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The Myth of Growing Pains

Discussion in 'Pediatrics' started by Kevin Kirby, Apr 9, 2015.

  1. Craig Payne

    Craig Payne Moderator

    Articles:
    8
    I never said it did.

    You were the one dropping Ron Valmassy's name (ie appeal to authority logical fallacy).

    I do not see what he has to do this. I wonder what he thinks about you dragging him into this?

    I peer review a lot of papers for a lot of journals and would be very ****** and angry (as I am sure the journal's editor would be as well), if the author(s) of any of the papers that I review started dropping my name when trying to justify their paper.
     
  2. drhunt1

    drhunt1 Well-Known Member

    Dr. Valmassy can handle any criticism any of the posters can dish out on this thread or in real time, but next time I see him, I'll forward your concerns. After he reviewed the complete work we had a chance to talk at length about the content, impact and ramifications. He was well aware of the "slings and arrows" that would be directed at me, although I am surprised from whom. It appears that the greatest push back I'm receiving currently is from Aussie podiatrists. Rather interesting, actually. I'm waiting for the PCPs response, but I will predict that they will be much more respectful. And fwiw, it was your own Angela Evans that claimed the article wasn't reviewed. I just pointed out that it was, by whom, and how much weight his opinion still carries in the world we know. He is, indeed, a big dog. Hope this helps.
     
  3. Finally...
     

    Attached Files:

  4. He read the paper and said he liked the idea I think you said or basically that

    That is not review for a peer Journal you saying what a 3rd party said holds no weight
     
  5. drhunt1

    drhunt1 Well-Known Member

    No...Kevin Kirby wrote that he "liked" it. Valmassy's exact words I have not disclosed. Hope this helps.
     
  6. drhunt1

    drhunt1 Well-Known Member

    "The truth is incontrovertible. Malice may attack it, ignorance may deride it, but in the end, there it is."-Winston Churchill
     
  7. You quote who you like, Matt - it doesn't add anything to your position. It's been a painful experience watching your demise throughout this thread and you've done your case no favours in pursuing your derogatory diatribe against Angela Evans, who was simply giving her opinion on your paper - as you asked of her. A better response would have been to thank her and carefully consider what she said. As it is, no dummy has ever been spat so far.

    I don't know if you have a regulatory authority where you practise, but if you have I would be giving some consideration to what constitutes "bringing the profession into disrepute" before a registered letter arrives. A public apology might help..
     
  8. drhunt1

    drhunt1 Well-Known Member

    The anger that exudes from your post is quite evident...and I'm a little perplexed why. But read slowly Mark...the truth shall set you free. Angela Evans deserved the response she got, because it was her that attacked me, my methodology, my presentation, the supposed lack of review, etc. She used BS links to bolster her position, (while simultaneously attempting to take the Higher road), while making sweeping generalizations and ad hoc arguments...and you applaud her. LOL! But I've noticed one GLARING omission from ANY of the posts that have been written here from any of you...an attack on the findings itself. Now why is that? Is it because the article is correct...or is it because Podiatrists worldwide have yet to test/refute the conclusion?

    No apology is necessary and/or required from me. Considering you have experience with regulatory authorities, I will dismiss your threat/concerns with the same relative aplomb as I have with other criticisms. Your words are meaningless, Mark. Hope this helps.
     
  9. I couldn't care less if you claimed to have discovered the secret of eternal life. The abject disrespect you display towards colleagues annuls what little consideration one might give to anything you write. I imagine that is the same for many contributors on this forum. What a sad testament to carry with you through the rest of your career. Goodbye.
     
  10. drhunt1

    drhunt1 Well-Known Member

    I "treat" others with the same respect or indifference as they have treated me. And while you continue to throw arrows towards me and my supposed indecent behavior towards others, (there certainly is a double standard at PA), my legacy will be solving this medical mystery, not for the purported barbs I throw back at those that won't/can't offer viable alternatives, treat me with the same respect they demand from me or at least address the main issue here on a public Podiatry blog. After all...better patient outcomes is in our interest. Hope this helps...and goodbye to you as well.
     
  11. Lab Guy

    Lab Guy Well-Known Member

    I do not ever recall seeing a transient synovitis of the STJ as a cause for growing pains. I have seen synovitis after trauma due to an ankle injury or in long term pes planus and these cases the pain continues despite conservative treatment (which includes foot mobilization) and a cortisone injection is usually needed. I also find it interesting that in some patients with advanced PT dysfunction with the STJ functioning at the end range of motion (high interosseous compression as a result of the floor of the sinus tarsi pushing up against the downward force of the lateral process of the talus) do not even have pain on palpation nor complain of pain of the sinus tarsi.

    I also do not think the pain is emanating from increased compression of the talo-calcaneal joint. If this were the case, we would see a lot of obese children with growing pains as well as a lot of active/athletic kids.

    Lastly, I do agree the subtalar joint is an important contributing factor in growing pains as high pronation moments of the subtalar joint affects the kinetic chain distally and proximally causing increased tensile and compressive stress of the musculoskeletal structures especially during growth spurts.

    When I was in practice, on every new patient, I would always do a lower extremity assessment by palpating the musculoskeletal structures from the hip to the forefoot to check for tenderness. I found that other segmental components could be overused due to compensation or overuse but the patient may not even know these structures were also sensitive unless directly palpated.

    I observed that often times, when there were activated trigger points in the structures above the ankle that frequently there was tenderness on deep palpation of the sinus tarsi (as well as other areas of the foot) in adults and children. When I mobilized as well as distracted the subtalar and ankle joint the previously tender areas (trigger points) in the musculoskeletal structures were no longer sensitive to deep palpation and nor was the sinus tarsi.

    Mobilization as well as distraction applied 5-10 seconds to the subtalar and ankle joint applies tension and stimulates the articular mechanoreceptors of the surrounding ligaments and tendons of the subtalar and ankle joint. At the same time, a distraction force is also being applied to the knee and hip joint. Upon release of the distraction force, there is a relaxation of the musculoskeletal structures due to the articular mechanoreceptors inhibiting the nociceptive afferents. This in turn blocks both the pain messages to the CNS, and stimulation of the muscles from the efferent neurons. Ultimately, this enables relaxation of the extrinsic and intrinsic muscles of not just the lower extremity but upper extremity as well with reduction of pain. Perhaps prescribing orthotics for subluxation of the subtalar joint is also decreasing muscle pain by inhibiting the nociceptive afferents as well, which would be the mechanism behind the referred pain.

    Many patients were amazed at the difference afterwards and I would strap and pad their feet to reduce their pronation (or supination) moment. I would follow them up a week later, and more often than not, they would feel better and their previous areas of tenderness would be less sensitive on palpation.

    I would recommend a complete biomechanical exam and orthotics to reduce the load of the tissues long term and mobilize and distract their subtalar joint/ankle joint as well as other joints of their feet if necessary weekly (and strap and pad their feet) until their orthotics arrived. I would also prescribe stretching exercises if necessary, especially the calf, hamstrings and quads. With children growing, these muscles can get tight and when kids are super active and going through growth spurts, it is important to keep these muscles stretched out to keep their tissues in the zone of optimal stress. Rest or reduced activity, change in appropriate shoe gear (or having patient wear shoes) is also important. I believe it behooves the practitioner to treat growing pains as an overuse injury (and poor mechanics can certainly play a role) to obtain short and long term relief.

    Yes, I do think the subtalar joint is an important contributor in growing pains (nothing new here) but it is not the only etiology behind growing pains. If it was, I would have seen a lot of kids with growing pain symptoms in my practice and adults with resting leg syndrome as I saw a great deal of patients with subtalar (and midtarsal) joints undergoing high pronation moments.

    I do not agree that there is one cause and only one treatment for diffuse muscle pains in the lower extremity of children. It is just not that simplistic in my view just as nothing in life rarely is.

    Steven
     
  12. drhunt1

    drhunt1 Well-Known Member

    Lab Guy-thanks for your considerate response. Let me address some of your concerns. First, you are not likely to witness the transient synovitis in your office or clinic. As the historical record indicates, and what we wrote about in the article, is that these severe symptoms occur after the child retires to bed, ie., once activity has ended. Unless you happen to be in the patients' house an hour or two after they go to bed, you're just not going to see it. However, the parent can report on extreme pain in the STJ after being instructed what/where to check. What the practitioner will see in the examination is increased pain with direct palpation to the STJ...either pressing on the sinus tarsi or directly on the posterior facet from either medially or laterally. I have found that scheduling these patients after school and/or at the end of the work day increases the potential for replicating the painful response with such palpation. What you're looking for is the guarded response when patients pull their feet away from the examiner...and you're witnessing inflammation of this joint.

    Second, increased body mass has been linked to GP's in children by multiple researchers. Third, in patients with PT dysfunction, these are typically older patients, so are you asking about RLS and not GPs? In more severe cases of PT dysfunction, (although I never specifically targeted those patients), I would imagine that, indeed, they have symptoms of RLS, whether reported to their PCP or not. Many of the patients I have treated don't report these complaints for many reasons, not excluding the fact that they present with more significant pain elsewhere in the feet. One young patient I treated, (15 y.o.), certainly did have PT dysfunction, and her presentation is the last foot seen on the treadmill in the following video. She had GP's and lateral instability:

    https://www.youtube.com/watch?v=O-5qHOOSaQs&feature=youtu.be

    Fourth, while strapping feet is an excellent method to limit STJ motion, (Low-Dye), they typically only are effective for 2-3 days. As per the article, the young GP patients will respond by the second night of orthotic treatment, but once the strap becomes loose, the symptoms should return. Orthotics will address all these issues and give longer lasting results, until they either outgrow the device, or break it as was described in the article. In adult patients with RLS, a simple STJ anesthetic block will prove to the patient that your diagnosis is correct. I call these injections a "poor man's CT scan", but can also be therapeutic.

    Finally, it has been my experience in private practice that GPs and RLS are a continuum of the same problem...referred pain from the STJ. Hashkes was/is wrong. So are many other researchers. Once excessive pronation, which subluxes that joint to its end of ROM, is controlled, the symptoms disappear...with kids typically on the second night, in adults by the third. The symptoms return if/when the patient doesn't wear the devices, or, as the article suggests, either the child outgrows them, or they are broken. The symptoms are reproducible and consistent. While much more study focusing on this needs to be undertaken, my continued treatment successes direct me to follow this line of reasoning and improve patient's lives...all with a simple orthotic device.
     
  13. drhunt1

    drhunt1 Well-Known Member

    Not to ask a trick question...but here's a radiograph of a 17 y.o. male patient that came into my office the other day. These are WB radiographs. Now...is this foot supinated, or pronated? And can anyone here comment on the forefoot to rear foot and the type of foot this is?
     
  14. drhunt1

    drhunt1 Well-Known Member

  15. drhunt1

    drhunt1 Well-Known Member

    I posted the AP and Lateral plain film radiographs of the 17yo patient above on May 14th of this year....4 1/2 months ago...and no response. I suppose I'm going to need to submit a video showing that these patients have no further eversion at the STJ available at static stance, which is what these WB X-rays represent. As I've indicated before, it appears we have a "definitional" problem. What is a supinated foot at static stance? How can the foot be "supinated" at static stance, considering that we know the STJ everts in order to bring the forefoot into contact with the ground, beyond being the shock absorber of the lower extremity? I will upload videos when they become available. And FWIW...the AP view of the above patient indicates a skewfoot deformity. Hopoe this helps.
     
  16. drhunt1

    drhunt1 Well-Known Member

    The other thread on this topic was "shut down" by the administrator for wholly considerate reasons, yet the NewsBot still posts associated articles referencing this condition.

    http://www.theguardian.com/healthcare-network/2015/sep/23/gps-support-spot-childhood-cancers

    In this article, written by a nurse in the UK, a paucity of initial symptoms are given. She does mention that 6/10 subjects were given the diagnosis of GPs. Perhaps this is because PCPs have not either researched the topic enough, or do not have a quick, easy and reliable clinical test to determine this malady, thus differentiating it from much more serious diseases. Considering that GPs should have a different presentation to neoplasms, but with "some" possible overlap, it is critical to educate those PCPs in developing a timely and effective method to create a differential diagnoses.

    Perhaps, now they do...a quick, easy, reliable method of clinical diagnosis for growing pains, above and beyond the information acquired in the initial questioning and HPI.

    http://www.podiatrym.com/Biomechanics_Footwear_Sports_Podiatry2.cfm?id=1632

    Hope this helps...
     
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