What is the recommended management for leg pain in children?

Management of Leg Pain in Children

For most children presenting with leg pain, the initial approach should focus on identifying whether this represents benign growing pains versus a pathological condition requiring specific intervention, with NSAIDs and non-pharmacological measures forming the cornerstone of symptomatic management for benign cases.

Initial Assessment Priorities

When evaluating leg pain in children, focus on these key distinguishing features:

• Red flags requiring urgent evaluation: Persistent unilateral pain, joint swelling, systemic symptoms (fever, weight loss), nighttime awakening from pain (rather than pain upon awakening), morning stiffness, or functional impairment 1
• Dietary history is critical: Specifically ask about restrictive eating patterns, particularly in children with autism spectrum disorder, as vitamin C deficiency (scurvy) is an increasingly recognized cause of leg pain and limping 2
• Pattern recognition: Growing pains typically occur bilaterally in the evening or night, affect the thighs, calves, or behind the knees, and resolve by morning without functional limitation 3

Management Algorithm for Benign Growing Pains

Pharmacological Options

• NSAIDs are the first-line pharmacological treatment when medication is needed, though they should be used judiciously given potential gastrointestinal, renal, and antiplatelet effects (rare in children) 3
• Acetaminophen dosing for children 12 years and older: 2 caplets every 8 hours with water, maximum 6 caplets in 24 hours, not to exceed 10 days unless directed by physician 4
• Avoid undertreatment: Proactive use of appropriate analgesic therapy is recommended rather than waiting for severe symptoms 3

Non-Pharmacological Interventions (First-Line)

• Heat application: Warm compresses or heating pads help relax muscles and reduce discomfort 3
• Distraction techniques: Useful tools during pain episodes, similar to approaches validated in post-tonsillectomy pain management 3
• Anxiety management: Address parental and child anxiety, as this can exacerbate pain perception 3

Conditions Requiring Specific Management

Inflammatory Arthritis (JIA with Enthesitis)

• NSAIDs as adjunct therapy are conditionally recommended 5
• Physical therapy and/or occupational therapy should be initiated in children with or at risk for functional limitations 5
• Consider DMARD therapy if inflammatory arthritis is confirmed 5

Familial Mediterranean Fever

• NSAIDs are suggested for exertional leg pain in this population 5
• Colchicine remains the primary treatment for FMF, but musculoskeletal manifestations may require additional interventions 5

X-Linked Hypophosphatemia (XLH)

• Presents with leg bowing and bone pain 5
• Requires specialized metabolic bone disease management with phosphate supplementation and active vitamin D 5
• Regular orthopedic assessment needed for limb deformities 5

Scurvy (Vitamin C Deficiency)

• High index of suspicion in children with restrictive eating, particularly those with autism spectrum disorder 2
• Characteristic MRI and radiographic findings can guide diagnosis 2
• Vitamin C supplementation leads to repletion within weeks, though underlying feeding issues require ongoing specialist intervention 2

When to Refer

Refer to pediatric specialist when:

• Pain significantly impacts daily functioning or quality of life 3
• Persistent unilateral symptoms 1
• Joint swelling, morning stiffness, or systemic symptoms present 1
• Abnormal gait persists beyond initial evaluation 1
• Restrictive eating patterns with concerning imaging findings 2

Common Pitfalls to Avoid

• Do not dismiss bilateral leg pain as "just growing pains" without considering vitamin D deficiency (present in 87% of one study cohort), increased joint mobility, or ankle dorsiflexor strength abnormalities as contributing factors 6
• Do not overlook dietary history: A simple question about diet can prevent unnecessary imaging, procedures, and prolonged symptoms in cases of scurvy 2
• Do not undertreat pain: Children experiencing chronic or recurrent pain are at risk for medical traumatic stress, more intense responses to subsequent pain, and development of chronic pain syndromes 7
• Do not assume all nighttime leg pain is benign: Pain that awakens a child from sleep (rather than being present upon awakening) warrants further investigation 1