Growing pains

We missed you, Robert. Welcome back.:drinks

 

Thanks for the comments. This article was submitted to PMM according to their restraints on space, so it was "pared down" to 3K words. The original transcript was 10K words, 42 pages long on MS Word. It was not easy to accomplish that while retaining the essence of the pilot study. The first 13 pages of the original manuscript was devoted to the historical record, complete with the citations you viewed as lacking. The hypothesis is that GP's, (and at least a subset of RLS), is referred pain from the STJ. I offered a working hypothesis,and even discussed expansion of the study to further delineate this problem. This pilot study also included animation, video interviews with the patients and the parents, and in the case of RLS, included an interview with a Board Certified Prosthetist/Orthotist whom experienced GP's as a child and RLS as an adult. His interview is compelling. But I digress.

You mention a lack of a control group. Fair enough. At least you didn't mention the lack of utilizing placebo orthotics. Were you as candid with Angela Evans in her 2003 article for the same? If you read the historical record, particularly the article from Hawksley 1939, you will find even less "scientific" constructs, yet the answer was there for all to read and test.

All this article was intended to do was to begin the discussion. I not only offered a working hypothesis, (subluxation of the STJ), but a manner to test efficacy of the treatment as well as determing the source of pain. Perhaps you missed that. Considering you have a large Pediatric practice, maybe you can use the same testing methods to test that hypothesis. For 192 years, physicians have told parents that "little Johnny or little Suzie" would grow out of these pains. One would think that you'd be delighted that this misinformation was soon to be discarded as my hypothesis gets more exposure and tested. Every one of the parents I interviewed, (and many more since I concluded the pilot study), knew that the information that was being told to them by their Pediatrician was bogus. Imagine that. And without exception, they are thrilled that I have an answer that works. Better patient outcomes, after all, is the name of the game, n'est pas?

 

Indeed, as I said. One usually finds the hypothesis at the beginning of the methodology (as it informs the methodology). But the data you collected, such as it was, does not support this hypothesis.

At the time, no. I was considerably less ornery back then, and less aware of the nature of research. However it should be noted that after Angela's pilot study, she followed it up in 2007 with a broader study, with higher numbers, and crucially, a FALSIFIABLE hypothesis. And indeed, she discovered that the postulation of her earlier trial, that GP was associated with flat feet, was not correct. That's what a good scientist does, tries to prove themselves wrong. That is why the order of things, hypothesis, NULL hypothesis methodology etc is so important.

What she never did, anywhere, was confidently state "X is the cause of growing pains" and wonder why everyone did not stand up and shout "eureka".

I don't doubt it! Evidence based medicine has come on an awful long way since 1939.

Wait, what?! You just said that

That's two different hypotheses. One for the nature of GP (referred pain) and one for the cause of the referred pain (subluxation of the stj). Either one of those could be true, or both. Or neither come to that!This is why the hypothesis needs to be clearly and unequivocally set out at the beginning of the text. A single barrelled hypothesis is hard to prove. A double barrelled? Almost impossible.

Indeed I did miss it! What was the method to test the efficacy of the treatment. Pain scores? Owlestry disability questionaire? Where is the data? And how do these things determine the source of the pain?

If you mean where you said that if you poke the sinus tarsi and the patient says ouch you can infer that that is why a different part of the body hurts at night, well thats just silly. That is, again, bald assertion. One might as well say that if you jab them in the eye and they respond symptomatically then its proof that the leg pain is referred from they eye.

You think this article BEGAN the discussion?

One of your references, which you referenced incorrectly by the way, you did not include the title and you made an incorrect attribution, was angela evans rather excellent literature review.

She cites no less than 45 studies, 23 review articles, and 22 original studies, on the topic of growing pains in children. Within these we find 7 proposed aetiologies, 7 proposed associations and several proposed treatments with differing levels of evidence to support them.

These proposed mechanisms are laid out, logically and fairly, with the evidence, or lack thereof, to support each hypotheses.

So no, this article does not start the debate. Its not like we've all been scratching our head wishing we had a hypothesis for GP for the last 20 years. We have plenty, and a couple of very good ones.

What this article does, is throw in another new theory as to the aetiology and nature of GP. It does so, without any supporting evidence beyond your opinion. Because the investigation side of the piece supports it not at all.

Eleven People "getting better" after being prescribed with some orthoses, and thats a charitable way to describe the data since neither the treatment protocol nor the outcome measure are clearly described, is not in any way evidence for this theory. We would expect to see the same outcome if any one of 4 of the 7 models previously described in Angela Evans review was the true culprit. Orthoses might help were the problem hypermobility, anatomical, muscle fatigue or indeed pschological.

In order to accrue data to support your hypothesis, one would have to construct a protocol where the treatment for a subluxing STJ would not ALSO treat the psychology, the effects of hypermobility, flat feet or muscle fatigue.

 

Growing Pains Hypothesis=referred pain from the STJ. Etiology=subluxation of the STJ. Mechanism=transient synovitis secondary to said subluxation. Cause=uncompensated rear foot varus/FF varus or both.

I guess you missed my paragraph: "But just because a patient presents with a pes planus, or flatfoot deformity, doesn?t mean that the sub-talar joint is functioning at its? end of range-of-motion at forefoot loading or static stance. Conversely, a foot that presents with a very high arch, or pes cavus, does not exclude the possibility that the sub-talar joint is functioning at its everted end of range of motion during the gait cycle."

While admittedly, I did not break down the individual patients' foot type, I discussed the 3 main causes that I observed in the study, (and dozens more since that time). In all, there were 17 patients included in this pilot study, which is over twice as many as Angela Evans had in hers. I'm also assuming the finding offered in the study of the symptoms returning after the orthotic was removed, but once again resolving after re-introduction, is meaningless in your world? Further, the painful symptoms expressed by the patient prior to treatment, that vanish afterwards are also meaningless to you. So be it.

You mention several studies that offer viable explanations for the cause of GP's. Having read much of the literature on the subject, and having found zilch, could you please provide a link to some of these studies? That would be appreciated. Off to work! Successfully treating pain is so rewarding...isn't it?

 

Bloody hell, they're breeding! Thats FOUR hypotheses!! Any one of which are not interdependant and none of which are tested by sticking insoles in peoples shoes.

Nope. You OBSERVED pain. You OPINED about the causes of that pain.

Its kinda stating the obvious, but correlation =/= causality. Just because somebody has growing pains AND a rf varus or a FF varus, does not mean that they had growing pains BECAUSE of rf varus or FF varus.

To put it another way, I'm quite sure all of your GP patients ate bread. But you can't say, "well, all these patients had GP and ate bread, hence I observed that the bread was the cause of the GP".

As I said, even if we give you a pass on the total lack of methodolgy, data collection tools etc and accept your findings, they show one thing only. That the patients you treated with an undescribed orthotic, using an undisclosed protocol, had relief of growing pain. Nothing more.

No, I saw it. Didn't see the relevance, of it to your contention, but I saw it.

In her PILOT study. Considerably less than in her follow up study, in which she disporved her own hypothesis.

That finding, (n=2), is by no means meaningless (although probably statistically insignificant if you'd done any statistics). But all it does is support the contention that those insoles helped those patients with their GP. As I explained, that finding would also dovetail with 4/7 of the other proposed aetiologys of GP, and in no way supports any of your growing number of Hypotheses.

Sheesh, I already gave you the link to the meta analysis which you claimed as one of your references. But since I have a heart of gold, I'll copy pasta from the paper for you. You'll have to follow up on the references youself. Although if your plan is to find holes in all the OTHER theories, that would in no way add to the validity of your. Just sayin.

 

I think it would be fairly safe to say, given the in-depth nature of your thoughts on Dr Sciaroni's article, that you probably didn't miss anything, let alone a whole paragraph?

Always good to read your thoughts Robert, so long as they are down in word form, because, despite my many elastic band and coin tricks, I can't mind read

 

Yeah sorry. I got a bit battle fatigued going around the same stumps with the same people. But now there are all new stumps with all new people. .

 

If we screened a group (number?) of children in the appropriate age group for GP's and divided them into groups:
Group A: Those that are positive for uncompensated rear foot varus
Group B: Those that are positive for FF varus
Group C: Those that are positive for both FF varus and uncompensated rearfoot varus
Group D: Those that are negative for any of the above
And then had them, with the assistance of a parent, complete a questioner that asked, amongst other non-related questions, about the history of growing pains, would this give us an indication that parts of this hypothesis might be true? In other words, would we see the highest incidence of GP in group C? Would we find a significantly higher incidence of GP in groups A, B and C as compared to group D?

Jeff

 

Hey Jeff. Been a while. :drinks

Short answer, no, I don't think so. This would come closest to number 4, that the cause was FF/RF varus. However all it would show would be correlation, not causality. There might be a separate variable which caused both rf varus AND GP. Or there might be a more proximate variable.

A hypothesis with the word "Cause" in it is bloody hard to prove. He's given himself an absolute mountain to climb with that one.

The other problem would be how one would validly measure rf varus and how one would distinguish between forefoot varus and supinatus.

Tweak the hypothesis to read that GP is predicted by, there might be something to work with...

 

Yeah, yeah, yeah...I read all those articles you submitted. Actually, a psychological "association" was first written about in 1937 by Neustatter, and later written about by Winnicott in 1939, Flind and Barber in 1945 and Sheldon in 1946...all referenced in my expanded manuscript, and dismissed thereafter. I've also read Hashkes most recent articles on arterial perfusion, but he came to the conclusion that there was no association. But I just wonder if you were as vehemently opposed to the process by which he and his colleagues summarily dismissed an articular source, and the process by which they came to that conclusion? I seriously doubt you gave a second thought about it. I can look up the sources offered by many others, and have. What I asked YOU, was what YOU deem viable explanations...not the regurgitation of studies from post-WWII that never explain jack-diddly.

So...let's get down to the nitty-gritty. How many parents in your career did you tell that little Johnny or Suzie would grow out of the pain? How many patients did you offer the same tired excuse that the long bones are growing faster than the soft tissue can keep up with, without ever once thinking about why we never observe GP's in the arms?

Deliver treatment...pain goes away. Take the treatment away...pain returns. Reproducible pain elicited with palpation to the STJ that completely vanishes with treatment. Never mind the facts...and in the words of Mark Twain: "Never let the facts get in the way of a good story(rant)."

The way this discussion is heading, I might have to consider you the Neville Chamberlain of Podiatry.

 

Sorry, the ones from PRE world war 2 are not so good.

Actually, what you said was

So to be clear, when you asked for links to studies, you did not want me to regurgitate studies. That's brilliant.

I deem several of those to be viable explanations, although the one I think most viable is the tissue fatigue one. Are you asking me for explanation which I think are viable or the ones which YOU think are viable. You seem confused on this point.

By the by, did you see how eerily prophetic I was when I said

Not that this line of justification was predictable in any way

Lets see... 18 years, 10 specificly in paeds, say 100 pts per week... carry the 9, adjust for windage...

I'd say approximately... none. Like many podiatrists I've been treating growing pains very successfully for many years, with a combination of orthoses and stretching. As have all the people in my team. As has, I hope, anybody who's been to one of my lectures on Paediatrics. Actually, its one of the easier conditions to treat, in my experience even pre fabs do the job pretty consistently.

You seem to be laboring under the quaint assumption that you're the only one to be treating this very common, bread and butter condition successfully with orthoses. Hate to tell you, you're not. You're storming a bastion which has long since fallen. The battle goes on to educate our medical brethren of course.

Wax on, wax off. You still don't seem to grasp that having treated some of these successfully is a distinction you share with a very large number of colleagues. It does not afford you any insights which are unavailable to the rest of us. Did you understand the point I made that the insoles in your picture would have addressed the pain if any one of four proposed aetiologies is the right one?

As simply as I can state it. I don't disbelieve that your orthoses helped those patients. I'd have been surprised if you had NOT been able to issue orthoses which helped these patients. But that adds not a whisper of credence to the rest of your theory.

Wow. Its almost like the the insoles had some sort of effect on the sub talar joint. Bizarre. That blows my mind man!

If your goal was to establish a correlation between pain on palpation of the sinus tarsi and night pain, you needed to conduct a different study. Oh, and have some sort of methodology a little more sophisticated than "I poked it and they said ow".

 

Jeff-thanks for the attempt at designing a study that might be easier to pass peer review in all parts of the world. While I recognize the need to better define the patients' structural deformities in an expanded study, I simply refuse to abide by those that adhere to utilizing placebo orthotics as a "null" or control group. In an expanded study, sheer numbers will most certainly overwhelm the nattering naybobs that exist, not only here at PA but in other regions worldwide.

I find it interesting, however, that the biggest "push back" I've received is from Podiatrists that hail from the UK and Australia...and I write that in deference to being labeled a xenophobe. Isaacs writes about eating bread as something that should be considered, as an example, of course. Are you kidding me? Forget the fact that the reported rate for GP's is anywhere from 13-37%. Why stop at eating bread? Why not include breathing air, which should be excluded? Oh, that's right...only 13-37% of children report having the disorder. Oh well.

My point is, that some are more concerned about the process than they are about discovering the truth, ie., the information. Being proper is more important than the actual information offered. Isaac's post are an illustration of that. Angela Evan's rebuttal to my article, where she holds my pilot study to a higher standard than either of her own studies in 2003 and 2008, another. Let's be "proper" in our studies, and be damned about the information. The world can wait for resolution of a problem that was discussed 192 years ago, and in the case of RLS, before that. Forget trying to prove me wrong, or correct...ad hominems and presentation are more important in their world than the message itself. In the meantime, I'll just continue to offer patients welcome and necessary relief...it's the right thing to do.

 

I had Ron Valmassy review the material prior to submission for publication, and he and I had a long chat about this very subject. Yes...while many Pods have and are successfully treating GP's with orthotics, many are not. Further, until I defined the source, not one Podiatrist knew why the orthotics worked. I reviewed VOLUMES of publications...and not one word about referred pain from the STJ...mine is the first. Further still...until my pilot study, no researcher has made the anatomic/neurologic connection between GP's and RLS. Oh, Walters et al have tried...but researchers have, for the past few years, described GP's as the adolescent form of RLS...which is exactly backwards...RLS is the adult version of GP's. Not one researcher and/or doc has written about that...not even someone as accomplished as yourself. And when did I ever write that the patient said "ow", when I palpated the sinus tarsi or posterior facet? You're not applying your own bias towards the information...are you?

However...I have to give credit where it is due...you have admitted that you have successfully treated GP's with orthotics. Good. Now you know why they work. And you should be able to also determine why they don't. Using Root biomechanics, hold the patient's STJ in more neutral position and thereby not allowing that joint to function in a totally everted position, and voila!...the pain resolves. Next time...try asking the parents if they have RLS...you'd be surprised how many actually do, whether previously Dx'd or not. Just test my hypothesis...prove me correct or wrong. But most importantly, remember that better patient outcomes is in everyone's interest.

 

Think we're almost to the point of repeating ourselves here, but we shall drink the cup to the dregs....

I'm actually curious. Pre your study there were 4 models for GP which would explain why the orthotics would work. Now there are 5. You freely dismiss the other 4 as not viable.

Since you thus clearly appreciate the process of rejecting somebody else's work as flawed, why do you not understand why other people may not do the same to yours. Your paper is clearly not the only attempt to explain GP and its certainly not the best presented. Is it so hard to believe that other people consider your work the same way you consider other peoples?

Eh? So let me understand you here. You're saying that they are the same condition in paediatric and adult forms respectively, and that where in the past people described gp as the paed form of RLS, you, being the maverick you are boldly deduced that rls is the adult form of GP?
That makes none sense. That's like saying that in the past peole thought children were like shorter adults, you're the first to say that adults are like taller children.

Nope, now I know why YOU think they work.

Now I have 5 people with models which explain why they work, whereas before I had 4.

You didn't. I was paraphrasing. Fact is you did not properly describe the test you carried out for that, nor the outcome measured, nor how it was recorded. You said, I believe, that they "responded symptomatically" which could mean almost anything. Again, this is why its important to have a hypothesis, research question, methodology etc clearly laid out. Validated measurement etc. All that boring "research methods" stuff.

No, numbers don't do it. A large, badly constructed study is as useless as a small badly constructed study. If you can't control your variables its just a LOT of useless data instead of a little useless data. The problem is not the sample size, it's the sloppy design of the study and the disconnect between the hypotheses (emphasis plural) and the "data).

Consider. There are a plethora of studies which attempting to explain GP out there. You, apparently have dismissed them all as unsatisfactory. That's fair enough. Now consider WHY you did so and you will have the beginnings of an idea why other people may dismiss YOUR work.

You don't dismiss those other explanations because you are a "nattering naybob", you dismiss them because they do not satisfy you. Or because of methodological or conceptual flaws in the paper. Why would you be surprised when other people apply the same thinking to YOUR work?

There are several ways one could construct a convincing study on this. The crux would be to construct a protocol which would work if your model is correct, but which would NOT work if any of the other models were correct. For eg, lets say you were trying to prove that the forefoot varus correction was an important element. Find a group with FF varus (whatever you think that is) and randomize them between a group who get an insole with a ff varus extension and a group with a simple pre fab with a neutral heel and no ff varus extension. Blind it if possible to reduce tester bias. Establish ahead of time your outcome method (episodes of night pain in a 4 week period say). Do it properly, with a limited, testable and pre set hypothesis, and a clear methodology, which you come up with BEFORE you start data collecting.

Then look at the results. If you found significantly (use stats to test if it is significant) better outcomes in the group with the ffvarus extension, THEN you would have a finding worth talking about.

In short, if the community seems underwhelmed by your paper, you can either raise your voice, or you can improve your argument.

 

Oh, I missed a bit.

Um... yes, lets.

.

That's why we need to be proper in our studies, because otherwise the information is meaningless. Are you seriously advocating that good experimental design is not necessary?! Is that for everyone or just for you?

You're backsliding. As I've pointed out, we've been successfully treating this problem for years. Nobody has been waiting for anything.

Actually I've not (yet) indulged in ad hominems. Not because I'm above it (I'm really, really not) , but simply because it adds nothing to the argument. Me saying "this article is not convincing because.... " is relevant, and can be discussed. Ad hominem would be if I'd questioned it not on the basis of the article itself, but on the basis of, say, the nationality of its author, a factor which is utterly irrelevant to the veracity of its content.

 

You never answered my question about the studies Hashkes published that summarily dismiss an articular origin for GP's without ever revealing why/how he came to that conclusion. Surely you have read those articles, right? I mean...they're heavily referenced in the literature...one would think that someone of your prominent position would've read those. I tried to contact him myself, as he has left the Cleveland Clinic and is now practicing in Tel Aviv. I talked directly to his nurse...but he never bothered to return my call. I was interested in his continuous conclusions and how he arrived at them without any reference to studies that would show that. Now...as far as your questioning the process by which I assessed a guarded response in children/adults to noxious stimulation, you can nit-pick all you want about not having a scaled response chart or system to measure pain...and that's very British of you. I prefer to solve problems and successfully treat patients. "Blind" the study comparing FF varus extended orthotics vs. pre-fabs so as to not bias the tester? LMAO! That's ripe! I think we're back to the bread analogy you discussed above.

Now...why didn't you list the 4 other studies that seek to explain why orthotics work when I asked you to list viable studies? Instead, you listed studies that have been either unchallenged or dismissed. Heck...you could've listed rheumatic fever in that tedious list, eh?

If you could be so kind as to list those 4 other studies that seek to explain why orthotics work, that would be appreciated. I promise not to nit-pick their process and/or findings in the manner you've attempted to address my article.

 

Matt - I've been making Amfit and EVA orthoses with full length medial posting to the toes, where required, for years - so that's not new. I'm sure many others have too.

Cheers Dave

 

Dave-good for you...glad to read about it. I actually researched this topic prior to finishing my original manuscript, but found sparse references to these types of extensions in the literature. The best I could come up with was:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2383477/

As I wrote...it is not a unique idea, but one, IMO, that hasn't been offered enough. Further, I am the only Podiatrist on the west coast of the US that's ordering these types of devices from the largest manufacturer of orthotics...KLM.

 

Funny that.

As to other people's work on GP, I've given you the meta analysis and the link to the paper. Angela was far more thorough and careful in her referencing than you were, so you have everything you need. I don't really have the inclination to spoon feed you. Look at the modes described, look at the Lil number and look at the paper next to the Lil number at the bottom of the page. She describes 7 theories by the by, not seven papers.

As I predicted you seem to have shifted focus from defending your article to trying to increase its relevance by pretending it's the only show in town. Not really a winning strategy I would suggest. Even if yours really was the very first paper to offer any explanation for growing pains (and it's really, really not) that would still not make it right. The impact of a paper is defined by its own quality, not the competition.

Yes, yes I can. Do you not feel that describing the tests used and outcomes measured in studies is important?

As to that being British of me, that is a handsome compliment, but one I am unable to accept. The application of good research methods is international, we claim no special status there.

Uh, yes. I presume you are familiar with the term? It's a straightforward enough process. Single blinding would be very easy. Double blinding would be harder, but one could still have a good go at it.

Im curious, do you find the idea funny because you do not see the relevance or value of blinding, or do you find it funny because you cannot see how it could be achieved?

 

I'm still interested in reading the 4 other articles you mentioned that discuss the possible modes of efficacy of orthotics in treating GP's. When I did my research, I didn't find them. BTW, the reference list on my original manuscript is much more expansive than the revised edition. But most physicians here in the States that are interested in the subject have already read the references, ad infinitum, ad nauseum, so in the interest of reducing redundancy and reader fatigue, I limited that discussion in the revised article. In my original manuscript, which was 42 pages long on MS Word, the first 13 pages was devoted to historical review...complete with references. That should cover the topic, eh?

It was on the advice of a Vascular/Thoracic Surgeon who went on to become CEO/President of the largest hospital complex/trauma center here in central California that I should have a revised version published ASAP. His objections to the information were not what anyone here has mentioned, and he never discussed the objections you've forwarded. Now...let's see...should I listen to some obscure and anonymous textfield on a public Podiatry forum whom has never even seen a STJ on a living patient, or that of someone lightyears more accomplished in the medical field that has written and read more articles on a variety of medical topics than I would care to think about? Hmmm...tough choice. I'm sure you can appreciate my quandry. He wanted me to get my name attached to this subject as quickly as achievable...and that I did.

But I'm also still interested in determining your response to Hashke's articles, several in fact, where he denies an articular source, even though he never defines how he came to that conclusion.

First, you act as a nattering naybob...then you admit that orthotics work for treating GP's and have been treating patients in this manner FOR YEARS, and that there are 4 other articles already published that discuss this topic, (even though you haven't cited one). Now, you're backsliding into a nattering naybob once again...please...make up your mind.

 

Hey Matt...

 

Certainly not you. I just wonder how many patients that suffer from these problems feel the same way?

 

Quite possibly most of them, if they had to trawl through all the posts on this thread. Maybe you should do a study - I'm sure Robert will be delighted in helping you design the format. Good luck! :drinks

 

How many posts did Isaacs write, denigrating the process before he finally admitted that he "knew this all along"? Then, he reverts back to slamming the process, lecturing me on "proper" scientific approaches. What a complete waste of bandwidth...much like your contributions. And he STILL hasn't offered me the links to the 4 other articles that discuss why orthotics work on GP's patients. Imagine that?

Now imagine a patient coming to this forum, looking at the contributions from the UK and Aussie Pods. They should/would be scratching their heads wondering what the big deal is. I can imagine their response to your and Isaac's posts, wondering out loud: "What's the problem here...this guy has an answer to my child's problem, and these other Pods can't accept that...WTH?"

I've laid a golden egg in all of your laps, and have asked for very little in return...and that really bothers you...doesn't it? Ego? Dislike of Yanks? All I ask is that you test my hypothesis on your own patients. That's really difficult...isn't it?

Cheers!

 

Sorry, was busy having fun last night. Gimmie a minute...

In brief, while I agree that you've laid something in our laps, it sure ain't a golden egg...

Bill hicks immortal line springs to mind.

Oh and I think the casual xenophobia you continue to exhibit is unique to you. And, I believe a first on pod arena. You are the only one who appears to ascribe any relevance to the nationalality of posters, most of us are a little more enlightened than that.

So that at least IS some new ground you've broken. Gold star.

 

Ok. Obviously I was STILL not clear enough. At this rate I'll be resorting to black and white line drawings. But we'll keep trying. Lets go around again. Perhaps if I highlight the salient points, I do sometimes wax loquacious.

The use of orthoses for Growing pain is nothing new. It's been done for years, by many people
http://www.spectrumfootclinics.ie/growing-pains/
http://www.footankle.com/children-feet/growing-pains/
http://astepahead.com.au/orthotics-and-children/
http://www.kirbypodiatry.com/document_disorders.cfm?id=133

Lil, shout out there for you Kevin :drinks

That's just a few off the front page of google.

and indeed Has an evidence base.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4414976/

This is what a properly written piece of research looks like by the by. You'd do well to read it and reflect.

That insoles work well for GP was not, and has never been, in dispute. I said that from the getgo.

That, however, is not your hypothesis, and not what you claim to have shown. Your claim is to have SHOWN (not speculated but SHOWN) that orthoses work in a different way than what was originally thought, but offers no evidence for the hypothesis. You offered 4 hypotheses WHICH APPEARED NOWHERE IN THE TEXT OF THE ARTICLE, none of which were supported by your "data".

If you had written it properly, with an abstract, hypothesis, methodology, results, discussion and conclusion, and if the data was that all of your patients got better, and you'd run it through a statistical analysis, then It would have supported the following conclusion.

"Insoles of the type used in this study appear to be effective in the treatment of growing pains in children".

Which would have been useful.

But that's not what you're claiming. Your conclusions are writing cheques which your "data" cannot cash!

And for the Nth time, I've given you the literature review, which has the references for the 7 existing proposed mechanisms for GP. Some of them are good, some are less convincing. The references which support AND the references which appear to dismiss these mechanisms are listed there. I'm not going to do your homework for you. I guess you are still trying to cling to the idea that you're the first to HYPOTHESISE a mechanism for GP. The lit review demonstrates abundantly that you are not. You wanna go after one of the other explanations, fill your boots. Hell, I'll join in. The evidence for other explanations in no way affects the quality of the total lack of evidence you offered for yours.

 

1. Perhaps you should have asked somebody with knowledge of the subject. Stephen Hawking is a terribly accomplished physicist, but I would not ask his advice on how to make an orthotic.
2. Remind me the name for the logical fallacy where one disputes an argument on the basis of the person making it, rather than the argument itself? Ad something...

 

I've obviously struck a nerve, given your use of the bold feature. Good. I'm getting somewhere. You stated that there were 4 other "theories" why orthotics work for GP's and mine was a 5th, yet the links you offered don't even come close to supporting that. From the first link:

http://www.spectrumfootclinics.ie/growing-pains/

"These are referred to as growing pains even though it has not been diagnosed that growth is the cause of the pain." Nope...no help to you there.

From the second link: http://www.footankle.com/children-feet/growing-pains/

"Leg, foot and ankle pains of unknown cause in children are often called ?growing pains?." Nope...no help there, either, but certainly supports my argument...doesn't it?

From your third link:

"Please consider having your children?s feet checked. It is our opinion that many times growing pains may be able to be stopped by simply looking at how your child walks or runs and treating any imbalances." Really doesn't support your statement, does it? All encompassing, generalized and sweeping statements is NOT what you stated...is it?

From your NCBI link: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4414976/

This is the closest to supporting your contention, but it was released the same month as my article, and only states that orthotics are helpful in treating the problem...it does not define the source of the pain, or really offer an explanation of how/why they work. So again...no help to your statement. So far, you're 0-4. But it's Kirby's link that REALLY buries you.

http://www.kirbypodiatry.com/document_disorders.cfm?id=133

Kevin is "on the record" as stating that GP's are an overuse syndrome...here and in an Intracast, non-peer reviewed newsletter. His website just confirms that. Again...no help to you there, either. So now you're 0-5, with the caveat that you think Kevin's description of GP's as an overuse syndrome is viable. Here's a taste of Kevin's early response to my presence here at PA:

http://www.podiatry-arena.com/podiatry-forum/showpost.php?p=355736&postcount=105

"Simon was right. Drhunt1 is putting on a very good display of the type of arrogant and ignorant behavior which will be the downfall of podiatric biomechanics within the USA podiatric medical community within the next few decades. Everyone following along, please watch the response of Drhunt1 and you will see the future of why podiatric biomechanics will continue to go downhill within the coming years here in the USA."

The dogmatists are squirming hard, aren't they? Here's my hypothesis: "Simply stated, the majority of growing pains that present into physicians’ offices are the result of chronic subluxation of the sub-talar joint, (STJ), creating transient synovitis with referred pain symptoms into the lower leg, typically with cessation of activity".

LOL! In the words of Darryl Philips: "Keep throwing rocks".

 

Ron Valmassy reviewed the original manuscript initially and approved of its content. You've heard of Dr. Valmassy...right?

The original program was intended to target MD's that see these types of maladies in the office, ie., PCP's, neurologists, pain management docs, sleep disorder specialists, etc. I had no idea that my own profession would be so disingenuous, disparate, fractured and egocentric, that I should have targeted Pods first. MD's are appreciative of the information I've sent them. There's no accounting for the "taste", (or lack thereof, as it were), of those that share my degree, or some such variation.

Cheers!

 

Sigh. No, apparently you don't understand, even when it was writ large.

Yes I did. but not in that post. Please at least TRY to read what I actually wrote.

Again then. The first 4 of those links were evidence that the treatment of GP with orthoses is nothing new. That it has been done rather widely and successfully for some years. They were adverts from people treating GP with orthotics, not references. All they prove is that the successful treatment of GP with orthoses long before your paper was released upon the world.

The fifth was evidence (from a properly carried out trial) that orthoses for GP work.

These in response to your misrepresentation that I had changed my position from disputing your research to agreeing with it. I agree that orthoses work for GP (always have). I dispute that any of your 4 hypotheses were supported by what passes for your data.

Those links were nothing to do with your rather lazy request that I provide with individual citations to support some of the other explanations which have been offered for GP. As I've said before, I gave you the literature review which details them rather clearly.

 

Indeed. And in spite of his (apparently quite warrented) comments about you, and to my considerable surprise, Prof Kirby appeared to endorse your paper when it came out. I've not read the original paper but I'm baffled how anyone found anything good to say about the abridged version. That's the kind of guy he is, he calls it how he sees it, irrespective of who hit it.

However I do know that professor Kirby, who I presume to count as a mentor, would be desperately disappointed in me if I formed my view on it based on his, or anybody else's view, and not on my own. If he taught me anything at all it was that one must hold to ones own beliefs and not hitch ones wagon to any star. Your paper may be one of several areas where Kevin and I disagree.

You could have saved yourself some time had you directed them instead to one of the literature reviews which had already been carried out. But I am slightly reassured that sufficient of your own profession were unimpressed by this paper to convince you that it was for reasons other than it being, charitably, a poor attempt at science.

 

I have a vision of my future. Its a little depressing.

Stage 1.
I will continue to hold, and espouse, the view that your conclusions are not warranted or supported by your "data" and that even that was collected in such a shoddy and slapdash fashion, with complete disregard for the scientific method that even that is inadmissible as scientific evidence in any event.

Stage 2
You will continue to evade talking about those issues, and the disconnect between your hypotheses and your data, focusing instead on arguments like "important people said nice things about it", "nobody else has done any better", "your view is not important because you're English" and your favourite "It really is the only explanation which has been offered.". I don't know if you have any other tacks to try, but I'm fairly confident they will be about anything but defending the shortcomings of your paper.

Stage 3
I will eventually get frustrated with your evasions, give in, and provide references for several papers in which authors offer alternative explanations for GP, in a vain effort to make you realize that you were really, truly, not the first, and that some of these explanations remain far more cogent and well evidenced than yours.

Stage 4
You will gleefully attempt to dismiss those other explanations (continuing to attempt to divert attention from the shortcomings of your own study), because the ONLY circumstances in which your paper would have ANY interest or cogency would be if it was the ONLY paper to offer an explanation.

Stage 5
I will point out that YOUR view on other peoples work is not relevant to OTHER PEOPLES view on YOURS, and that even IF all the other explantions were as flawed or short on evidence as yours (which they are not), then that would merely mean we had one more shaky model.

It gets foggy at that point. My guess is you'll resort to some sort of academic conspiracy theory to explain why nobody seems very impressed with your work. But that's how its going to be isn't it.

 

Serious waste of bandwidth. Bottom line: you made a statement that there were 4 other theories as to WHY orthotics work for GP's, and you provided none. I stated that while some Podiatrists have determined that orthotics work, they don't know why or how. My article offers an hypothesis that not only suggests a mechanism for this problem, but links this malady to RLS in adults as a continuum of the same problem. Crikey, you should view the patient interviews! They are splendid. Oh well...off to work...

Keep throwing rocks...

 

Straight in at number four.... *deejay stylee*

Robert, do you have next weeks winning lottery numbers, please?

 

Certainly is, since we know where it ends. Unfortunately, since you have posted this, we have to go through the motions.

Ha! Of course, but if I put it online we'll have to share the jackpot. I'll pm you. In any event, Matthew has helpfully stuck to the script, coming in at number 2

Stage 2 I would remind you was

And matthew's Response?

Gasp at my eerie precognitive powers.

So I guess that moves us right along to stage 3...

 

Oh that's me isn't it.

Stage 3, I remind those watching at home, was where I finally acquiesced to the request for references for the other explanations which have been offered for the aetiology of GP.

This is not an exhaustive list. I've left off some of the odder ones. But since Drhunt seems to think he is the ONLY person to even HYPOTHESISE an aetiology, they should suffice.

Low pain threshold
Supporting
Hashkes P, Friedland O, Jaber L, Cohen A, Wolach B, Uziel Y. Children with growing pains have decreased pain threshold. J Rheumatol. 2004;31:610?613
Found correlation between low pain threshold and GP

Decreased bone density
supporting
Friedland O, Hashkes PJ, Jaber L, Cohen A, Eliakim A, Wolach B, Uziel Y. Decreased bone strength in children with growing pains as measured by quantitative ultrasound. J Rheumatol. 2005;32:1354?1357. Significant finding on dx US. See what they did there? Came up with a hypothesis, came up with a methodology, tested it...

Blood perfusion issues
supporting
Aromaa M, Sillanpaa M, Rautava P, Helenius H. Pain experience of children with headache and their families: a controlled study. Pediatrics. 2000;106:270?275. doi: 10.1542/peds.106.2.270
Disputing
Hashkes PJ, Gorenberg M, Oren V, Friedland O, Uziel Y. Growing pains" in children are not associated with changes in vascular perfusion patterns in painful regions. Clin Rheumatol. 2005;24:342?345. doi: 10.1007/s10067-004-1029-x.
This one seems a bit weak to me. But still, more evidence here than for referred pain from STJ subluxation...

Psychosomatic
Oster J: Recurrent abdominal pain, headache and limb pain in
children and adolescents. Pediatrics 1972, 50:429-436
raises possibility of PS cause

Oberklaid F, Amos D, Liu C, Jarman F, Sanson A, Prior M: "Growing
Pains": clinical and behavioral correlates in a community
sample. J Dev Behav Pediatr 1997, 18(2):102-106

Palermo TM: Impact of recurrent and chronic pain on child
and family daily functioning: a critical review of the literature.
J Dev Behav Pediatr 2000, 21:58-69.
I don't buy this one for a minute. But It IS a hypothesis. If quite a rubbish one.

Restless leg syndrome
Rajaram SS, Walters AS, England SJ, Mehta D, Nizam F: Some children
with growing pain may actually have restless leg syndrome.
Sleep 2004, 27:767-773.
Association shown, but polysomatograph suggest movement not the cause.
Murali Maheswaran, DO, Staff Physician and Clete A. Kushida Restless Legs Syndrome in Children
MedGenMed. 2006; 8(2): 79. Published online 2006 Jun 20. PMCID: PMC1785221 Suggested the two may be one. Totally different from Drhunts hypothesis of course...

Hypermobility
postulated as a cause, since there is correlation with fibromyalgia
Gedalia A, Press J, Klein M, Buskila D: Joint hypermobility and
fibromyalgia in school children. Ann Rheum Dis 1993, 52:494-6.
Uziel Y, Hashkes P: Growing pains in children. Pediatr Rheumatol
Online J 2007, 5(1):5

Difficult to show as hypermobility is hard to quantify, however disputed on the basis that Hypermobility would seem likely to correlate with flatter feet, and no correlation was found with flatter feet. To broad to be classed as an aetiology IMO, but still more internally consistent than referred pain.

And of course the correlation to foot posture was disproved here

By the same person who proposed it here

So that theory was somewhat dented. By the same person who proposed it. I admire anyone who does that, it shows they are more interested in getting to the truth than in "getting their name on it" as drhunt rather crassly put it.

It has also been postualed that it could be a muscular fatigue issue, since GP is often associated with increased activity levels
Evans A, Scutter S, Lang L, Dansie B: 'Growing pains' in young children:
A study of the profile, experiences and quality of life
issues of four to six year old children with recurrent leg pain.
Foot 2006, 16(3):120-124.
Which although supported by a lot of anecdotal belief
Oberklaid F, Amos D, Liu C, Jarman F, Sanson A, Prior M: "Growing
Pains": clinical and behavioral correlates in a community
sample. J Dev Behav Pediatr 1997, 18(2):102-6.
Evans AM, Scutter SD: Prevalence of "growing pains" in young
children. J Pediatr 2004, 145(2):255-8.

has not been properly investigated. But it remains on the table.

Oh and more recently, someone suggested that it was caused by subluxation of the STJ referring pain proximally, but offered no data to support his conclusion other than a much lower quality dataset consistent with this study
Hong-Jae Lee, MD,1 Kil-Byung Lim, MD,1 JeeHyun Yoo, MD,1 Sung-Won Yoon, MD,1 and Tae-Ho Jeong
, MS2Effect of Foot Orthoses on Children With Lower Extremity Growing Pains Ann Rehabil Med. 2015 Apr; 39(2): 285?293.

Which showed that orthoses were effective in the treatment of pain and several other theraputic criteria.

There we go. Lots of other people with theories as to the cause of GP, good, bad and indifferent.

 

:good:
Great post, Robert. Seems like your time away from PA has sharpened your skills. Keep up the good work!

 

Indeed.

 

You're very kind.:drinks: But if you stick around you'll get to see drhunt explain how none of those things are really proposed aetiologies for gp, since he is the first to offer an explanation. #popcorn #anysecondnow

 

RobertIsaacs-Additional waste of bandwidth. Why stop where you did, regurgitating one study after the other? There are >290K studies listed on Google Scholar, so why not just list a link to that site and be done with it? Is it because you want to be so incredibly "proper" and appear astute? Is it because you want people here to think you actually read those articles you listed? Here...let me make it easier for you:

http://scholar.google.com/scholar?hl=en&q=growing pains in children&btnG=&as_sdt=1,5&as_sdtp=

I've noticed that you STILL haven't addressed Hashkes et al's study where they determine that GP's is non-articular, yet doesn't ever state how he came to that conclusion. Have you yet contacted his office to let him know how shoddy you think his research is? Or how about Angela Evans' 2008 article where she used navicular drop as the determining factor in foot type...have you contacted her yet too?

Nah...one must work hard, as you most certainly are, to retain the title of the Neville Chamberlain of Podiatry. When logic indicates X, you rise up, stomp your feet, post a bunch of drivel and declare Y. But why listen to logic? Why simply test an hypothesis, when it's much more tedious and time consuming to be the ornery contrarian? One thing you most certainly have proven, is that Mark Russell is wrong...so congratulations on that. One down, several more to go, right?

Please continue to flail away...it appears to be what you do best.

But here's one for you, Robert...in the words of Minnie Driver: "Oh Isaacs, will you just go away?!"

https://www.youtube.com/watch?v=ymsHLkB8u3s