Defining Growing Pains – Scoping Review +MP3
Research Review By Dr. Ceara Higgins©
Audio:
Date Posted:
November 2022
Study Title:
Defining Growing Pains: A Scoping Review
Authors:
O’Keeffe M, Kamper SJ, Montgomery L, et al.
Author's Affiliations:
Institute for Musculoskeletal Health, Sydney, Australia; Centre for Pain, Health and Lifestyle, New South Wales, Australia; Sydney Medical School, Sydney, Australia; The University of Sydney, Sydney, Australia; Nepean Blue Mountains Local Health District, Penrith, Australia; The University of Newcastle, New South Wales, Australia; The University of Toronto, Ontario, Canada; Royal North Shore Hospital, Sydney, Australia; Aalborg University, Aalborg, Denmark; University of Southern Denmark, Odense, Denmark; The Chiropractic Knowledge Hub, Odense, Denmark; Hunter New England Population Health Unit, Newcastle, Australia; University of Newcastle, Callaghan, Australia
Publication Information:
Pediatrics 2022; 150(2): e2021052578.
Background Information:
Growing pains are thought to be a common cause of musculoskeletal pain in children, with an estimated prevalence from 3.5% to 36.9% depending on the country, setting, and definition (1, 2). There is a great deal of uncertainty as to the definition of growing pains and whether it is a diagnosis of exclusion for nonspecific musculoskeletal pain or a specific condition or pathology. Many causes have been suggested including anatomic (5), psychological (3), vascular (4), and metabolic causes (6). However, these are either unsupported by research or have inconsistent evidence (6).
This article aimed to identify how growing pain(s) are defined in peer-reviewed literature and diagnostic systems.
This article aimed to identify how growing pain(s) are defined in peer-reviewed literature and diagnostic systems.
Pertinent Results:
Literature Search Results:
145 studies met the inclusion criteria. Of these, 41 (28%) did not provide a definition or criteria for growing pains. The definitions contained in the remaining 104 studies (72%) were categorized into 8 areas: pain location, age of onset, pain pattern, pain trajectory, pain type and risk factors, relationship to activity, severity and functional disability, and physical examination and investigations.
145 studies met the inclusion criteria. Of these, 41 (28%) did not provide a definition or criteria for growing pains. The definitions contained in the remaining 104 studies (72%) were categorized into 8 areas: pain location, age of onset, pain pattern, pain trajectory, pain type and risk factors, relationship to activity, severity and functional disability, and physical examination and investigations.
Pain Location:
45 studies (31%) and 1 diagnostic system described growing pains as bilateral, while only 1 study described them as unilateral. 99 studies (68%) did not specify bilateral nor unilateral. 72 studies (50%) and 1 diagnostic system claimed that growing pains mainly affect the lower limbs. Other locations mentioned included arms (8 studies), shoulder, back, groin, or ligaments and tendons (1 study each). 57 studies (39%) did not identify the location of growing pains.
40 studies (28%) claimed growing pains were not joint-related while 3 claimed that they were. 102 studies (70%) did not mention joint involvement. 39 studies (27%) identified growing pains as muscular while 106 studies (73%) did not mention muscular involvement.
45 studies (31%) and 1 diagnostic system described growing pains as bilateral, while only 1 study described them as unilateral. 99 studies (68%) did not specify bilateral nor unilateral. 72 studies (50%) and 1 diagnostic system claimed that growing pains mainly affect the lower limbs. Other locations mentioned included arms (8 studies), shoulder, back, groin, or ligaments and tendons (1 study each). 57 studies (39%) did not identify the location of growing pains.
40 studies (28%) claimed growing pains were not joint-related while 3 claimed that they were. 102 studies (70%) did not mention joint involvement. 39 studies (27%) identified growing pains as muscular while 106 studies (73%) did not mention muscular involvement.
Age of Onset:
12 studies (8%) claimed that growing pains occur between 3 and 12 years of age. A similar number of studies made claims falling within that range, with 3 studies extending the age range to 13, 14, and 15 years. 122 studies (83%) did not identify an age of onset.
12 studies (8%) claimed that growing pains occur between 3 and 12 years of age. A similar number of studies made claims falling within that range, with 3 studies extending the age range to 13, 14, and 15 years. 122 studies (83%) did not identify an age of onset.
Pain Pattern:
70 studies (48%) stated that growing pains only occur during the evening or at nighttime, while 75 studies (52%) did not mention evening/night pain. 31 studies (21%) said that growing pains were absent in the morning, while 1 stated that they may be present in the morning. A further 113 studies (78%) made no reference to morning time.
Descriptions of episode duration varied widely, ranging from minutes to hours (3 studies), 30-60 minutes (1 study), 30 minutes to 2 hours (1 study), under 72 hours (5 studies), and over 72 hours (1 study).
70 studies (48%) stated that growing pains only occur during the evening or at nighttime, while 75 studies (52%) did not mention evening/night pain. 31 studies (21%) said that growing pains were absent in the morning, while 1 stated that they may be present in the morning. A further 113 studies (78%) made no reference to morning time.
Descriptions of episode duration varied widely, ranging from minutes to hours (3 studies), 30-60 minutes (1 study), 30 minutes to 2 hours (1 study), under 72 hours (5 studies), and over 72 hours (1 study).
Pain Trajectory:
61 studies (42%) and 1 diagnostic system described growing pains as episodic or recurrent, 21 (14%) described them as often persistent in nature, and 16 of these articles stated that a diagnosis of growing pains can only be made if the child or adolescent has pain for > 3 months. 7 studies (5%) stated that growing pains are not persistent in nature.
4 studies (3%) claimed that growing pains occur daily, while 2 studies (1%) claimed that they only occur once or twice a week. Single studies claimed that growing pains occur at least monthly and at least twice in 1 year. 3 studies (2%) noted that growing pains resolve with time and maturity. 71 studies (49%) did not refer to the trajectory of growing pains.
61 studies (42%) and 1 diagnostic system described growing pains as episodic or recurrent, 21 (14%) described them as often persistent in nature, and 16 of these articles stated that a diagnosis of growing pains can only be made if the child or adolescent has pain for > 3 months. 7 studies (5%) stated that growing pains are not persistent in nature.
4 studies (3%) claimed that growing pains occur daily, while 2 studies (1%) claimed that they only occur once or twice a week. Single studies claimed that growing pains occur at least monthly and at least twice in 1 year. 3 studies (2%) noted that growing pains resolve with time and maturity. 71 studies (49%) did not refer to the trajectory of growing pains.
Pain Type and Risk Factors:
19 studies (13%) referred to growing pains as vague or being of an unknown nature.
7 studies (5%) claimed that growing pains are or can be related to growth, 2 studies (1%) claimed they are unlikely to be caused by growth, and 1 study stated that they occur during periods of declining growth. 135 studies (93%) did not refer to the relationship between growing pains and growth. 96 studies (66%) did not mention pain type or possible causes of growing pains (a bit surprising, right?). 1 diagnostic system identified growing pains as being of “other cause” or “unspecified cause”, and 1 identified them as being of “no cause”.
19 studies (13%) referred to growing pains as vague or being of an unknown nature.
7 studies (5%) claimed that growing pains are or can be related to growth, 2 studies (1%) claimed they are unlikely to be caused by growth, and 1 study stated that they occur during periods of declining growth. 135 studies (93%) did not refer to the relationship between growing pains and growth. 96 studies (66%) did not mention pain type or possible causes of growing pains (a bit surprising, right?). 1 diagnostic system identified growing pains as being of “other cause” or “unspecified cause”, and 1 identified them as being of “no cause”.
Relationship to Activity:
14 studies (10%) claimed that growing pains do not affect the ability to engage in physical activity, while 120 studies (83%) did not comment on this.
14 studies (10%) claimed that growing pains do not affect the ability to engage in physical activity, while 120 studies (83%) did not comment on this.
Severity and Functional Impact:
17 studies (12%) described the pain intensity as varying from mild to severe, while 128 studies (88%) did not describe pain intensity. 1 diagnostic system described the pain as “intense”.
24 studies (17%) claimed that growing pains do not limit walking or exercise ability, while 4 studies (3%) said that individuals may experience walking difficulties. 117 studies (81%) did not mention functional limitations. 15 studies stated that individuals with growing pains may experience trouble sleeping or may wake at night, while 130 studies (90%) did not mention sleep.
17 studies (12%) described the pain intensity as varying from mild to severe, while 128 studies (88%) did not describe pain intensity. 1 diagnostic system described the pain as “intense”.
24 studies (17%) claimed that growing pains do not limit walking or exercise ability, while 4 studies (3%) said that individuals may experience walking difficulties. 117 studies (81%) did not mention functional limitations. 15 studies stated that individuals with growing pains may experience trouble sleeping or may wake at night, while 130 studies (90%) did not mention sleep.
Physical Examination and Investigations:
51 studies (35%) described individuals with growing pains as presenting with a normal physical examination, with no swelling, infections, range of motion deficits, gait abnormalities, or musculoskeletal impairments. 93 studies (64%) did not refer to physical examination findings. 31 studies (21%) said that patients with growing pains present with normal radiographs and laboratory tests, while 114 (79%) of studies did not refer to radiographs or laboratory tests.
51 studies (35%) described individuals with growing pains as presenting with a normal physical examination, with no swelling, infections, range of motion deficits, gait abnormalities, or musculoskeletal impairments. 93 studies (64%) did not refer to physical examination findings. 31 studies (21%) said that patients with growing pains present with normal radiographs and laboratory tests, while 114 (79%) of studies did not refer to radiographs or laboratory tests.
Clinical Application & Conclusions:
This scoping literature review demonstrates the lack of consensus on how to define growing pains and how to diagnose them in clinical practice. The current literature in characterized by contradictions in all subcategories. This inconsistency reinforces calls from Walters et al. (7) for standardized diagnostic criteria for growing pains.
Interestingly, very few studies discuss the relationship between growth and growing pains. This, and the lack of clarity of the pathophysiology raises the possibility that this condition should not be called growing pains. As the prevalence may be as high as 37%, the lack of clarity around pathophysiology and the substantial variability in the application of the label make it clear that we need a better understanding of pain in children. As well, researchers should not use growing pains alone as a diagnostic term to categorize study participants or as an explanatory variable. Both clinicians and researchers using the term need to clearly describe the clinical criteria used to define growing pains.
Interestingly, very few studies discuss the relationship between growth and growing pains. This, and the lack of clarity of the pathophysiology raises the possibility that this condition should not be called growing pains. As the prevalence may be as high as 37%, the lack of clarity around pathophysiology and the substantial variability in the application of the label make it clear that we need a better understanding of pain in children. As well, researchers should not use growing pains alone as a diagnostic term to categorize study participants or as an explanatory variable. Both clinicians and researchers using the term need to clearly describe the clinical criteria used to define growing pains.
Study Methods:
Data was collected from medical journals and disease classification systems. Reference lists were examined, and citations were tracked to identify further studies. Two authors independently screened titles and abstracts and then two authors read and reviewed identified full texts to determine eligibility. Disagreements were resolved through discussion. Peer-reviewed, full-length articles, thesis publications, or dissertations containing text referring to the terms growing pain(s) or growth pain(s) in relation to children or adolescents were included. Conference abstracts, articles with an available abstract only, or studies not in English, where translation could not be arranged were excluded.
Two authors independently extracted data from the studies and disease classification systems. 13 authors were emailed to obtain information not included in the articles. The outcome for this study was the reported definition of growing pains.
Two authors independently extracted data from the studies and disease classification systems. 13 authors were emailed to obtain information not included in the articles. The outcome for this study was the reported definition of growing pains.
Study Strengths / Weaknesses:
Strengths:
- All types of study designs were included.
- A sensitive search was performed in several databases and disease classification systems.
- Data was collected and assessed by 2 or more independent reviewers.
Weaknesses:
- No risk of bias assessment was conducted on the included studies (because they dealt with definitions versus treatment interventions).
- The studies included were not specifically designed to define growing pains so may not have explicitly reported definitions or criteria.
- Sixteen study designs were included in this review with varying aims. This may have led to some of the variability seen in definitions.
Additional References:
- Lehman PJ, Carl RL. Growing pains. Sports Health 2017; 9(2): 132-138.
- Hawksley JC. Race, rheumatism and growing pains. Arch Dis Child 1931; 6(35): 303-306.
- Naish JM, Apley J. “Growing pains”: a clinical study of non-arthritic limb pains in children. Arch Dis Child 1951; 26(126): 134-140.
- Evans AM. Growing pains: contemporary knowledge and recommended practice. J Foot Ankle Res 2008; 1(1): 4.
- Friedland O, Hashkes PJ, Jaber L, et al. Decreased bone speed of sound in children with growing pains measured by quantitative ultrasound. J Rheumatol 2005; 32(7): 1354-1357.
- Vehapoglu A, Turel O, Turkmen S, et al. Are growing pains related to vitamin D deficiency? Efficacy of vitamin D therapy for resolution of symptoms. Med Princ Pract 2015; 24(4): 332-338.
- Walters AS, Gabelia D, Frauscher B. Restless legs syndrome (Willis-Ekbom disease) and growing pains: are they the same thing? A side-by-side comparison of the diagnostic criteria for both and recommendations for future research. Sleep Med 2013; 14(12): 1247-1252.
