The Myth of Growing Pains

The pinkest of the pinks. You won't be mocking on X-day.

 

When have I ever read your similar excoriations of Kevin Kirby's contributions for his work in non-peer reviewed Intracast contributions or Podcasts? I guess I must have missed that. The simple fact that you had to look Valmassy up, indicates to this astute observer your own lack of cred. Valmassy is world reknown and respected in the world of Podopediatrics. Further, notice I wrote that the vascular surgeon has forgotten more about GENERAL MEDICINE than Griff will ever know. When did I mention growing pains and biomechanics? I didn't. But no matter, foot function, normal vs. abnormal biomechanics...it all must be so difficult for a vascular/thoracic surgeon to comprehend...eh, Sparky? And btw...it was on his advice that I had it published ASAP...which happened to be the venue I chose.

And I can fully understand and appreciate your affinity to the "Piled higher and deeper" crowd...that association seems to suit you.

So let me define the discussion. I made the statement in my article that growing pains in children and RLS in adults are a continuum of the same problem. My hypothesis is that these problems are referred pain from the STJ. Now...tell me the problems you have with those statements.

Let me offer you a quote that was given to me by Dr. Harvey, then head of Pediatric Orthopedics at USC Med Ctr/LAC General Hospital and a graduate of Harvard Med School back when it meant something: "Boy...in life, there are big dogs, little dogs and no dogs". Valmassy is a big dog. Evans is a little dog, and you, Dobbs are a no dog. Hope that helps.

 

That's Great Dr Hunt. The angry angle sells. More sales = higher ordination. Do you think Valmasssy could buy into ordination too? The rest are all fools. Only you know the power of the slack and the varus insoles. Why would anyone take any notice of the "other" studies, when yours is so good and helps us sell insoles. A NEW SALE DAWNS http://www.subgenius.com/

 

I guess if you don't have anything to say, best to say it here: right?

 

J.R. "No Dog" Dobbs and Spooner...just let me know when you've contributed anything of importance to Podiatry. Until then, the papers I write, which resolve 192 y.o. medical mysteries, plus my biting, full-frontal commentary to your "types" will have to suffice.

Let's try this again....

I made the statement in my article that growing pains in children and RLS in adults are a continuum of the same problem. My hypothesis is that these problems are referred pain from the STJ. Now...tell me the problems you have with those statements.

 

That's right, you smashing them DR Hunt. You've contributed so much. Ignore the fact that much larger scale studies than yours demonstrated no predictive relationship between foot posture and growing pains, keep on saying that your hypothesis is where it's at. Obviously subluxed subtalar joints and forefoot varus don't contribute to foot posture, which is why the PhD researcher Angela Evans data from 180 children didn't support your hypothesis. http://www.ncbi.nlm.nih.gov/pubmed/18045309?dopt=Abstract&holding=f1000,f1000m,isrctn but we can sweep that under the carpet (between you and me, I wouldn't try to critique her methods because 1) I don't think you got it in your locker, as much as I admire your fight ready ego, 2) I think her methods were pretty good). Not talking about that study at all is gonna be best after all you "predicted all of this". Why don't your predictive powers extend to your hypothesis, when Dr Evans was already able to test for its predictability? Is she a better predictor than you? No way. You are the best predictor of them all.

Ignore the "types' here Dr Hun, the rest of us here are just gunning for you to be right- predictably you the best subgenius ever!

 

Why thank you, Dobbs...always nice to read that people are beginning to acknowledge my accomplishments. But I'm laughing at your suggestion that talar height and navicular drop somehow translates into predicting foot "posture". Angela never addressed STJ motion or position at static stance...but somehow wants us to believe that measuring talar height succeeds in that regard? Ha! But good for you, Dobbs...keep right on thinking that way, and I do think you should discuss this with the tissue stress people. Have Simon tell you what to write here...it seems you're a little out of your league.

"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

You simply have no idea...do you?

Cheers!

 

Have I ever used PubMed? It is a bit like saying have I ever brushed my teeth? Last time I looked by publication record was running at about 90, including a paper in Science, several in The American Journal of Physical Anthropology, The Journal of Human Evolution, loads in The journal of Human Comparative Biology, God knows how many in JAPMA, book chapters with the Cambridge University Press. Have I ever used PubMed? Yes.

 

Never actually read the paper Dr Hunt and don't let on that the PhD researcher, Angela Evans performed a foot posture examination in which the "measurements used were
navicular height (NH), navicular drop (ND), resting calcaneal stance position (RCSP), foot posture index criteria 4, 5, 6 (i.e. FPI4 calcaneal inversion/eversion, FPI5 talo-navicular region, FPI6 medial longitudinal arch)." otherwise people might get the impression that Dr Evans looked at all these measures of foot posture in 180 children and still found that none of them predicted growing pains. Navicular height was significant only in the left foot, but still didn't predict growing pains, but that's OK because no measures of foot posture could detract from your genius hypothesis that growing pains are caused by STJ subluxation and forefoot varus even though Dr Evans study demonstrated that this is highly unlikely, we'll ignore her. After all she spurned your offer of help. Tsssk, Tsssk.

 

That's the beauty of my article, Dobbs....time will tell. None of Evan's measurements will tell us where the STJ was functioning...will they? If you ponder her 2008 study, it actually supports my contention....foot "types" don't correlate to GPs, but STJ position does...something she never addressed. And forefoot varus deformities are not the only foot "type" that can cause this problem...but you just keep thinking that way, and refuse to actually read my article. Ignorance is obviously bliss in your world. Keep that ruler handy.....

 

As a general rule, once you find yourself in a hole, it is usually best to stop digging...

 

I agree. Making sweeping generalizations about an article and the information given within, and then admitting that you haven't even read the article is a pretty deep hole.

 

Can we tell from the above measurements whether or not the STJ is functioning maximally pronated or not? Last week Doug Richie sent me an interesting article which evaluated rearfoot position radiographically. Although we can't necessarily tell from this technique whether the STJ is maximally pronated or not, it does suggest that we may be able to find better methods of assessing rearfoot and STJ position.

I have attached the full article pdf.

For me the question becomes how could one test Dr. Sciaroni's theory that maximum pronation of the STJ, and not just increased STJ pronation, creates a referred pain which is a cause of "growing pains"?

Jeff

 

The differential diagnosis, and the methods by which, not only the practitioner determines how the pain presents itself, but by the physician's techniques in the examination, is critical. For instance, while myelogenous leukemia, neuroblastomas, rhabdomyosarcoma and osteosarcomas are real concerns, for the most part, they present differently than true GPs.

Rhabdomyosarcoma:

http://www.cancer.org/cancer/rhabdom...signs-symptoms

osteosarcoma:

http://kidshealth.org/parent/medical...eosarcoma.html

myelogenous leukemia:

http://www.cancer.gov/cancertopics/p.../Patient/page1

neuroblasomas:

http://kidshealth.org/parent/medical...blastoma.html#

The key and common finding, if these cancers do present in the LE, is SWELLING in the limb with pain upon palpation to the swelling, ie., the localized mass. In GPs, there is no swelling, mass or pinpoint pain elicited with palpation to the lower or upper leg. While blood tests and plain film radiographs can be utilized to R/O these rare cancers, (as well as Still's Ds), there is no positive findings from these tests with GPs.

Dr. Hight and myself have made the hypothesis that the majority of GPs is referred from the STJ.

http://www.podiatrym.com/Current_Issue2.cfm?id=1632

Considering the percentages of children that present with pain in their legs at night, we stand by that hypothesis. The only pain that is elicited by the practitioner, is palpation to the sinus tarsi, or posterior facet of the STJ, usually much worse in the afternoon, which resolves after orthotic therapy after the 2nd night of treatment. Much more research needs to be performed on the tie between GPs and RLS, but the authors feel this was a necessary start to the discussion.

 

I am currently sitting on my boat on the Coorong, just having watched the sunrise over a cup of tea. I read the last few posts with increasing dismay. Angela is one the most decent people I have ever had the privilege of knowing. Her working is entirely ethical, entirely altruistic, and all generated from a caring base - not a money base. Put bluntly, and this is not the first time I have said this on arena - who the Clucking bell do you think you are? When you have grown up, please feel free to come back.

 

Angela may be exactly what you stated...and I might be the same, or maybe not. It makes little difference to me what you think of me, my study, Angela Evans or whatever. As far as I'm concerned, you're nothing more than another nattering naybob of negativism that places personalities before principles. Not a good thing in science...is it? All Angela had to do in her study in 2008 was show that the kids had further eversion available at the STJ at static stance. She didn't. All that money spent on the study, and that's the most obvious and glaring item she never addressed. All that YOU, as well as others have done, including Angela, is attack me, the study, the methodology, the presentation and, according to Angela, kids will die due to more serious disease being overlooked because of my findings, (even though she never brought those up in her differential diagnosis herself). Balderdash. I used my OWN resources to fund this project, in many cases, paying for the orthotic manufacturing. I paid for animators, illustrators and a videographer. All money out of my pocket, with zero financial aid from any other source. How much did Angela get paid to conduct her expanded study in 2008? How much does she receive for speaking engagements worldwide? You think she does that for free? Enjoy your tea.

 

"nattering naybob of negativism" EEEh - I will put that on my grave stone. One of the best compliments I have ever been given. Oh, by the way, you may have noticed that my last post was not addressed to anyone in particular: how did you know it was you?

 

Considering how well I've been treated at PA, and considering your unyielding support of Angela, I made that assumption. And fwiw..."nattering naybob" is not an original. Spiro Agnew coined that phrase. I loved it then...I like it even more now.

 

Jeff-before I read the pdf file, let me offer the following. In some cases, a plain film radiograph can show maximal STJ pronation. It has been called the "see through sign", when the sulcus tali and calcanei line up. I've attached a lateral view to this post to show it in two different patients.

Further, it would not be difficult to demonstrate maximum eversion in any patient....and your Dad discussed this. Have the patient attempt to evert their feet further, while in static stance. Simple, concise and reproducible.

 

Jeff, the problem with clinical tests of maximum pronation are that one cannot differentiate movement at the STJ from movement at the ankle. Given Nesters findings regarding frontal plane motion within the ankle mortise, it would seem reasonable to assume a high likelyhood of false negatives if all we do is ask the patient to evert their feet from relaxed stance. Lateral weightbearing X-ray might be helpful- if we have a positive Kirby's sign with occlusion of the sinus tarsi then one might consider this as an indicator of maximal subtalar pronation. http://www.podiatry-arena.com/podiatry-forum/showpost.php?p=7699&postcount=3 As I understand it from conversations with Don Green, if the sinus tarsi is "bullet holed" then the STJ is not maximally pronated. I'm sure Kevin can provide more detail.

 

I described this sign on Podiatry Arena over 9 years ago: Positive Kirby's Sign

 

Do you have an image of this you could post up please, Kevin?

 

All I can find is your reference to the lateral process of the talus...nothing about the "see through sign" or "bullet-holed" STJ. I have found that the patient with this radiographic presentation is indeed maximally pronated. Clinical confirmation quite easy to achieve...in spite of Nester's suggestion that false positives will occur due to AJ frontal plane motion, (which, btw, I don't subscribe to).

 

Simon,

I was also taught that a bullet hole in the sinus tarsi is a sign of supination. In examining foot bones, it appears that there is one point (possibly at what we call the neutral STJ position?) in which the calcaneus and the talus are closely coupled. If you supinate or pronate the STJ from this position of maximum contact, separation occurs between these bones and as a result the space between them increases.

For a long time I have wondered that if my observation also occurs in vivo, then why would we only see a bullet hole when the foot is supinated? It may be due to the angle of the view of the x-ray. Perhaps if we shot the films of a pronated foot from a different angle, we might see this space (bullet hole) occur. I have mentioned this years ago on the PA but I have never heard anyone else suggest this.

Jeff

 

When you watch Don Green's fluroscopy video, you can clearly see that with maximal pronation the lateral process of the talus slides right down and abuts the floor of the sinus tarsi; there is complete occlusion and no bullet hole.

 

On those particular patients, perhaps. Did Green et al also submit WB lateral X-Rays for correlation and to confirm their findings? From what Fuller has discussed previously, those videos were taken on 4 patients. What was their pathology?

 

While posters here still are nit-picking some of the "details" in my study, none have addressed the REAL issue...that of GPs in children and RLS in adults being referred pain from the STJ caused by chronic/acute subluxation and transient synovitis. Why is that?

 

These are from a book chapter by Don Green (not sure of the book, it was included within the lecture notes for a summer school). The chapter is called "radiology and biomechanical foot types" and it's chapter 48, so it's from a big book. So Jeff, if you wanted to test a theory that maximum pronation of the STJ, and not just increased STJ pronation, creates a referred pain which is a cause of "growing pains", you'd expect to see all the radiological findings described by Green in the "growing pains" patients- do we? I'm sure even the casual observer could compare the radiological findings described by Green below to the radiographs supplied by someone promoting such a theory.

 

And not find those radiological findings within children without "growing pians" otherwise we lack predictive power.

 

And so the discussion begins...and that's a good thing. Does everyone agree that the foot at static stance is pronated, ie., the STJ is pronated? If a "see through sign", or "Bullet hole" sign is shown on a lateral X-Ray, does this mean the foot is supinated...or does this mean the position of the foot is still supinated, even though the STJ has pronated? According to Root, the "normal" foot reaches it's highest degree of pronation just after static stance. So a plain film, WB X-Ray of the foot should show where the patient's foot is "functioning" just prior to maximum eversion of the calcaneus and STJ pronation.

Further, considering that up to 40% of children are effected by GPs, there are a lot more expanded studies that need to be performed in order to separate the wheat from the chaff...as I wrote in my article in re to RLS, but more numbers are needed for GPs research as well.

 

You got it Dr Hun. Best not to talk about the X-ray images you posted in post #59 because the top image shows a bullet holed sinus tarsi, and the bottom image shows a talo-navicular joint which is posterior to the calcaneocuboid joint which creates a posterior break in the cyma line- neither image shows a positive Kirby sign, and some might say that neither image show's a maximally pronated subtalar joint when we judge it by the published criteria for a maximally pronated subtalar joint described by Don Green. We can get around this if we invent some new radiographic criteria to serve our point, I know- I am "bOb" afterall so did you expect anything less than genius? Or else we could just ignore all of that because they might still be maximally pronated during gait. That doesn't really help though, but we can ignore it. If you do, I will. I'm not sure how we measure that during gait, so best not to talk about it too much. i'm ignoring it. Cosnider me not mentioning it again. The less we say about how we could show a "subluxed subtalar joint" the better. Stop putting your foot in your mouth. We better not mention that forefoot to rearfoot alignment is strongly correlated to navicular drop either because that way someone might suggest that the PhD researcher Angela Evans should have found a relationship between navicular drop and growing pains which she didn't. If we don't mention the forefoot varus thing again, I think we might get away with that one. No my friend, a new sale dawns. Let's ignore all of that "detail" and stick to our guns. Here's to the next sale, they are all nittering, none of them are "Bob", with the exception of Kidd, he is a "Bob", but not the "Bob" so that doesn't really matter, he's more bobble than "Bob". Praise be to "Bob". I for twelve certainly didn't think the way you addressed this Kidds so called "post" made you look stupid and paranoid at all= he is nothing more than a false "Bob". Praise the only one true "Bob" and yourself, obviously.

 

That's what you get when you treat radiographs. I treat patients. 100% success, btw on GPs, and pretty much the same with RLS. Most competent Podiatrists know that orthotics are very effective in treating GPs...but until now, didn't know why. Perhaps now, they do. And fwiw...those X-Rays in post #59 were of adults...so are you discussing GPs, or RLS? [I don't believe you know, either.] But one can easily determine if there's more eversion available by having the patient try to evert the foot more while in static stance. Ooops! X-Rays don't show that, either...do they? It's a clinical test. Since you failed to answer my question...let me try again. If the patient presents with a lateral radiograph like the top one in post #59, and that patient has no more eversion available in static stance at the STJ...is that foot supinated or pronated?

Angela was attempting to correlate foot type using navicular drop. The answer to my question to you above should indicate that there's more there, there. So let me add another question. If one is totally reliant on plain film radiographs to determine STJ position, or measuring navicular drop in order to arrive at that same point, how accurate do you think they will be?

 

Oh Dr. Hunny you are so clever. 100% success is something you should really shout about. I bet no other podiatrist on this planet can or, dare I say it would, be so bold as you to claim a 100% success rate in their treatments. We can ignore the failure that you already admitted to because that would detract from your grade point average. To all the world it seemed that when you said in post #59:

that you were trying to provide images of maximally pronated feet. That they didn't seem like maximally pronated feet when compared to the radiographic criteria for maximally pronated feet described by Green wasn't your problem, it was everyone elses.

When you said that a patient with a "bullet-holed" STJ was a sign of maximum pronation:

that was just great. I love it when you ignore what the published literature tells us. You are so much clevererer than them.


You've been really sub-genius here and shifted away from the X-ray's to clinical testing. "Can they evert anymore"? I like the way you dismissed the possibility of frontal plane motion of the calcaneus being produced at the talo-crural joint earlier in the thread

, we can ignore the bone pin studies that show that the frontal plane motion within the ankle mortice is often greater than the frontal plane motion at the subtalar joint, that's for sure because no-one will have read those studies http://www.jfootankleres.com/content/2/1/18 and "you don't subscribe to" any crazy ideas like research science. No if they can evert, they can't possible be at end of range at the subtalar joint, can they? You Dr Hunt-e-bunt are way too clevererererer for even the great "BoB' himself. But most of all I love that "you don't treat radiographs", can I ask: do you treat photographs? I could send you one of my feet if you did. What about video's? I can send you some great video's I picked up in Amsterdam.

Keep up the good hypocritism, carry on making it up as you go along and praise be to "Bob". A new sale dawns.

 

Yaaaaawn......let's try this again, since you obviously are ducking the question: In the example of an uncompensated rear foot varus deformity...is that foot pronated or supinated at static stance?

I love how the TST minions cling to Nester's study about frontal plane motion of the AJ in cadaver studies...it really "makes the case"...doesn't it? We witness SO much DJD from that abnormal motion in the AJ which is a ginglymus...don't we?

Perhaps it's time for you to relinquish your position as the head of the sub-genius church, Bob...and join reality. Or...just answer my question above and we'll see where this heads.

 

I can appreciate your concerns. After all...the foot has changed SO much in 17 years. Your comment doesn't rise to the level of even sub-genius. Hope this helps.

 

Why do you find it necessary to repeatedly sink so low to use ad hominem attacks on members?

Why do you find it necessary to repeatedly use logical fallacies to argue your case; eg the appeal to authority fallacy is the most recent one,

 

First, when have you questioned why Dobbs uses an alias? Second, please direct me to any of your posts where you counter similar "attacks" towards myself by Simon, Dobbs, Griff, etc. Is there a double standard at play here? Third, I was merely using terms that Dobbs used himself. Hope this helps.

 

I have never used ad hominem attacks directed at you. If you think I have or others have, please use the report post function and Admin will deal with it.

Like others who have been banned from here in the past you are confusing an ad hominem with a disagreement.

 

Then let me ask you....does the fact that Dr. Valmassy has not contributed to Pub Med in 17 years make him any less of an authority on Podopediatrics, or any less capable of offering peer review?