genu recurvatum or toe-walking may also present as compensations for an equinus foot.

Assessment
Assessment should include tests such as the Silverskiold test and a standing squat test to specifically differentiate between gastrocnemius and soleus/ achilles tissue restrictions. Always test with the subtalar joint in neutral (neither supinated nor pronated, with arches rolled outwards until the calcaneus is vertical). Otherwise, you will be observing the compensations rather than a true range of motion. Osseous restrictions are rare, but if in doubt referral to an orthopedic specialist may be in order.

Treatment
Off-the-shelf arch-supports, orthotics, or arch cookies combined with stable shoes will help, but because most children’s shoes are very flat, remember to elevate the heels enough to minimize the reason for the compensating hyperpronation. Wearing shoes and supports in the house as well as outdoors may be required in some cases. Laced hiking-style boots and shoes are ideal but often impractical in the winter or for smaller children. Regular stretching is difficult for children and parents to maintain, but requesting coaches and instructors to incorporate specific exercises into their regimes may be somewhat effective.

While some growing pains are unavoidable (think of your first day at school or even your first date), many others are treatable and can help a youngster enjoy his or her childhood with a minimum amount of pain.

** The above information is not intended to replace a physicians advice. Seek a physicians advice first.