Growing Pains or Something Else?

More recently I have started seeing an increased number of younger patients coming through my door. The primary reason for this is that I have recently become associated with a number of local sports clubs, which are full of enthusiastic young athletes. Their enthusiasm however can sometimes cause them to mask underlying problems and injuries, with the potential to make them worse.

Growing pains is a term that is often given to conditions that affect children and while that is generally accepted it does not mean that treatment should end there. We all suffer from sporting injuries and children are no exception however from my experience of seeing some young patients who have visited their doctor with their symptoms, it appears that there is sometimes the tendency to diagnose growing pains and leave it at that. The aim of this blog is to highlight some of the more common conditions that can present in the lower limb and provide some more information.

Growing pains

To give growing pains there true name we must refer to them as Osteochondroses. Osteochondrosis affects the growth plates in children and occurs when the blood supply is interrupted. This can cause a degeneration or necrosis of the growth plate and causes include: trauma, overuse, vascular issues, abnormal growth and abnormal stresses/forces. It’s most common between the ages of 2-18 until the skeletal bone develops and matures (hence growing pains). Literature tends to suggest boys are generally more likely to suffer but only because historically they run around more and are more likely to suffer from trauma, although any child who is active is more at risk.

Symptoms and diagnosis

Generally there will be specific sites of pain or tenderness, sometimes accompanied with swelling and inflammation. There can be difficultly in walking but often it is on activity that pain starts to appear.

X-ray imaging is usually the most successful form of diagnosis as it enables us to see the affected bone fragment.

 

Common locations

The Knee

 

Image from www.sportsinjuryclinic.net

Image from www.sportsinjuryclinic.net

 

Osgood Schlatters

A relatively common condition which affects the tibial tuberosity (the bony bit at the top of the shin just beneath the knee) where the patella tendon inserts into the leg. Micro trauma caused by the pulling of the tendon on the growth plate produces pain and swelling. More common between the ages of 10-15 and in boys it will be painful during exercise and for a period after exercise. High intensity work from the quadriceps will make things worse so exercises such as jumping and squatting may be worse.

Treatment will include icing the affected area after exercise, stretching exercises for the quadriceps, and soft tissue massage to help with any tightness. Sometimes the bones can grow at a quicker rate than the muscle and tendon, so the pull of the tendon is greater. During sport a patella band or sports tape can help direct the force away from the area.

Sinding-Larson Johannson’s

Similar location to the above however this affects directly beneath the patella (knee cap). The cause is similar to that of Osgood Schlatters

Treatment is very similar to Osgood Schlatters, with cold therapy, taping and stretching being very important. Trying to stabilise the knee cap is important, and there may be a consideration for orthoses if there is an excessive amount of rotation around the leg.

The Foot

Severs

A common cause of heel pain in young athletes and something that I suffered with myself. Pain and tenderness occurs where the Achilles tendon attaches to the heel bone. Often occurs after a growth spurt or at the start of a new sporting season. Football boots and studded footwear often seem to exacerbate the condition.

Treatment often involves stretching of the calf complex and relieving tightness there, gel heel cups and heel raises can also relieve symptoms by reducing the strain on the Achilles tendon. It is worth noting that certain footwear that rubs the back of the heel can also irritate the area further so should be addressed. It is important to rule out other issues such as Achilles tendinopathy or other heel pain.

Freibergs

A painful condition affecting the forefoot, an avascular necrosis of the second metatarsal head. Pain is present around the ball of the foot particularly behind the second toe. This condition affects girls more so than boys, especially those that participate in ballet and dance. The exact cause is unknown although repetitive stress and trauma are likely. X-ray usually shows a flattening or widening of the joint.

In most patients metatarsal pads and an increase in cushioning beneath the foot can give an immediate resolution of symptoms.

 Kohlers

An osteochondrosis of the navicular bone. Often presents between 2-8yrs of age. There is usually no history of trauma and if there is then surgical opinion may be required. Pain around the mid-foot and a limp are the most common presentations. There can be tenderness over the navicular bone along with mild warmth and swelling.

Again it is a self limiting condition and symptoms should resolve on their own, however recent reviews have suggested that a short leg cast for up to 8 weeks can accelerate the resolution of symptoms, although long term outcomes are favourable regardless of treatment.

Iselins

Iselins is a less common osteochondrosis and I have to admit that I wasn’t fully aware of it until it presented in clinic the other month. Typically painful on the base of the 5th metatarsal on the outside of the foot. There can be localised pain, warmth and swelling on the area. The pain is usually worse during activity and improves on rest.

Tight or overactive calf and peroneal muscles can be a factor with Iselins. The peroneal muscle attaches around the area of pain and in a similar way to the patella tendon in the knee conditions, the peroneal tendon can have the same effect in the foot. Stretching and strengthening of the peroneal muscles will be important, along with correct footwear orthoses are an option if foot biomechanics are part of the cause.

If there is a history of trauma then an X-ray should be considered to rule out a stress fracture as this is a common site. Peroneal tendinopathy may also be considered as a diagnosis.

 

xray dorsal - annotations

 

The Hip

Perthes

This is a hip disorder that results from a partial interruption of the blood supply to the femoral head. Children between 4-8yrs are most at risk. Risk factors include, low birth weight, higher birth order, complications at birth and family history.

Patients can present with hip pain, limping and referred knee pain. Limited hip range of movement is also demonstrated on examination. Investigation including scans is recommended to rule out other conditions and surgical treatment is often required. If patients are treated early then there is a lower risk of later life arthritis and range of motion can be preserved.

As with all of these conditions they are usually self limiting and pain can be improved with a tailored exercise plan. Stretching and strengthening exercises become an important part of rehab and should be followed carefully to improve and prevent problems from arising.