Synopsis
Recognise common benign flexibility and recurrent nocturnal limb pain while identifying the minority with inflammatory, neurological, malignant, metabolic or heritable connective-tissue disease, and manage function without unnecessary restriction.
- Generalised joint hypermobility describes movement beyond the expected range for age, sex and background. It is common in children and is not a disorder when painless and functionally harmless.
- A Beighton score standardises selected joint movements but is not a diagnosis by itself; interpret it alongside age, symptoms, other joints, skin and tissue features and functional effect.
- Symptomatic hypermobility may cause activity-related pain, fatigue, recurrent sprains, instability, poor proprioception and coordination difficulty, yet pain severity does not correlate reliably with flexibility score.
- Growing pains are recurrent bilateral aching or throbbing leg pains in children, usually aged 3 to 12 years, occurring in the evening or night and disappearing by morning with a normal examination.
- Growing pains are not caused by physical growth. The diagnosis is clinical and should not be used for unilateral, focal, morning or activity-limiting pain, limp, swelling, weakness, systemic illness or abnormal examination.
- No investigation is needed for a classic growing-pains pattern or uncomplicated asymptomatic hypermobility. Tests should answer a specific alternative diagnosis rather than provide an indiscriminate screen.
- First-line symptomatic hypermobility management is education plus graded strength, endurance, balance and proprioception work, usually supported by paediatric physiotherapy when function is affected.
- Encourage normal school, play and low-impact exercise with pacing; prolonged rest, routine braces and fear-based activity avoidance can worsen deconditioning and disability.
- For growing pains, use reassurance, massage, warmth and occasional child-appropriate paracetamol or ibuprofen if necessary, while giving explicit advice about red flags and reassessment.
- Marked skin fragility or hyperextensibility, atrophic scars, recurrent atraumatic dislocations, unusual fractures, marfanoid or vascular features, significant developmental regression or a concerning family history needs specialist assessment.
Key red flags
Unilateral, focal or progressively worsening pain is not the usual growing-pains pattern.
Morning pain, persistent stiffness or objective joint swelling suggests inflammatory disease.
Limp, refusal to bear weight or pain during normal daytime activity requires assessment rather than reassurance.
Fever, weight loss, pallor, unusual bruising, lymphadenopathy or night sweats raises concern for infection or malignancy.
Focal night pain that continues into daytime or produces local bony tenderness warrants imaging and blood tests.
Objective weakness, Gowers manoeuvre, regression or altered reflexes requires urgent neurological evaluation.
Fragile or very stretchy skin, atrophic scars, recurrent atraumatic dislocations or vascular and ocular features suggests a connective-tissue disorder.
A family history of arterial rupture, aortic disease or sudden unexplained young death requires specialist assessment.
Fever, weight loss, pallor, bruising, lymphadenopathy or focal persistent night pain requires urgent medical assessment.
Regression, objective weakness, Gowers manoeuvre or altered reflexes indicates a neurological pathway rather than flexibility alone.
Investigation priorities
Define timing, laterality, function and red flags, then examine gait, joints, bones, power, reflexes, skin and systemic signs.
Management branches
Pain is bilateral, evening or nocturnal, absent by morning and examination and daytime function are normal.
- Explain that the episodes are benign, are not caused by growth and often fluctuate over months before resolving.
- Use massage, warmth, sleep support and occasional age-appropriate simple analgesia when discomfort requires it.
- Provide written return advice for unilateral, morning or focal pain, limp, swelling, weakness, fever, bruising or weight loss.