Postgraduate Medicine
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Growing pains John J. Calabro, Antonio E. Wachtel, William B. Holgerson & Michael M. Repice To cite this article: John J. Calabro, Antonio E. Wachtel, William B. Holgerson & Michael M. Repice (1976) Growing pains, Postgraduate Medicine, 59:2, 66-72, DOI: 10.1080/00325481.1976.11714268 To link to this article: http://dx.doi.org/10.1080/00325481.1976.11714268
Published online: 07 Jul 2016.
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Citing articles: 7 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20 Download by: [Australian Catholic University]
Date: 23 August 2017, At: 05:41
medical practice today • • grow1ng pa1ns
Downloaded by [Australian Catholic University] at 05:41 23 August 2017
fact or fiction? John J. Calabro, MD, FACP Antonio E. Wachtel, MD
Worcester City Hospital, Worcester, Massachusetts William B. Holgerson
University of Massachusetts Medical School Worcester Michael M. Replce, MD
Worcester City Hospital
What seem to be growing pains could be a manifestation of a serious disease-juvenile rheumatoid arthritis, rheumatic fever, even leukemia. If results of pertinent laboratory tests are normal, it still takes months of close observation before a diagnosis of growing pains can be made with certainty.
• The preparation of this article was prompted by an inquiry submitted to POSTGRADUATE MEDICINE by a physician in Ohio and published in the Problems/Solutions department. * The problem concerned a 7-year-old girl with a five-year history of intermittent leg pains occurring usually at night and lasting for a half hour to an hour. A consultant replied th at three diagnoses might be considered: rheumatoid myositis, muscle cramps, and trichinosis. Subsequent! y, two of us (J .J .C., W.B.H.) suggested in a letter to the Editor that the most plausible explanation was growing pains. Growing pains have received only seant attention in recent medicalliterature. 1 Nevertheless, we hope to convince readers of this article that growing pains represent a clinical entity of importance in the differentiai diagnosis of musculoskeletal disorders in children. The term "growing pains" is ofunknown origin. lt was used as early as 1823 by Duchamp 2 and is widely used today by both physicians and laypersons. Se ham and Hilbert 3 in 1933 defined growing pains as vague recurrent afebrile muscu1ar pains. Hawksley 4 in 1938 expressed disagreement, saying that it was not possible to give the syndrome an exact definition. In 1951, Naish and Ap1ey 5 proposed a set of diagnostic criteria including 1imb pain of at !east three months' duration th at was not specifically located in the joints and was of sufficient se verity to cause sorne interruption of normal activity. The cause of growing pains is also unknown. Early reports implicated excessive use of the legs; in Bennie's 6 words, "the little legs have performed an unusual amount ofwork during the day.'' Hawksley 7 expressed the belief that the limb pain is caused by the increased strain of faulty posture from .scoliosis, pes planus, knock-knee, or other similar abnormality. Os ter and Nielsen 8 contended that the disorder has no organic basis and is an expression of emotional disturbance. To add still another view, we have often wondered whether growing pains are the childhood counterpart of the fibrositis syndrome seen in adults. The reported frequency of growing pains varies considerably, ranging from 4% to 50%. The variability more th an likely reflects differences in diagnostic criteria. 5 • 9 • 10 A recent survey 8 of 2, 178 subjects 6 to 19 years of age gave rates of 13% for boys and 18% 1 for girls. *See p 23, Jul 1974; p 47. Sep 1974.
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During the past five years, we have observed almost 50 children with growing pains. Clinical presentation varied from intermittent acute attacks of limb pain occurring only at night to more or less chronic, generalized muscle aches and joint pains. Perhaps the best way to highlight sorne of the variability in clinical pattern is to summarize severa! cases.
llluatratlve
ca...
Case 1-A 7-year-old boy had had recurrent calf pain for three years and had been evaluated by nine physicians on as many separate occasions. A number of diagnoses had been suggested, including juvenile rheumatoid arthritis. Attacks occurred almost nightly and were characterized by intense calf
Photo: Tha Ballmann Archiva
Vol. 59 • No. 2 • Fabruary 1978 • POSTGRADUATE MEDICINE
67
John J. Calabro
Downloaded by [Australian Catholic University] at 05:41 23 August 2017
Dr. Calabre is chief of medicine and director of rheumatology, Worcester City Hospital; professer of medicine, University of Massachusetts Medical School, Worcester; consultant in pediatrie rheumatology, New England Medical Center, Boston; and professer of pediatries, Tufts University School of Medicine, Boston.
Antonio E. Wachtel Dr. Wachtel is a pediatrie intern, Worcester City Hospital.
pain that began suddenly and subsided as promptly, usually within 30 minutes. Local massage seemed to ease the discomfort. Physical examination gave normal findings. A battery of laboratory studies, including determination of the erythrocyte sedimentation rate (ESR) (Westergren), disclosed no abnormalities. X-ray films of the knees and lower limbs were normal. A diagnosis of growing pains was made, and aspirin, · 10 grains/day to be taken at bedtime, was prescribed. The parents were reassured that the condition was benign. After three months, during which time the patient had only two recurrences of calf pain, aspirin was discontinued. In the ensuing three years of followup, limb pain did not recur. Comment-The duration of the attacks (three years) and the absence of evidence of accompanying joint inflammation rule out juvenile rheumatoid arthritis and suggest growing pains as the most likely diagnosis. Equally important is the history of a typical pattern ofleg pain occurring on! y at night and awakening the child. When limb pain is more generalized, diagnosis is more difficult. Case 2-A 13-year-old girl had a six-mon th his tory of recurrent pain and stiffness beginning in the knees and later affecting the ankles, elbows, and wrists. Redness and swelling of the joints were said not to be present during the bouts of pain. Also noted as ab-
68
sent were fe ver, rash, anorexia, and weight Joss. On severa! occasions the patient complained of pain in the ante ri or part of the chest wall and of vague abdominal discomfort. On physical examination, the girl appeared healthy but was moderately apprehensive. Knees, ankles, elbows, and wrists were slightly but diffuse! y tender to firm palpation. Examination of the joints was otherwise unremarkable. Laboratory data, including ESR, seriai antistreptolysin-0 (ASO) titers, serum complement leve!, and results of latex fixation and antinuclear antibody tests and ofprotein electrophoresis, were entirely normal. X-ray films of the knees, ankles, wrists, and upper gastrointestinal tract and an electrocardiogram were normal. A diagnosis of growing pains was made, and aspirin, 65 grains/day, was prescribed. At a follow-up visit six months la ter, the patient reported marked subjective relief of pain and stiffness. She had resumed normal activity, including participation in sports. She has now been symptom-free for a year without taking aspmn. Comment-The presentation in this case was atypical. Initially, rheumatic fe ver and juvenile rheumatoid arthritis were considered as diagnostic possibilities. The diagnosis of growing pains was made only after appropriate laboratory determinations had given normal results and we had observed the patient for over a year to make certain that joint swelling did not occur. The patient remains under our observation. Case 3 -For eight months, a 9-year-old boy had had recurrent frontal headaches and abdominal pain associated with bilateral groin and thigh pain that was intensified by motion. There was no history of joint pain, rash, or fever. The boy's mother, a nurse, was apprehensive and overprotective, describing each bout of illness in detail and reading from carefully guarded notes. The aggregate of symptoms occurred about twice a month. Two extensive inpatient workups had been carried out two months apart. On bath occasions, x-ray films of the skull and abdomen were normal and lumbar puncture gave normal findings. Routine blood studies and latex fixation and antinuclear antibody tests showed no abnormalities. The ESR was 7
POSTGRADUATE MEDICINE • February 1976 • Vol. 59 • No. 2
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mrn/hr. An electroencephalogram and an aiIergy workup were noncontributory. When we saw the boy, he was having episodes of groin and calf pain daily. Physical examination, including a metieulous musculoskeletal survey, gave normal findings. The boy appeared withdrawn and apprehensive, and his mother took the initiative to answer ali our questions. X-ray films of the knees, pelvis, and long bones of the legs were normal. A complete blood count and the ESR were normal. Latex fixation and antinuclear antibody tests were negative. Aspirin, 20 to 30 grains/day, was tried intermittent) y, without apparent beneficiai effect. Meprobamate gave relief of the recurrent headaches. When aspirin was given in a dosage of 40 grains/day, the patient became symptom-free and remained so for severa) months. Then, while he was taking the same amount of aspirin, the bouts of pain recurred, but Jess frequently. We are continuing to observe him. Psychiatrie evaluation and observation of the home environment have been suggested repeatedly, but the mother refuses to accept either recommendation. Comment-This boy's illness is hard to define but appears to be an example of a symptom complex described by Oster, 11 who suggested that the triad of symptoms (recurrent abdominal pain, headache, growing pains) is based on psychologie conflicts stemming primarily from unrest in the home environment. Differentiation from psychogenie rheumatism is difficult. Case 4-A 9-year-old boy was hospitalized because of pain in the anterior aspect of the thigh, primarily on the left side, which caused him to limp. The pain occurred only during the day. It would sometimes make falling asleep at night difficult, but it did not awaken the child during the night. Fever and other symptoms of systemie disease were absent. Traction was instituted as the only form of therapy, and within two weeks the thigh pain subsided. One year later, the boy was hospitalized again bec au se of thigh pain. Physical examination gave entirely normal findings, as did laboratory studies, including a complete blood cell count, determination of ESR, and antinuclear antibody and ASO tests. X-ray
Vol. 59 o No. 2 • FebrullfY 1976 • POSTGRADUATE MEDICINE
William B. Holgerson Mr. Holgerson is a senior medical student, University of Massachusetts Medical School.
Michael M. Repice Dr. Repice is a medical resident, Worcester City Hospital.
films of the affected limbs were normal. We examined the boy saon after the second hospitalization and could not find physical or la bora tory evidence of abnormality. He is one of seven children of divorced parents. It was our impression after taking a complete his tory that there was a general Jack of discipline in the family and that older brothers subjected the patient to repeated harassment. Aspirin, 25 grains/day, was prescribed (boy's weight, 50 lb) and afforded prompt relief. He has been able to resume normal activities. Cllnlcal Spectrum
Sex, age-Growing pains are reported to be slightly more common among girls than among boys. 7 • 8 Symptoms can occur at any age during childhood and earl y adolescence; a peak incidence is not discernible. In two reports, 1 • 7 a higher proportion of parents of affected than ofunaffected children were said to have had growing pains during childhood. Numerous provocative factors have been suggested, such as ill health, pes planus, and food aller gy. Sites of involvement-Typically, growing pains are intermittent and are localized deep in the Ieg. They are often qui te incapacitating. The pain is usually muscular, is sometimes periarticular, and is rarely articular. When the pain is articular, signs of joint inflammation other th an tenderness (red ness, warmth,
69
falling asleep but awakens during the night and cries out when an attack occurs. The frequency of attacks varies from once a day to once or twice a month. Rarely, if ever, are growing pains continuous.
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Examlnatlon and Studles
Figure 1. lrregular fragmentation of tibial tubercle (arrow) due to Osgood-Schlatter disease.
table 1. dlsorders to consider when IImb pain ln a chlld ls generallzed Dleordera
MaJor diagnostic fallturea
Juvenile rheumatoid arthritis
Joint swelling (90% of cases), typical systemic manifestations, neutrophilic leukocytosis, elevation of erythrocyte sedimentation rate
Rheumatic fever
Joint swelling, carditis, documentation of previous streptococcal infection
Polymyositis or dermatomyositis
Proximal muscle weakness, elevation of serum muscle enzyme values
Leukemia
Periosteal proliferation or ether typical articular changes evident on x-ray films; characteristic blood smear and bene marrow abnorrnalities; progressive anemia
The musculoskeletal examination of a child with growing pains is characterized by absence of joint swelling, erythema, warmth, or limitation of motion. At most, articular and muscular tenderness may be present. Children who are asked to localize the areas of discomfort will point to a nonarticular area such as thigh or calf in most instances. The most striking aspect of growing pains is the absence of fe ver and other symptoms of systemic disease. Fatigue, anorexia, and weight loss do notoccur. Sorne of the children appear apprehensive or withdrawn, but this is not a constant feature. Laboratory studies invariably give normal findings in children with growing pains who are otherwise healthy. In fact, a normal ESR may be the first clue to the absence of inflammatory disease of muscles or joints. X-ray films of affected areas are also normal. Course of Dlsease
Attacks may recur for months or, in sorne instances, years. Eventually, growing pains simply subside. Occasionally, after a remission lasting for as long as a year or more, attacks may recur (as they did in case 4). Dlagnosis
swelling, limitation of motion) are notably absent. The most common sites are the thigh, calf, and posterior aspect of the knee. Less common sites are the back, shoulder, arm, instep, and groin. 1 • 7 • 8 Pain Pattern
Growing pains can occur at any ti me of the day or night but typically occur only at night. As a rule, an affected child has no difficulty in
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There is no simple approach to definitive diagnosis of growing pains. Pertinent laboratory and roentgenologic studies are needed, essentially to rule out other diagnostic possibilities. Even th en, it takes months of careful observation and deliberation before the physician can be certain of the diagnosis. Differentiation of growing pains from conditions often confused with them depends primarily on the his tory. Whether the pain is localized or generalized is an important question bearing on what studies are done. For example, if pain is localized to groin, thigh, or knee, roentgenologic examination is important to rule out tumor, osteomyelitis, or a
POSTOAADUATE MEDICINE o Fabruary 1978 o Vol. 59 o No. 2
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form of osteochondritis such as OsgoodSchlatter disease or Legg-Calvé-Perthes disease. Occasionally, the findings may be misleading. During the first month after onset of osteomyelitis, x-ray films of the involved bone may be normal; a correct diagnosis can be made only by blood culture. A child who has knee or shin pain without local swelling may be thought to have early OsgoodSchlatter disease when minimal roughening of the tibial tuberosity is evident on x-ray films. However, this finding represents a normal variation frequently seen in children. In the absence of roentgenologic evidence of progressive changes (figure l ), a diagnosis of Osgood-Schlatter disease should not be made. A similar error may occur when LeggCalvé-Perthes disease is suspected in a child with hip, thigh, or groin pain. Initially, x-ray films of the hip may show a localized area of rarefaction. Only when the changes progress to diffuse rarefaction of the metaphysis and fragmentation of the epiphysis is the diagnosis of this disease justified. If the limb pain is generalized, differentiai diagnosis may be more difficult (table l ). The two diseases most frequently confused with growing pains are juvenile rheumatoid arthritis and rheumatic fe ver. Two thirds of the children with growing pains who have been referred to us were thought by their referring physicians to have rheumatoid arthritis or rheumatic fever. Sorne physicians still regard episodic joint and muscle discomfort as a forme fruste of either ofthese diseases. This is simply not so. Ninety percent of patients with juvenile rheumatoid arthritis will have swelling of one or more joints as an initial manifestation of the disease (figure 2). In the remaining 10% of cases, a diagnosis of juvenile rheumatoid arthritis is made only in the presence of typical systemic manifestations, such as high fe ver, rheumatoid rash, generalized lymphadenopathy, and splenomegaly, as weil as a striking neutrophilic leukocytosis and elevation of the ESR. 12 A diagnosis ofrheumatic fever is made only in the presence of joint swelling, usually with migratory polyarthritis, carditis, or bath, as weil as documentation of previous streptococcal infection, eg, rising ASO titers.
Polymyositis or dermatomyositis is rarely difficult to distinguish from growing pains. An exception may be a case of bilateral hip, thigh, or shoulder pain in a child. Polymyositis may evolve insidiously, and proximal muscle weakness may be so minimal at first that it goes unrecognized. Difficulty in squatting or climbing stairs often is the earliest clinical clue, but demonstration of elevation of serum muscle enzyme values is
Vol. 59 • No. 2 • Fabruarv 1976 • POSTGRADUATE MEDICINE
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Figure 2. Swelling of left knee and overgrowth of left leg due to juvenile rheumatoid arthritis. For three years before the arthritis was diagnosed, the child was thought to have growing pains.
Figure 3. Periosteal new bone formation (arrows) of the femur in a patient with limb pain due to leukemia.
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needed to confirm the diagnosis. Early elues to the presence of dermatomyositis include violaceous periorbital edema (heliotrope facies) and atrophie, scaly erythema over extensor surfaces of joints, particularly the knees, elbows, and bands. Early features of acute leukemia often inelude rheumatic manifestations. 13 In children especially, the clinical pic ture at first may suggest growing pains. These manifestations are caused by leukemic infiltration or hemorrhage into joints or periarticular structures, secondary hypertrophie osteoarthropathy, secondary gout, or combinations of these. X-ray films of painful areas often will show evidence of perioste al new bone proliferation (figure 3) or other distinctive changes. 14 Rapidly progressive anemia is another clue, but diagnosis ultimately depends on demonstration of characteristic abnormalities in blood and bone marrow. Management
The key to successful management of children with growing pains is education of parents and children concerning the benign nature of the syndrome. Once the diagnosis is certain, this approach must be both decisive and reassuring. Growing pains res pond readily to treatment with aspirin or other analgesies. In a typical case of pain occurring at night, we prescribe aspirin, 2.5 to 10 grains (depending on the child's age and weight), to be taken once a day at bedtime for three to six months. For the
more chronic form of growing pains, we recommend a dosage of 1 grain (60 mg) of aspirin per kilo gram of weight per day, taken in four divided doses, again for three to six months. If growing pains recur when aspirin is discontinued, another three- to six-month course can be gi ven. Supportive measures such as beat and massage help to relieve acute pain, particularly at night. We do not recommend limitation of activity, however, des pite the expressed belief of sorne observers that excessive physical activity may be a pro vocative factor. Thoughtful attention must be given to emotional conflicts or unmet needs. Summary
Growing pains are recurrent limb pains peculiar to children. Brief episodes of leg pains occurring intermittently at night are typical, but the clinical spectrum is variable. A diagnosis of growing pains can be made with certainty only after other possible conditions have been ruled out by appropriate studies and after the child has been observed carefully for a period of months. The two diseases most often confused with this syndrome are rheumatic fever and juvenile rheumatoid arthritis. Aspirin and supportive measures are beneficiai. • Supported in part by a grant from the Massachusetts chapter of The Arthritis Foundation. Address reprint requests to John J. Calabro. MD. Worcester City Hospital, 26 Queen St, Worcester, MA 01610.
References
1. Brenning R: Growing pains. Acta Soc Med Upsal 65:185-201, 1960 2. Duchamp M: Maladies de la croissance 1823. In Levrault FG (Editor): Mémoires de Médecine Practique. Paris, Jean-Frederic Lobstein, 1832 3. Seham M, Hilbert EH: Muscular rheumatism in childhood. Am J Dis Child 46:826-853, 1933 4. Hawks1ey JC: The incidence and signifie ance of growing pains in children and adolescents. J R Inst Public Health 1:798-805, 1938 5. Naish JM, Apley J: "Growing pains": Clinical study of non-arthritic limb pains in children. Arch Dis Child 26:134-140, 1951 6. Bennie PB: Growing pains. Arch Pediatr 11:337-347, 1894 7. Hawksley JC: The nature of growing pains and their relation to rheumatism in children and adolescents. Br Med J 1:155-157, 1939
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8. Oster J, Nielsen A: Growing pains: A clinical investigation of a school population. Acta Paediatr Scand 61:329334, 1972 9. Williams MF: Rheumatic conditions in school children. Lance! 1:720-721, 1923 10. Oster J: Growing pain: A symptom and its significance. Dan Med Bull 19:72-79, 1972 Il. - - : Recurrent abdominal pain, headache and limb pains in children and adolescents. Pediatries 50:429-436, 1972 12. Calabro JJ, Marchesano JM: The earl y natural history of juvenile rheumatoid arthritis: A 10-year follow-up study of 100 cases. Med Clin North Am 52:567-591, 1968 13. Calabro JJ: Cancer and arthritis. Arthritis Rheum 10:553-567. 1967 14. Calabro JJ, Castleman B: Multiple osteolytic lesions in a 16 year old boy with joint pains. N Engl J Med 286:205212, 1972
POSTGRADUATE MEDICifE • February 1976 • Vol. 59 • No. 2
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Growing pains John J. Calabro, Antonio E. Wachtel, William B. Holgerson & Michael M. Repice To cite this article: John J. Calabro, Antonio E. Wachtel, William B. Holgerson & Michael M. Repice (1976) Growing pains, Postgraduate Medicine, 59:2, 66-72, DOI: 10.1080/00325481.1976.11714268 To link to this article: http://dx.doi.org/10.1080/00325481.1976.11714268
Published online: 07 Jul 2016.
Submit your article to this journal
View related articles
Citing articles: 7 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20 Download by: [Australian Catholic University]
Date: 23 August 2017, At: 05:41
medical practice today • • grow1ng pa1ns
Downloaded by [Australian Catholic University] at 05:41 23 August 2017
fact or fiction? John J. Calabro, MD, FACP Antonio E. Wachtel, MD
Worcester City Hospital, Worcester, Massachusetts William B. Holgerson
University of Massachusetts Medical School Worcester Michael M. Replce, MD
Worcester City Hospital
What seem to be growing pains could be a manifestation of a serious disease-juvenile rheumatoid arthritis, rheumatic fever, even leukemia. If results of pertinent laboratory tests are normal, it still takes months of close observation before a diagnosis of growing pains can be made with certainty.
• The preparation of this article was prompted by an inquiry submitted to POSTGRADUATE MEDICINE by a physician in Ohio and published in the Problems/Solutions department. * The problem concerned a 7-year-old girl with a five-year history of intermittent leg pains occurring usually at night and lasting for a half hour to an hour. A consultant replied th at three diagnoses might be considered: rheumatoid myositis, muscle cramps, and trichinosis. Subsequent! y, two of us (J .J .C., W.B.H.) suggested in a letter to the Editor that the most plausible explanation was growing pains. Growing pains have received only seant attention in recent medicalliterature. 1 Nevertheless, we hope to convince readers of this article that growing pains represent a clinical entity of importance in the differentiai diagnosis of musculoskeletal disorders in children. The term "growing pains" is ofunknown origin. lt was used as early as 1823 by Duchamp 2 and is widely used today by both physicians and laypersons. Se ham and Hilbert 3 in 1933 defined growing pains as vague recurrent afebrile muscu1ar pains. Hawksley 4 in 1938 expressed disagreement, saying that it was not possible to give the syndrome an exact definition. In 1951, Naish and Ap1ey 5 proposed a set of diagnostic criteria including 1imb pain of at !east three months' duration th at was not specifically located in the joints and was of sufficient se verity to cause sorne interruption of normal activity. The cause of growing pains is also unknown. Early reports implicated excessive use of the legs; in Bennie's 6 words, "the little legs have performed an unusual amount ofwork during the day.'' Hawksley 7 expressed the belief that the limb pain is caused by the increased strain of faulty posture from .scoliosis, pes planus, knock-knee, or other similar abnormality. Os ter and Nielsen 8 contended that the disorder has no organic basis and is an expression of emotional disturbance. To add still another view, we have often wondered whether growing pains are the childhood counterpart of the fibrositis syndrome seen in adults. The reported frequency of growing pains varies considerably, ranging from 4% to 50%. The variability more th an likely reflects differences in diagnostic criteria. 5 • 9 • 10 A recent survey 8 of 2, 178 subjects 6 to 19 years of age gave rates of 13% for boys and 18% 1 for girls. *See p 23, Jul 1974; p 47. Sep 1974.
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February 1976
o
Vol. 59
o
No. 2
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During the past five years, we have observed almost 50 children with growing pains. Clinical presentation varied from intermittent acute attacks of limb pain occurring only at night to more or less chronic, generalized muscle aches and joint pains. Perhaps the best way to highlight sorne of the variability in clinical pattern is to summarize severa! cases.
llluatratlve
ca...
Case 1-A 7-year-old boy had had recurrent calf pain for three years and had been evaluated by nine physicians on as many separate occasions. A number of diagnoses had been suggested, including juvenile rheumatoid arthritis. Attacks occurred almost nightly and were characterized by intense calf
Photo: Tha Ballmann Archiva
Vol. 59 • No. 2 • Fabruary 1978 • POSTGRADUATE MEDICINE
67
John J. Calabro
Downloaded by [Australian Catholic University] at 05:41 23 August 2017
Dr. Calabre is chief of medicine and director of rheumatology, Worcester City Hospital; professer of medicine, University of Massachusetts Medical School, Worcester; consultant in pediatrie rheumatology, New England Medical Center, Boston; and professer of pediatries, Tufts University School of Medicine, Boston.
Antonio E. Wachtel Dr. Wachtel is a pediatrie intern, Worcester City Hospital.
pain that began suddenly and subsided as promptly, usually within 30 minutes. Local massage seemed to ease the discomfort. Physical examination gave normal findings. A battery of laboratory studies, including determination of the erythrocyte sedimentation rate (ESR) (Westergren), disclosed no abnormalities. X-ray films of the knees and lower limbs were normal. A diagnosis of growing pains was made, and aspirin, · 10 grains/day to be taken at bedtime, was prescribed. The parents were reassured that the condition was benign. After three months, during which time the patient had only two recurrences of calf pain, aspirin was discontinued. In the ensuing three years of followup, limb pain did not recur. Comment-The duration of the attacks (three years) and the absence of evidence of accompanying joint inflammation rule out juvenile rheumatoid arthritis and suggest growing pains as the most likely diagnosis. Equally important is the history of a typical pattern ofleg pain occurring on! y at night and awakening the child. When limb pain is more generalized, diagnosis is more difficult. Case 2-A 13-year-old girl had a six-mon th his tory of recurrent pain and stiffness beginning in the knees and later affecting the ankles, elbows, and wrists. Redness and swelling of the joints were said not to be present during the bouts of pain. Also noted as ab-
68
sent were fe ver, rash, anorexia, and weight Joss. On severa! occasions the patient complained of pain in the ante ri or part of the chest wall and of vague abdominal discomfort. On physical examination, the girl appeared healthy but was moderately apprehensive. Knees, ankles, elbows, and wrists were slightly but diffuse! y tender to firm palpation. Examination of the joints was otherwise unremarkable. Laboratory data, including ESR, seriai antistreptolysin-0 (ASO) titers, serum complement leve!, and results of latex fixation and antinuclear antibody tests and ofprotein electrophoresis, were entirely normal. X-ray films of the knees, ankles, wrists, and upper gastrointestinal tract and an electrocardiogram were normal. A diagnosis of growing pains was made, and aspirin, 65 grains/day, was prescribed. At a follow-up visit six months la ter, the patient reported marked subjective relief of pain and stiffness. She had resumed normal activity, including participation in sports. She has now been symptom-free for a year without taking aspmn. Comment-The presentation in this case was atypical. Initially, rheumatic fe ver and juvenile rheumatoid arthritis were considered as diagnostic possibilities. The diagnosis of growing pains was made only after appropriate laboratory determinations had given normal results and we had observed the patient for over a year to make certain that joint swelling did not occur. The patient remains under our observation. Case 3 -For eight months, a 9-year-old boy had had recurrent frontal headaches and abdominal pain associated with bilateral groin and thigh pain that was intensified by motion. There was no history of joint pain, rash, or fever. The boy's mother, a nurse, was apprehensive and overprotective, describing each bout of illness in detail and reading from carefully guarded notes. The aggregate of symptoms occurred about twice a month. Two extensive inpatient workups had been carried out two months apart. On bath occasions, x-ray films of the skull and abdomen were normal and lumbar puncture gave normal findings. Routine blood studies and latex fixation and antinuclear antibody tests showed no abnormalities. The ESR was 7
POSTGRADUATE MEDICINE • February 1976 • Vol. 59 • No. 2
Downloaded by [Australian Catholic University] at 05:41 23 August 2017
mrn/hr. An electroencephalogram and an aiIergy workup were noncontributory. When we saw the boy, he was having episodes of groin and calf pain daily. Physical examination, including a metieulous musculoskeletal survey, gave normal findings. The boy appeared withdrawn and apprehensive, and his mother took the initiative to answer ali our questions. X-ray films of the knees, pelvis, and long bones of the legs were normal. A complete blood count and the ESR were normal. Latex fixation and antinuclear antibody tests were negative. Aspirin, 20 to 30 grains/day, was tried intermittent) y, without apparent beneficiai effect. Meprobamate gave relief of the recurrent headaches. When aspirin was given in a dosage of 40 grains/day, the patient became symptom-free and remained so for severa) months. Then, while he was taking the same amount of aspirin, the bouts of pain recurred, but Jess frequently. We are continuing to observe him. Psychiatrie evaluation and observation of the home environment have been suggested repeatedly, but the mother refuses to accept either recommendation. Comment-This boy's illness is hard to define but appears to be an example of a symptom complex described by Oster, 11 who suggested that the triad of symptoms (recurrent abdominal pain, headache, growing pains) is based on psychologie conflicts stemming primarily from unrest in the home environment. Differentiation from psychogenie rheumatism is difficult. Case 4-A 9-year-old boy was hospitalized because of pain in the anterior aspect of the thigh, primarily on the left side, which caused him to limp. The pain occurred only during the day. It would sometimes make falling asleep at night difficult, but it did not awaken the child during the night. Fever and other symptoms of systemie disease were absent. Traction was instituted as the only form of therapy, and within two weeks the thigh pain subsided. One year later, the boy was hospitalized again bec au se of thigh pain. Physical examination gave entirely normal findings, as did laboratory studies, including a complete blood cell count, determination of ESR, and antinuclear antibody and ASO tests. X-ray
Vol. 59 o No. 2 • FebrullfY 1976 • POSTGRADUATE MEDICINE
William B. Holgerson Mr. Holgerson is a senior medical student, University of Massachusetts Medical School.
Michael M. Repice Dr. Repice is a medical resident, Worcester City Hospital.
films of the affected limbs were normal. We examined the boy saon after the second hospitalization and could not find physical or la bora tory evidence of abnormality. He is one of seven children of divorced parents. It was our impression after taking a complete his tory that there was a general Jack of discipline in the family and that older brothers subjected the patient to repeated harassment. Aspirin, 25 grains/day, was prescribed (boy's weight, 50 lb) and afforded prompt relief. He has been able to resume normal activities. Cllnlcal Spectrum
Sex, age-Growing pains are reported to be slightly more common among girls than among boys. 7 • 8 Symptoms can occur at any age during childhood and earl y adolescence; a peak incidence is not discernible. In two reports, 1 • 7 a higher proportion of parents of affected than ofunaffected children were said to have had growing pains during childhood. Numerous provocative factors have been suggested, such as ill health, pes planus, and food aller gy. Sites of involvement-Typically, growing pains are intermittent and are localized deep in the Ieg. They are often qui te incapacitating. The pain is usually muscular, is sometimes periarticular, and is rarely articular. When the pain is articular, signs of joint inflammation other th an tenderness (red ness, warmth,
69
falling asleep but awakens during the night and cries out when an attack occurs. The frequency of attacks varies from once a day to once or twice a month. Rarely, if ever, are growing pains continuous.
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Examlnatlon and Studles
Figure 1. lrregular fragmentation of tibial tubercle (arrow) due to Osgood-Schlatter disease.
table 1. dlsorders to consider when IImb pain ln a chlld ls generallzed Dleordera
MaJor diagnostic fallturea
Juvenile rheumatoid arthritis
Joint swelling (90% of cases), typical systemic manifestations, neutrophilic leukocytosis, elevation of erythrocyte sedimentation rate
Rheumatic fever
Joint swelling, carditis, documentation of previous streptococcal infection
Polymyositis or dermatomyositis
Proximal muscle weakness, elevation of serum muscle enzyme values
Leukemia
Periosteal proliferation or ether typical articular changes evident on x-ray films; characteristic blood smear and bene marrow abnorrnalities; progressive anemia
The musculoskeletal examination of a child with growing pains is characterized by absence of joint swelling, erythema, warmth, or limitation of motion. At most, articular and muscular tenderness may be present. Children who are asked to localize the areas of discomfort will point to a nonarticular area such as thigh or calf in most instances. The most striking aspect of growing pains is the absence of fe ver and other symptoms of systemic disease. Fatigue, anorexia, and weight loss do notoccur. Sorne of the children appear apprehensive or withdrawn, but this is not a constant feature. Laboratory studies invariably give normal findings in children with growing pains who are otherwise healthy. In fact, a normal ESR may be the first clue to the absence of inflammatory disease of muscles or joints. X-ray films of affected areas are also normal. Course of Dlsease
Attacks may recur for months or, in sorne instances, years. Eventually, growing pains simply subside. Occasionally, after a remission lasting for as long as a year or more, attacks may recur (as they did in case 4). Dlagnosis
swelling, limitation of motion) are notably absent. The most common sites are the thigh, calf, and posterior aspect of the knee. Less common sites are the back, shoulder, arm, instep, and groin. 1 • 7 • 8 Pain Pattern
Growing pains can occur at any ti me of the day or night but typically occur only at night. As a rule, an affected child has no difficulty in
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There is no simple approach to definitive diagnosis of growing pains. Pertinent laboratory and roentgenologic studies are needed, essentially to rule out other diagnostic possibilities. Even th en, it takes months of careful observation and deliberation before the physician can be certain of the diagnosis. Differentiation of growing pains from conditions often confused with them depends primarily on the his tory. Whether the pain is localized or generalized is an important question bearing on what studies are done. For example, if pain is localized to groin, thigh, or knee, roentgenologic examination is important to rule out tumor, osteomyelitis, or a
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form of osteochondritis such as OsgoodSchlatter disease or Legg-Calvé-Perthes disease. Occasionally, the findings may be misleading. During the first month after onset of osteomyelitis, x-ray films of the involved bone may be normal; a correct diagnosis can be made only by blood culture. A child who has knee or shin pain without local swelling may be thought to have early OsgoodSchlatter disease when minimal roughening of the tibial tuberosity is evident on x-ray films. However, this finding represents a normal variation frequently seen in children. In the absence of roentgenologic evidence of progressive changes (figure l ), a diagnosis of Osgood-Schlatter disease should not be made. A similar error may occur when LeggCalvé-Perthes disease is suspected in a child with hip, thigh, or groin pain. Initially, x-ray films of the hip may show a localized area of rarefaction. Only when the changes progress to diffuse rarefaction of the metaphysis and fragmentation of the epiphysis is the diagnosis of this disease justified. If the limb pain is generalized, differentiai diagnosis may be more difficult (table l ). The two diseases most frequently confused with growing pains are juvenile rheumatoid arthritis and rheumatic fe ver. Two thirds of the children with growing pains who have been referred to us were thought by their referring physicians to have rheumatoid arthritis or rheumatic fever. Sorne physicians still regard episodic joint and muscle discomfort as a forme fruste of either ofthese diseases. This is simply not so. Ninety percent of patients with juvenile rheumatoid arthritis will have swelling of one or more joints as an initial manifestation of the disease (figure 2). In the remaining 10% of cases, a diagnosis of juvenile rheumatoid arthritis is made only in the presence of typical systemic manifestations, such as high fe ver, rheumatoid rash, generalized lymphadenopathy, and splenomegaly, as weil as a striking neutrophilic leukocytosis and elevation of the ESR. 12 A diagnosis ofrheumatic fever is made only in the presence of joint swelling, usually with migratory polyarthritis, carditis, or bath, as weil as documentation of previous streptococcal infection, eg, rising ASO titers.
Polymyositis or dermatomyositis is rarely difficult to distinguish from growing pains. An exception may be a case of bilateral hip, thigh, or shoulder pain in a child. Polymyositis may evolve insidiously, and proximal muscle weakness may be so minimal at first that it goes unrecognized. Difficulty in squatting or climbing stairs often is the earliest clinical clue, but demonstration of elevation of serum muscle enzyme values is
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Figure 2. Swelling of left knee and overgrowth of left leg due to juvenile rheumatoid arthritis. For three years before the arthritis was diagnosed, the child was thought to have growing pains.
Figure 3. Periosteal new bone formation (arrows) of the femur in a patient with limb pain due to leukemia.
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needed to confirm the diagnosis. Early elues to the presence of dermatomyositis include violaceous periorbital edema (heliotrope facies) and atrophie, scaly erythema over extensor surfaces of joints, particularly the knees, elbows, and bands. Early features of acute leukemia often inelude rheumatic manifestations. 13 In children especially, the clinical pic ture at first may suggest growing pains. These manifestations are caused by leukemic infiltration or hemorrhage into joints or periarticular structures, secondary hypertrophie osteoarthropathy, secondary gout, or combinations of these. X-ray films of painful areas often will show evidence of perioste al new bone proliferation (figure 3) or other distinctive changes. 14 Rapidly progressive anemia is another clue, but diagnosis ultimately depends on demonstration of characteristic abnormalities in blood and bone marrow. Management
The key to successful management of children with growing pains is education of parents and children concerning the benign nature of the syndrome. Once the diagnosis is certain, this approach must be both decisive and reassuring. Growing pains res pond readily to treatment with aspirin or other analgesies. In a typical case of pain occurring at night, we prescribe aspirin, 2.5 to 10 grains (depending on the child's age and weight), to be taken once a day at bedtime for three to six months. For the
more chronic form of growing pains, we recommend a dosage of 1 grain (60 mg) of aspirin per kilo gram of weight per day, taken in four divided doses, again for three to six months. If growing pains recur when aspirin is discontinued, another three- to six-month course can be gi ven. Supportive measures such as beat and massage help to relieve acute pain, particularly at night. We do not recommend limitation of activity, however, des pite the expressed belief of sorne observers that excessive physical activity may be a pro vocative factor. Thoughtful attention must be given to emotional conflicts or unmet needs. Summary
Growing pains are recurrent limb pains peculiar to children. Brief episodes of leg pains occurring intermittently at night are typical, but the clinical spectrum is variable. A diagnosis of growing pains can be made with certainty only after other possible conditions have been ruled out by appropriate studies and after the child has been observed carefully for a period of months. The two diseases most often confused with this syndrome are rheumatic fever and juvenile rheumatoid arthritis. Aspirin and supportive measures are beneficiai. • Supported in part by a grant from the Massachusetts chapter of The Arthritis Foundation. Address reprint requests to John J. Calabro. MD. Worcester City Hospital, 26 Queen St, Worcester, MA 01610.
References
1. Brenning R: Growing pains. Acta Soc Med Upsal 65:185-201, 1960 2. Duchamp M: Maladies de la croissance 1823. In Levrault FG (Editor): Mémoires de Médecine Practique. Paris, Jean-Frederic Lobstein, 1832 3. Seham M, Hilbert EH: Muscular rheumatism in childhood. Am J Dis Child 46:826-853, 1933 4. Hawks1ey JC: The incidence and signifie ance of growing pains in children and adolescents. J R Inst Public Health 1:798-805, 1938 5. Naish JM, Apley J: "Growing pains": Clinical study of non-arthritic limb pains in children. Arch Dis Child 26:134-140, 1951 6. Bennie PB: Growing pains. Arch Pediatr 11:337-347, 1894 7. Hawksley JC: The nature of growing pains and their relation to rheumatism in children and adolescents. Br Med J 1:155-157, 1939
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8. Oster J, Nielsen A: Growing pains: A clinical investigation of a school population. Acta Paediatr Scand 61:329334, 1972 9. Williams MF: Rheumatic conditions in school children. Lance! 1:720-721, 1923 10. Oster J: Growing pain: A symptom and its significance. Dan Med Bull 19:72-79, 1972 Il. - - : Recurrent abdominal pain, headache and limb pains in children and adolescents. Pediatries 50:429-436, 1972 12. Calabro JJ, Marchesano JM: The earl y natural history of juvenile rheumatoid arthritis: A 10-year follow-up study of 100 cases. Med Clin North Am 52:567-591, 1968 13. Calabro JJ: Cancer and arthritis. Arthritis Rheum 10:553-567. 1967 14. Calabro JJ, Castleman B: Multiple osteolytic lesions in a 16 year old boy with joint pains. N Engl J Med 286:205212, 1972
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