Drs. Matthew Sciaroni and Douglas Hight just had an article published in the April 2015 issue of Podiatry Management magazine titled The Myth of Growing Pains .
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I liked the article and think the article introduces some new ideas that will hopefully stimulate further research on this important subject. Good job Drs. Sciaroni and Hight!
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Notice that in this article, we "hedged" our bets, by appearing vague about ALL restless leg syndrome having the root cause as referred pain from the STJ. That was because all of the patients in that subset I saw distinctly remember having growing pains as children. Since the time of this study, (data stopped being collected 3 years ago), I have had a LOT of patients with RLS that did not have GP's as children. Same result...clinical cure, and no longer needing any medication.
One more noteworthy point...the one failure I had in this study was a female patient that was applying for total disability, although she never informed me of that...ie., she was not going to get better no matter what I did, and/or how the orthotics "worked". The results would've been 100% success rate in both groups if not for her application for disability, IMO. -
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Can someone in Australia please forward the above link to Dr. M. Angela Evans. The last email link I had for her no longer works. TIA.
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I've forwarded the link to Angela.
I'll admit I have many reservations about the surety of this statement:
That said, if there is foot/leg biomechanical issue, nutritional or systemic then it's NOT growing pains. It's muscle overuse or whatever your preferred term about osseus malignlinment is, deficiency or systemic issue actually is.
I think we need to stop confusing each other, our less experienced colleagues and the general public with saying a conditions is actually something the result of something with such limited proof. -
Let me address the concerns you raised. First, in Dr. Evans' epic paper published in 2003 in JAPMA, she concluded that growing pains were caused by pes planus based on the findings from 8 patients. Her paper basically launched her Podiatric research career and is still being referenced by many others which I witnessed when I performed my due diligence on the matter. My pilot program, single case studies has over twice as many subjects, (and MANY more since I closed the study window). In her follow-up study in 2008, (I'm assuming funded by the NIH in Australia), she moved away from the conclusions she reached in 2003.
Second, I stand by the statement you referenced. Knowing the differential diagnosis of a child that complains of pain in the feet/legs, especially at night helped me with that conclusion. The penetration of growing pains in children is remarkably high, depending on what study you believe. The range has been estimated from 15-49, with a mean of less then 40%:
http://europepmc.org/abstract/MED/15289780
Still's Disease, thankfully, is not nearly that high:
http://www.jrheum.org/content/29/7/1520.short
Neither is Osgood-Schlatters Ds. So it was no "leap of faith" on my part when I wrote that sentence and made that claim.
Third, the diagnosis is not only one of exclusion, as many authors have suggested, but there are physical signs that can be attributed to this malady which are the same for RLS. By pressing on the sinus tarsi, thereby increasing intra-capsular pressure, or by direct pressure on the posterior facet of the STJ from either medially or laterally, the observer will elicit a painful, often times guarded response. Have the Pediatric patient scheduled late in the afternoon, therefore allowing for a days activities to exacerbate the problem, and then check this patient yourself by the method I describe, (after you've ruled out more serious problems first). These symptoms disappear once the orthotic therapy is instituted, but will return if these devices are taken away.
Fourth, while many Podiatrists realize that orthotic therapy can successfully treat GP's in children, prior to my pilot study they didn't know why. Many of our colleagues described GP's as an "overuse syndrome", which it clearly is not. [I have a problem with the term overuse syndrome in many discussions for a variety of reasons] This study and study group, (and the many patients I've seen afterwards), identifies the problem after 192 years of inquiry and will make it vastly easier for the practitioner to successfully treat. Every Podiatrist that reads this study, should send a copy to the pediatricians in their area. The word needs to get out.
But the "cherry on top" of this study is the anatomic/neurologic/pathologic link to RLS in adults. No one has done this before either. The symptoms are similar, the exam is the same as is the treatment. Now you can successfully treat GP's in children and RLS patients in your own practice. If you don't believe the findings, results and conclusions of this study now, take the time to explore it on your own with your own patients. I'm very comfortable with what you will determine.
Cheers, -
Thank you for your response Matthew, I appreciate it but I'm still not sold. I'm don't think it is right to go into the scientific manner of how you have addressed your hypothesis as I feel your article is more of an observational piece written for peers, which is often a great place to start the conversation. But at the same time we need to remember the hierarchy of evidence and where opinions and case reports sit. They are great to start a conversation however should not be used to change practice.
I only work with kids and rarely see what I would class as true growing pains/RLS etc. You have described a diagnosis that shouldn't be called growing pains. I agree there are children who present with foot and referred leg pain but then why not call it what it is. You are treating kids who have pain with a diagnosis. Kids with GP's don't have sore spots no matter where you push, they are the ones that wake and a good stretch often helps or sometimes they need pain relief etc. They are essentially well children but somehow have diffuse and intermittent pain with no cause.
It's like the amount of times you see a child who's parent says they have the diagnosis of Idiopathic Toe Walking and Autism. Then it's not ITW! It's toe walking associated with autism because we know the two are linked. You have clearly identified that leg pain in children is associated with a biomechanical abnormality and that is great to encourage other practitioners to examine and explore other treatment options for this abnormality however then, why call it growing pains? Will they still have it when they are adults? Probably...then again it isn't GP's.
It's probably semantics but I really believe the clarity of what we say to our parents, kids and colleagues is important. Call it is what it is and don't add to the myth of what it isn't. -
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Dear Dr Sciaroni,
I have received the link to your recent article in Podiatry Management, and am about to send a letter to the editor.
The letter is actually addessed and directed to both the authors and editor, so I am also happy to post it here if you agree.
Unfortunately, I just don't have the time to also get to podiatry arena discussions, but thank you for ensuring that I received you paper.
Kind regards,
Angela Evans -
Although this article doesn't follow strict guidelines on presentation of scientific data, I think you would agree that Podiatric Medicine is not as amenable to Evidence Based Medicine as other medical disciplines.
Included in the original manuscript, I hired animators and a videographer to produce patient interviews and basic biomechanical animations to better explain some of the more common precepts in foot function and offer personal testimony to treatment course and history. This is one such video.
https://www.youtube.com/watch?v=7BSetRI_UH4&feature=youtu.be
Please post your letter here for all to read...good or bad...this is what this forum should be all about.
Best regards, -
Podiatry is every little bit amenable to any other health profession, all we need to do is use what we have and continue to push to have the gaps filled where they are identified. Not everything needs a double blinded placebo trial. Randomised comparative effecasy trials are becoming more common place, cheaper and more acceptable where there is established effect. Just being able to read a study and understand how to critique the evidence should be the basic skill that every podiatrist has yet it appears not?
Where we are continually accepting lower level anecdotal evidence in the face of better quality, we will continue to be seen as a dumb hick of the health world. I'm pretty sure there are other health professions out there that have this title, let's not aim to be one of them.
I'm bowing out from here on in as I'm pretty sure there will be no middle ground found. -
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Jeff -
In the words of Rod Stewart, "Every Picture Tells a Story". Here's a pic and a story that every practitioner that views/reads this thread should seriously think about.
The lady pictured here came to my office 6 months ago with a chief complaint of unilateral heel pain. But when I saw her feet dangling off the end of the examination table, and the significant varus, (inverted), attitude they maintained, alarms went off in my head. I took plain film radiographs which just confirmed what I witnessed clinically. I placed the x-rays in the viewbox in the treatment room and I began asking her questions about her childhood as I examined her feet, taking note of neutral position, ROM of the ST and MTJ's, presence or absence of equinus, etc. She confirmed that she had serious growing pains as a child. As the questioning turned to the present, she confirmed that she now has RLS and was on medication for it, (Neurontin). She also confirmed that she has always been laterally unstable and "falls down a lot". This was in front of her husband, whom was also in the room. I left the room, retrieved my Android tablet which I've downloaded the videos shown at this site as well as patient interview videos, which I have not shared here at PA. I left the room so they could watch the videos while I attended to other patients.
Upon my return, there were tears in her eyes. I looked over at the husband and asked if these were tears of joy. She responded that all of her life she had sought medical opinions about her condition and no one, until that day, had been able to answer them. She told me that first visit that she was so laterally unstable, that she's fallen down and cracked her front teeth, and those she presently had were dentures. I was amazed. I casted her for orthotics that first visit. I held her in an inverted position, (she had a rear foot varus deformity with a forefoot varus deformity on top of that, ie., a skewfoot). I had the varus extension applied, which extends to the end of the toes, much like what is pictured in the article.
On her second visit to pick up the orthotics, she was accompanied by her husband and mother-in-law. She told me at that when she was a child, she had severe growing pains...so much so that she would wake up screaming in pain and crying. Her mother took her to the pediatrician and was told that she would grow out of these pains. But she didn't. After that doctor visit, when my patient woke up screaming in pain, her mother beat her. My jaw hit the floor. I told her that hers was an extremely compelling story that needed to be told, and that I wished I had met her years before, before I finished writing my article and conducting my videotaped patient interviews. I was shocked, dismayed and disappointed. I did, however, tell her that her RLS should be gone by the third night she wore the orthotics, depending on the break-in time and her ability to wear them consistently throughout the day.
Her third visit confirmed that, indeed, her RLS had vanished, she was no longer taking Neurontin, she was no longer kicking her husband in bed and they were both sleeping much better. [Oh...and her heel pain was gone too]. She indicated to me that she was much more stable then before and not falling down nearly as often, even on uneven terrain. She has given me permission to tell her story for her, and sent me the jpeg seen below.
So what's the moral of this story? Doctors often don't realize that information they give patients, whether it be in haste, unintentional or for whatever reason, can have long lasting effects and impacts on the patient and their family. It is OK to tell a patient that you don't know the answer. But if you don't/can't offer immediate solutions, what they want to hear is that you're willing to find out the answer, and/or find someone that can be of assistance. Primary Care docs do that all the time, refer patients to specialists...but unfortunately, they also give patients misinformation as well. Many times I have asked parents if when they were told that "Little Johnny or Suzie would grow out of the pain", if that was a satisfying answer. Not one parent has told me it was...not one. "Food" for thought. In the words of Emiril Lagasse, maybe it's time to "kick it up a notch". Perhaps this article will do just that. -
Here's Dr. Evans' response on PM:
http://podiatrym.com/search3.cfm?id=81969
_____________________________________________________________________________
I will limit my response for now, but I will write an expanded version to submit to PM.
First, Angela, I chose the title for a very good reason...because it is a myth. For over 100 years, and still today, doctors are telling patients/parents that the pain is due to the long bones growing faster than the periosteum, (soft tissue) can keep up. Even though many researchers have moved away from that description, many have not. If that were the case, why don't we witness "growing pains" in the arms and UE? It is a myth that needed to be exposed.
Second, I contacted you 4-5 years ago to be a part of the study via email, because I knew that your database was prodigious. You declined, in spite of the fact that I told you I had discovered the answer. Your choice. But if you remember, you opted out because you were too busy and working on other projects. Really, Angela? In my email to you, I wrote that you were closer to the truth in 2003, then you were in 2008. I stand by that statement.
Third, my article was reviewed for accuracy, readability and content by Ron Valmassy and a vascular/thoracic surgeon that became CEO/President of the largest hospital complex in my region. They both loved it. Now, if I had to choose between Dr. Valmassy or yourself as a better reviewer of my work, you'll be disappointed which way I ventured every single time.
Fourth, while you nitpick at the presentation of the material, (I will admit that I didn't perform top level statistical analyses), I get the impression that you're missing the big picture as to the root cause of these pains, (why?). Simply put, you missed an opportunity to discover one of the longest held misconceptions in medicine. Think about that the next time you fly around the world discussing these maladies with Dr. Walters et al. at these high brow meetings. The answer is right in front of you, and has been for years. Quit measuring talar height and navicular drop and go back to the basics, which includes plain film, weight bearing radiographs and biomechanical evaluations. Oh, and try pressing on the sinus tarsi and posterior facet of the STJ, if and when you examine another child with these symptoms. IMO, you're making these problems MUCH more difficult than they really are...as most physicians, especially academics, do.
Fifth, while I did discuss Still's disease as part of the differential diagnosis, since when are Podiatrists allowed to take X-Rays of the lower leg? I'm assuming that you order them on each and every child that presents into your office? In the article you reference in Medicine Today, they discuss night pain in a 3 y.o. child. Really, Angela? You KNOW that the preponderance of studies indicate that GPs in children begin around age 6. Notice that they also bring up seronegative arthropathies, which I discussed...didn't I? Infection? Hemotogenous? Please explain that one. And wouldn't a simple CBC rule that out? Tumors? Again...I would venture to guess that the presentation would be much different in a child with a LE tumor, and wouldn't be referred to Podiatry to begin with.
Sixth, how disingenuous of you to denigrate our work, and use young Podiatric students to further your cause when the reality is you've seriously misled them in your 2008 article when you wrote: : "iv) Growing pains is not associated with flat feet." You missed it Angela...get over it.
Seven, I really couldn't care less about all the other research on treatment protocols on RLS. All I'm asking Podiatrists to do is to read the paper we wrote, understand the simplicity of the presentation and examine the patient in a manner that either proves us correct, or wrong. It doesn't take much time or effort on anyone's part to do just that. Perhaps you should be more concerned at discovering the truth which will ultimately translate into better patient outcomes then protecting your own study's findings and/or the manner in which you presented that information...or using Chinese proverbs to bolster your argument.Last edited by a moderator: Apr 14, 2015 -
Wow Matt
I would however like to thank you for publishing the letter From A Evans and for Cylie for taking the time in responding
and I think like this the most from the thread , of course we can expand our knowledge being open and discussing and taking in real evidence
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Dennis incarnate.
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Further, I knew she was still involved in these types of forums because Dr. Walters informed me of that in our first telephone conversation. And guess what? Dr. Walters, himself, is being funded by Big Pharma in his research on RLS at Vanderbilt University. Conflict of interest? You bet. How many hundreds of millions of dollars are spent each year on Requip, Mirapex, Cymbalta, Lyrica, tramadol, neurontin and hydrocodone for this treatment? Yet Angela is concerned about the cost of a pair of orthotics? Seems hypocritical to me.
Continuing, while I've already admitted that the study had few participants and, thus, is a pilot study, it had over twice a many as Angela's article in 2003, but she took two paragraphs to explain herself, her study and just how scientifically presentable her study was. How does that improve patient outcomes?
It seems that you've ignored my comment on the two docs that reviewed my work long before I submitted it. Why is that Mike? It certainly "closes the loop" on that topic and makes Angela's concerns about our presentation seem rather sophomoric...doesn't it?
As I've stated previously, the only treatment failure in the study was a patient that had already applied for total disability yet did not disclose that info to me prior to her inclusion in the study. My mistake. Since that time, however, I've treated dozens more patients with serious success rates that simply should not be ignored nor dismissed. Ditto for the essence of the study.
Finally, you thanked Cylie for her contribution, ignoring the fact that I initially asked someone here to forward the article to Angela. Did you miss that? And for completeness, Cylie is on the record as treating these patients with zinc therapy. DISMISSED! Hopefully our article puts an end to this type of treatment. It's easy to test our hypothesis...that's all we're asking other practitioners to do.
Comparing me to Dennis Shavelson? I've had two telephone conversations with him as well, but not since the article was published. He is very passionate about his ideas. I would like to compare myself, however, to Dr. Atkins whom singlehandedly pulled the rug out from under the exogenous cholesterol crowd, of which there were many.
Ignore my forum "attitude", (although it certainly pales in comparison to Simon's, which I've never read Mike Weber admonish), and focus on better patient outcomes...you just might be surprised what "falls in your lap", or has been staring you in the face for years. -
Wasn't coming back...wasn't coming back...... BUT in my defense I just have to comment based on this:
I get that you're defensive as you are obviously passionate about this topic. However most podiatrists here are just as, if not more educated as you are. Most don't work in academia, we work in private clinics and hospitals, just like you. How about a bit of professional courtesy and respect between colleagues because all I've seen so far is mainly an attempt at rational debate and you running around slinging off at anyone who has dared to disagree with you.
I'd be "busy" if you called me to do research with as well. -
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BTW, do you speak/write English as a second language? -
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Regards -
That being written, I also predicted the "push back" I have already experienced...and even predicted those that are pushing back the most. I discussed this at length on multiple occasions with MANY docs from a variety of specialties. Just follow the money and all pretty much par for the course. And the reality is, it's just begun. -
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― John Locke -
Response in PM News:
http://podiatrym.com/search3.cfm?id=82028 -
Bingo!
RE: The Myth of Growing Pains (Angela M. Evans, PhD)
From: A. James Fisher, DPM
“Growing pains” is a misnomer, and in my opinion, a myth. Dr. Sciaroni does a pretty good job introducing the subject, giving credit to those who have actually researched it. Dr. Sciaroni even says that more research needs to be done; he even has a suggestion for a biomechanical treatment—a treatment that I personally have used on myself (so I do not have to use oral meds now) and found it very helpful in patients (they do not need meds now either). This so criticized paper is just the beginning of a discussion.
When I did cancer research, a study as low as five was common; and decisions on vital, life-saving treatments were at stake. I am not saying that we should not criticize, because we should always be skeptical; but at least Dr. Sciaroni addressed a problem, developed a viable hypothesis, and produced a study, however small, that supported his hypothesis. The big sin is he had the temerity to publish it knowing, and even hoping, that he would be criticized.
A. James Fisher, DPM, Crescent City, CA -
1. Allowing passion to get in the way of objectivity
2. Attacking those who critique your viewpoint and praising those who agree with your viewpoint
Yeah....This isn't science... -
How many times have we seen that exact same approach? Its been an epic fail every time. -
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One of the more difficult aspects to this article, was reducing the size of the original article from 10K words down to 3K in order to fulfill space requirements of PM. There was a lot of ground to cover...history, neurology, anatomy, biomechanics, referred pain, etc. Dr. Valmassy read the entire manuscript and loved it. Are you now attacking his credibility as well? -
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To Bug, Griff, Craig Payne, William Fowler and everyone else that "thanks" each other, (as Griff and Ian deplore so much), as they attack our work:
http://podiatrym.com/search3.cfm?id=82028
"All we're asking podiatrists to do is to
read the paper we wrote, understand the
simplicity of the presentation and examine the
patient in a manner that either proves us
correct, or wrong. It doesn't take much time or
effort on anyone's part to do just that."
Hope this helps. -
Thanks Matt that does help.
I've already read the paper and made my mind up. Took barely any time or effort at all. -
Head, sand, stuck. Please contact Dr. Valmassy and forward your disrespect directly to him. And I'll give you the name of the vascular/thoracic surgeon, (whom has forgotten more about general medicine than you'll ever know), at some point so you can forward your incendiary comments to him, as well.
Cheers. -
Publishing your ground-breaking research in a magazine, rather than a peer reviewed journal was truly sub-genius. Unfortunately, sub-standard peer review is happening now, from people who actually understand the subject- ignore them all, they're all wrong. You know what's right. Repeat after me: Valmasy said it was good, Valmassy said it was good, Valmasssy said it was good. What does the PhD Angela Evans know about any of this anyway, anybody would think she'd published on the subject in a peer reviewed journal the way she is carrying on. Keep telling everyone that you had to cut it down, that seems to be working and throwing them off the scent. Keep challenging them to try it for themselves, that should keep them out of our hair for a while.
In the meaning time keep up the egotistical front, keep bombing their silly forum and playing these fools at their own game (you've done this well so far) apply for ordination at the Church- you will make a fantastic minister one day. You have given money willingly to this project, now give to the Church and we will protect your slackness from these pinks. http://www.subgenius.com/ -
5th July 1998 is just around the corner, Dobbs.
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