Nightime leg pain in 10 year old (Full Version)

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kiwi PT -> Nightime leg pain in 10 year old (May 8, 2008 11:14:10 PM)

I just evaled a 10 year old girl with diagnosis from PCP of "Arthalgia". According to the mother she has such severe nighttime pain in her lower leg almost every night that it makes her scream and she can hardly sleep, yet she can run around and play on the playground with out a problem.  I wasn’t able to do anything in the clinic that reproduced her pain, her gastroc that side was perhaps a little tighter than on the other side but she had no problem doing several unilateral heel raise, no TTP, and could jump, skip, and run without problem. The child had a difficult time describing the location the pain and said the whole leg below the knee hurt.  The mother was also very concerned about the hard bumps on the plantar surface of her toes that she would get at night that she “couldn’t rub out”. I asked the child if it was in her toes that she hurt too and she said “no”, I’m pretty sure the mother was just feeling a normal interphalengeal joint.

My first impression is that my wife’s (A social worker) services may be more valuable than mine.  I wonder about calf cramps from dehydration or salt imbalance but would doubt that it would be as consistent as it is reported.  The mother did most of the talking and the child seemed very bored and distracted and it was difficult to get her to do more of the talking.  I learned from the mother that parents are divorced and currently undergoing more legal battles, that the child and the mother sleep in the same bed, and that the father also has had leg pain which the mother believes her daughter must have inherited. Also the mother states that she been threatened with truancy papers from school because she is frequently late because she has so much trouble sleeping because of the pain that she tries to let her sleep a little more.

What am I missing from a musculoskeletal/medical perspective? How would you handle this pt?

Kyle PT



aph401 -> RE: Nightime leg pain in 10 year old (May 9, 2008 12:37:57 AM)

do you think it's possible she's just experiencing intense growing pains? but, according to medhelp, leg pain only at night time suggests that it might be due to some nerve compression at the lower back level.



SJBird55 -> RE: Nightime leg pain in 10 year old (May 9, 2008 6:49:15 AM)

I will assume you assessed her pulses in that lower extremity and everything was fine (I'm pretty sure they would be fine).

How long has the leg pain been occurring?  Does the little girl spend time with her father?  Does the little girl have the same symptoms at night when she is with her father?  (Might be a touchy situation to ask permission to speak to the father.)  Or another question, has the little girl recently spent the night at a friend's house OR another family member's house?  Another tough question that might be avoided, but at the same time could be asked - has the little girl been sexually abused?

With night pain and kids I think osteosarcoma... but it isn't as common in girls as in boys and is more common during teenage years with growth spurts, at first the pain is more common at night - but then progresses to pain with activity, swelling and sometimes a limp.

Has this little girl had any counseling prior, during or after the divorce?  Sounds like this divorce was a messy divorce and I'm sure the situation hasn't been easy for the little girl.



USAPT -> RE: Nightime leg pain in 10 year old (May 9, 2008 9:56:15 AM)

Agree with SJ.
Also, is the father listed anywhere on the intake forms at all, if so call him up unless the mother specifically said not too.

Any medications? Previous trauma? Pain is only in her leg, correct?

If you cannot find any Msk impairments, call the PCP and expalin your 'lack' of findings and you believe this may not be a PT case. Do some research and present some possibilities to the MD but obviously don't 'tell' the MD it's this or that. Good luck, keep us posted 
-Jason



Kaden -> RE: Nightime leg pain in 10 year old (May 9, 2008 11:51:28 AM)

Severe consistent night pain in my opinion is never a good thing.  I think CA possibly as allready brought up or psychosocial as allready brought to light in the post.  I think a phone call to the MD is a good place to start.  I am one that does not believe you would need to offer alternate explanations for this pain.  You are a musculoskeletal expert and if you don't feel that it is a musculoskeletal problem...or even have the remote thought that it may not be one then it is best to refer back. 

Severe night pain may ultimately show to be benign but combined with a MSK exam with little findings I think the patient should be referred back.  If this has not been occuring long you may be seeing the beginning of something more serious and thus the signs are not there.



steve -> RE: Nightime leg pain in 10 year old (May 9, 2008 2:09:29 PM)

Kaden,

You posted pretty much word for word what my response would be...

Here are your options with this kid - serious pathology, non organic pain presentation secondary to psychosocial issues and simple MSK pain. The probability of this being due serious pathology or psychosocial issues are significant enough to at the very minimum have a discussion with the referring PCP.

Steve



gerry -> RE: Nightime leg pain in 10 year old (May 9, 2008 5:23:08 PM)

All the above posters make good points, and should be considered.  The social situation certainly is a factor, if not in the reported pain itself, certainly in the way it is handled.  Hopefully, this will turn out to be "growing pains".  Two of my children have experienced pain at night to the point they cried, with no long term problems.  They would also have a difficult time pinpointing the area that hurt, and would be fine during the day.  It was often worse on nights that followed busy days.  Also, I could not do anything that reproduced the pain. 

Good Luck!



plhunter -> RE: Nightime leg pain in 10 year old (May 10, 2008 1:40:36 PM)

How about drinking a tonic with quinine before going to bed.  Pretty simple but it may work.  They do give medications, with quinine being the active ingredients for restless leg syndrome.  Or, she may be lacking in calcium or potassium.

Peggy



Kaden -> RE: Nightime leg pain in 10 year old (May 10, 2008 2:26:27 PM)

plhunter,

I think you are missing the point on this one.  Your idea of quinine may ultimately be a  solution but that is not your choice to make.  If something does not seem musculoskeletal then it probably is not and needs to be referred out.

If we ever want be direct access clinicians these are the scenarios we will face.  If we ignore the more serious medical issues (CA, psychosocial) and apply a convoluted thought process to make every patient that come through our door someone we can help with PT then we will ultimately be missing some possible serious pathology.

Bottom line.  If a patient presents with signs/symptoms that could be of serious pathology then this needs to be ruled out first, both in the PT assesment (which kyle did with a complete assesment showing no significant MSK issues) and with a referral to MD if determined to be needed. 

To take scant musculoskeletal findings, turn a blind eye to the  bigger picture, and fit this person into the "PT can help you box" is both irresponsible and more fuel to the physician fire as to why PT's should not be point of entry clinicians.



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