Children’s Leg Pain/Growing Pains: Benign Nocturnal Limb Pains vs Apophysitis
Leg pain in children is something many parents encounter but not all pain is the same. Two common causes are Non-Specific Benign Limb Pain of Childhood (often called “growing pains”) and apophysitis. Knowing the difference can help you respond appropriately and seek support when needed.
Benign Nocturnal Limb Pains (BNLP)
This is the medical term for what many call growing pains. Importantly, it is not directly caused by growth, but the exact cause is still unclear.
Key characteristics:
Common in children aged 3–12 years
Pain is typically felt in both legs (calves, thighs, or behind knees)
Occurs later in the day or at night
May wake a child but is gone by morning
No swelling, redness, or limping
Child remains active and well
When Is Reassurance Appropriate? (Based on NICE Guidance)
According to NICE Clinical Knowledge Summaries, reassurance is appropriate when:
The child is well with no red flag features
Aged 3–12 years
Pain is symmetrical in the lower limbs
Pain is intermittent (not constant)
No pain on waking
No limp or activity limitation
Normal physical examination (aside from possible hypermobility)
The child is meeting motor milestones appropriately
Management includes:
Reassurance and education
Gentle massage and warmth
Over-the-counter pain relief if needed
Encouraging normal activity
Signposting to trusted resources (e.g. NHS)
Parents should be advised to seek review if symptoms change.
When Should You Refer?
Growing pains is a diagnosis of exclusion, meaning other causes must be ruled out first.
Refer for further assessment if there are:
Red flags or atypical features, including:
Unilateral (one-sided) or asymmetrical pain
Pain that is persistent or worsening
Pain that is widespread (e.g. arms, back)
Pain occurring in the morning or during activity
Pain localised to a joint
Systemic symptoms (fatigue, malaise, reduced appetite)
Concerning clinical signs:
Limping or refusal to weight bear
Changes in gait or movement
Joint swelling, stiffness, or reduced range
Weakness or tenderness
Palpable masses
Functional concerns:
Reduced participation in sport, school, or play
School absence
Developmental delay or regression of motor milestones
Clinical judgement should guide the urgency of referral.
Apophysitis
Apophysitis is a growth-related condition affecting tendon attachment sites (growth plates), commonly seen in active children and adolescents.
Common examples:
Heel pain (Sever’s disease)
Knee pain below the kneecap (Osgood-Schlatter disease)
Key characteristics:
Localised pain (specific point)
Worse with activity (running, jumping)
May cause limping or reduced performance
Tender to touch
Improves with rest but returns with activity
How Physiotherapy Can Help
For children with apophysitis or ongoing concerns:
Support load management (balancing rest and activity)
Improve strength and flexibility
Address movement patterns
Guide a safe return to sport
Final Thought
While Benign Nocturnal Limb Pains is common and harmless, it’s important to recognise when something doesn’t quite fit the pattern. Apophysitis and other conditions require a more targeted approach, especially in active, growing children.
If in doubt, it’s always appropriate to seek advice. Early support helps children stay active, confident, and pain-free.
Bloom and Balance Physio – helping children move well through every stage of growth.
