From the Guidelines
The evaluation and treatment of pediatric leg muscle pain should begin with a thorough history and physical examination to determine the cause, with a focus on identifying inflammatory conditions such as juvenile idiopathic arthritis (JIA) that may require disease-modifying anti-inflammatory drugs (DMARDs) or biologic DMARDs, as recommended by the 2019 American College of Rheumatology guideline 1. The most common causes of pediatric leg muscle pain include growing pains, overuse injuries, trauma, or less commonly, inflammatory conditions like JIA. For growing pains, which typically occur in children 3-12 years old and present as bilateral leg pain in the evening or night, reassurance and comfort measures are the mainstay of treatment. Parents can provide gentle massage, warm compresses, and acetaminophen (10-15 mg/kg every 4-6 hours) or ibuprofen (5-10 mg/kg every 6-8 hours) for pain relief.
- For overuse injuries, rest from the aggravating activity for 1-2 weeks is recommended, along with ice application for 15-20 minutes several times daily, and NSAIDs like ibuprofen for pain and inflammation.
- Stretching exercises before and after physical activity can help prevent recurrence.
- If pain is severe, persistent, unilateral, associated with swelling, redness, fever, weight loss, or limited mobility, prompt medical evaluation is necessary as these may indicate more serious conditions like stress fractures, infection, or rheumatologic disorders.
- Physical therapy may be beneficial for persistent pain or specific muscle imbalances, focusing on strengthening and flexibility exercises, as conditionally recommended by the 2019 American College of Rheumatology guideline for the treatment of JIA 1. Most childhood leg pain is benign and self-limiting, but persistent or concerning symptoms warrant further investigation with imaging studies or laboratory tests to rule out more serious conditions.
- In cases of JIA, the use of DMARDs such as methotrexate is conditionally recommended, with subcutaneous methotrexate being preferred over oral methotrexate 1.
- Biologic DMARDs such as etanercept, adalimumab, or tocilizumab may be considered for patients with JIA who do not respond to DMARDs, with combination therapy with a DMARD being conditionally recommended over biologic monotherapy 1.
From the Research
Pediatric Leg Muscle Pain Workup
- The workup for pediatric leg muscle pain involves a comprehensive, multidisciplinary, systematic, and stepwise approach, considering the patient's individual anamnestic, psychosocial, and clinical characteristics 2.
- A thorough evaluation should be performed to identify the underlying cause of the pain, including a review of the patient's medical history, physical examination, and diagnostic tests as needed.
Treatment of Pediatric Leg Muscle Pain
- The treatment of pediatric leg muscle pain depends on the underlying cause and severity of the pain, and may involve a combination of pharmacologic and non-pharmacologic interventions 3, 4, 5.
- For mild to moderate pain, acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used as first-line treatments, with topical NSAIDs recommended for non-low back, musculoskeletal injuries 5.
- For severe or refractory pain, treatment may be escalated with the use of medications that work on opioid and monoamine receptors, or with the use of acetaminophen/opioid or NSAID/opioid combinations, with careful consideration of the risks and benefits of opioid use 5.
- Non-pharmacologic interventions, such as physical therapy and complementary therapies, may also be useful in managing pediatric leg muscle pain 3, 4.
Importance of Pain Assessment and Management
- Adequate pain management is essential for the emotional and physical healing of children with leg muscle pain, and a balance must be achieved to provide acceptable pain relief while minimizing opioid use and side effects from analgesic medications 3, 6.
- Nurses play a critical role in assessing and managing pain in children, and education and training on pain assessment and management can improve outcomes 6.