Can muscular symmetry be achieved in the presence of a LLD?

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Hi Everyone,
I have a case which has me a bit stumped to say the least although it is VERY interesting. I think it should also make a good discussion and reading point for people also as this is something that I guess isn't really seen in an NHS environment much?

Patient Overview
Male, early 20's, athlete specialising in weights (not a bodybuilder), professionersonal trainer, fit and healthy with no medical problems, trains approximately 3-4 times a week weights for an hour a session working different part of body at each session and cardio 3 times a week brisk walking for 50 minutes

Problem
Presenting with an approximate 3cm functional LLD, right is longer leg. No upper body problems or scoliosis. Mild pronation in both feet, more noted in longer leg, FHL present in both. Yet to do a proper gait analysis (nhs time restraints )
Patient is very concious of muscle tone and development due to profession and finds that in the longer leg it is easier to achieve 'normal' (oh that wonderful word :bang quad 'long, lean and proportionate' development whereas in the shorter leg (left) the quad muscle development is very short, big and bulky. The assymetry in development is quite obvious when observed. According to patient there is no difference in strength of the legs and they can each press the same weight etc.

What the patient wants
Symmetry and even development of both quads

What I wanted to know is, is even possible or our ball park? I mean we can treat the LLD with orthotics but will that overtime create even muscle tone if the patient trains with them in etc. Only reason I'm asking is I don't want to give the patient false hope and say 'yes these will make everything ok' and also I have never had this question answered before, even at uni.

Please excuse subjectiveness of this thread, was very quick assessment and he is coming back for a longer one soon so also any suggestions of what to check for at next appointment welcomed with open arms

ANY help MUCH appreciated

 

Hi Kerrie.

Think about lever arms, when you think about this patient.

In a basic way if we take the quads and the leg length only.
We say they produce the same amount of force when contracting.

We can for this example say the femur is 20 cm on the right and 18 cm on the left, The force provided by the muscle group the same, the question become what effects how effective the muscle is ?or how much force it can produce ? with me so far.

So the right femur is 20 cm and the left 18cm so the right has a longer lever arm, which all things being equal will me that it can produce x amount of force with less effort than the left. ie the right has a greater mechanical advantage than the left. Still with me.

Now the question becomes how can the left side still create the same amount of force? By working harder or producing more work. OK ?

So if a muscle works harder over a long time it will increase its cross section thickness, a training effect.

Does that make sense ?

So if your patient wants to have the same force from the Quads the left side must work harder and will be bigger in size. If he wants to look at same in the mirror then train the left side less and it will get weaker and smaller.

Hope that helps.

 

I will reply to Kerrie's request for clinical advice but first I must comment on the pedantic posting by Mr. Weber.

This is a case with no pathology, no symptoms, not even subclinical tissue stress. Spooner et al would say, learn to live with your asymmetry and come back to me if you are in pain and there is no evidence that I can offer you a solution to your problem because it really isn't a problem (learn to walk on your hands).

All this information, a lengthy BioNewtonian thought process and a clinical response of "train the left side less" or (implied) "get sick and come to me", PERIOD!.

My EBP says that the starting place would be to balance The Inclined Posture, the root of his problems, that will encourage his training results to be more symmetrical and maintain the symmetricity that your patient desires long term.

Please confirm TIP by testing that he has a relative ankle equinus with a relative subtalar varus with the short side being in more equinovarus.

I suspect he has a rigid rearfoot, flexible forefoot foot type owing to his "Mild pronation" and once confirmed, I would cast him for his foot type and post as usual with a 0 degree rearfoot post and a 3-4 degree forefoot post with an aggressive S/L 1st ray cutout.

Since there is most likely a B/L equinus influence, I would add a 5 mm heel lift to the long right Centring and a 10-12 mm heel lift to the short left side to start.

I would ask your patient to continue to train equally since that is his preference and explain that you have changed the dynamic (that lever arm stuff of Weber's) and that his muscle mass will become more symettrical over time (or he can train his left side less to make it happen quicker).

I would ask him to do more weighted work such as roadwork, treadmill, etc as that will encourage his bioreceptors to respond to the new symmetry you have produced with your Centring (the cross sectional thickness stuff of Webers).

I would suggest that you will adjust your his Centrings and your program as you monitor his progress and institute the importance of adding foot centering to his life for longevity, performance enhancement and success.

What I have presented is a course of care independent of language, semantics and level I Evidence, based on science, This is Wellness Biomechanics in Action.

Dr Sha

 

Kerrie:

This patient doesn't have a functional problem at this point, but rather a cosmetic problem, from what you have told us so far. However a 3.0 cm leg length discrepancy (LLD) is a very large amount of LLD so I would question whether this is accurate or not.

If there is a true 3.0 cm LLD, I would tell the patient if he were to make the two limbs be equal in shape, then the shorter one would likely be less strong than the longer one, which may cause him even more problems. Don't worry, once he ages another few decades, he will probably be mature enough to understand that he is probably more worried about the shape of his legs than anyone else is.

 

Dennis you are a TOOL.


I was explaining to Kerrie why the sides are different. The patient wants symmetry, that what the patient wants. So I was helping Kerrie to explain the patient that it´s his LLD and change in lever arms thats the cause.

Now she can explain to the patient and the patient can decide. If you read Kerrie post.

So Dennis I was helping Kerrie to discuss this with her patient, but you missed the point and went off on once again.

 

So Dennis I was helping Kerrie to discuss this with her patient, but you missed the point and went off on once again.

Why don't we let Kerrie decide this one Michael?

Dr Sha

 

:good:

 

Kerri wrote:

A distinction between LLD and FnLLD (or I prefer LLI - Leg Length Inequality) has already been made. It was also discussed by Michael how it could potentially affect muscular function and as Kevin pointed out that it is a cosmetic issue. I rarely see patients with perfect symmetry because of dominance (if you do not buy into this Dennis read up on Apley's scratch test) and again as Kevin said this is cosmetic.

At the end of the day who here adds a life for a FnLLD? So if this were an actual LLD of 3cm (30mm), I'm trying to get my head around the following:

1. using a lift at all for a FnLLD when it is probably muscular compensation. The fact that you would use a lift in this patient Dennis concerns me. I am sure it will concerns others as well.

2. All this brick-a-brack about centrings and the math Dennis presents. Let's call centrings cowpie, all agreed raise your hands :craig:

 

Kerrie,
Here is a paper which may be useful to you:

The Journal of Bone and Joint Surgery (American) 83:907-915 (2001)

Effects of Limb-Length Discrepancy on Gait Economy and Lower-Extremity Muscle Activity in Older Adults

Burke Gurney, PhD, PT, Christine Mermier, MS, Robert Robergs, PhD, Anne Gibson, PhD and Dennis Rivero, MD

Background: The amount of limb-length discrepancy necessary to adversely affect gait parameters in older adults is unknown, with information being largely anecdotal. This investigation was conducted to determine the effects of limb-length discrepancy on gait economy and lower-extremity muscle activity in older adults.

Methods: Forty-four men and women ranging in age from fifty-five to eighty-six years with no evidence of limb-length discrepancy of >1 cm participated in the study. Subjects walked on a treadmill at a self-selected normal walking pace with artificial limb-length discrepancies of 0, 2, 3, and 4 cm applied in a randomly selected order. Indirect calorimetry was used to measure oxygen consumption and minute ventilation. Electromyography was used to measure muscle activity of the right and left quadriceps femoris, plantar flexors, gluteus maximus, and gluteus medius. Heart rate, the rating of perceived exertion, and frequency of gait compensation patterns were also measured.

Results: There was a significant increase in oxygen consumption and the rating of perceived exertion with 2, 3, and 4-cm artificial limb-length discrepancies; a significant increase in heart rate, minute ventilation, and quadriceps activity in the longer limb with 3 and 4-cm artificial limb-length discrepancies; and a significant increase in plantar flexor activity in the shorter limb with a 4-cm artificial limb-length discrepancy compared with the same parameters with no artificial limb-length discrepancy.

Conclusions: Both oxygen consumption and the rating of perceived exertion were greater with a 2-cm artificial limb-length discrepancy than they were with no artificial limb-length discrepancy. There appears to be a breakpoint between 2 and 3 cm of artificial limb-length discrepancy in older adults with regard to the effects on most other physiological parameters. A 3-cm artificial limb-length discrepancy is likely to induce significant quadriceps fatigue in the longer limb. Elderly patients with substantial pulmonary, cardiac, or neuromuscular disease may have difficulty walking with a limb-length discrepancy as small as 2 cm.

The next steps for you are to determine if he really does have a 3cm leg length difference and to determine if this difference is structural or not. You may be able to improve this athletes performance by addressing the limb length discrepancy, but there is no such thing as a free lunch.

See these free full text papers which I think relate to David's point:
http://www.chiroandosteo.com/content/13/1/11
http://www.chiroandosteo.com/content/13/1/12

And also:
http://www.ncbi.nlm.nih.gov/pubmed/11869914

 

Hi Kerrie

The LLDs and LLIs always interest me too.

I was just wondering how you arrived at the diag of a functional LLD ? And the 30mm difference?

I know how challenging it can be to record all factors in the confines of nhs clinic slots , but I'd be interested to know.......

Did you take measurements with patient lying supine, from sternum to medial malleoli? And then Asis to mm? Did you check the patient in stance to see if the long leg was transferring through to L or R asis/psis?

Or did you arrive at your conclusion from other factors?

Kind rgds
Pete

 

Hi Guys,
Thank you so much for all your really helpful posts there, it is making me be able to look at the patient in a more concise and accurate way now which will really help me when he comes in. He is someone who is quite worried about his form as I think that he has been told by mulitple people over the past such as physios etc that he has this leg problem and I think that the overall concern about how it will affect his athletic capability has made matters worse for him in terms of how he sees is muscle development.
Simon thank you so much for the papers, they will definitely make for some good reading and arm me with the right intellectual arsenal
Kahuna, yes I agree with you in that LLD and LLI are a very interesting subject and did indeed take the measurements as you described there which is also the way I was shown on a clinical placement with uni, although a previous physio referral said 4cm and a GP referral 2.5cm so no wonder that the patient has been concerned!! I have not yet checked in stance, NHS haha, but am intending do it when he comes in. I will let you know what I find
Thanks Again Everyone

 

No need for concern - just explain it's due to the very poor inter-rater reliability (as is the case with most anthropometric measurements)

 

Kerrie when I am presented with determining LLD vs FnLLD if I have a niggling doubt as to whether or not it is truly anatomic, I order a LL xray. If you and others are quite certain that it is a FnLLD and is not reducible prone, I then perform the following:

Lay the patient prone, note effect if any at the hip. Flex the legs individually at the knee (Ely's test for a tight Rectus Femoris). The RF is the only quad muscle which crosses the knee joint, so flexion at the knee will lift the pelvis off the table with a tight or hypertonic RF. Normal is 135 degrees flexion at the knee or the heel touching the buttock. If the RF is very tight it may explain the difference in development.

Then have the patient turn over supine with their seat at the edge of that table so that the tested limb hangs over the edge freely. Flex the other bent knee to the chest, the low back should flatten out and the tested leg should remain on the table with the leg able to flex 90 degrees at the knee (Thomas test). If the tested thigh lifts off the table, the illiopsoas is the culprit. I add passive knee flexion while in the tested position to gauge the patient's response, a hypertonic, tight psoas will light the patient up visibly.

Other culprits are the Quadratus Lumborum and Erector Spinae. Typically though the QL favors exhibiting a good degree of pain when hypertonic and can refer, often mimicking low back pain and sciatica (non dermatomal and does not cross the knee). He does not complain of pain so he may just be tight in this area, the QL's are well documented generators of pain when dysfunctional. You can test the flexibility of the ES by laying the patient flat supine and bringing the knees to the chest.

If these appear normal (or with low back pain and a tight psoas) I order a standard lumbar view Ap & Lat and look for body rotation of the lumbar spine. Because the psoas originates at the lumbar spine, it can have a dramatic effect on vertebral body rotation and thus functional leg length. I never use a heel lift for a FnLLD. This is the type of patient that resolves very well with specific manipulation, deep tissue therapy, post-isometric exercise and stretching. Core strength is very important in maintaining the integrity of these muscle groups and many weight lifters are often notoriously lacking in flexibility I find.

I feel that working with the PT to correct any positive findings that you elicit would be of more value than a lift from experience. If there is dramatic lumbar rotation a series of manipulations followed by exercise specific to the affected musculature and to maintain the reduction of vertebral body rotation should correct the FnLLD. Patients are amazed at how dramatically and rapidly we get results with this type of issue after their initial surprise at me removing the lift from their shoe.

Good luck. Let us know how this patient fares please,

Regards,

 

As well pointed out by Dr. Spooner, there are neurological sets reinforcing FnLLD. As a DPM, I need sources of referral to eliminate fnLLD and I use lifts first finding that the soft tissue shortness often respond to produce new leverage and receptor sets. If this doesn't work, I refer to PT , Yoga, Pilades. Rolfing, etc.

I no longer refer to Chiropractic as in my experience, they never came up with a "Cure" rather they seem to establish a permanent relationship with my patient recommending never ending adjustments to reduce the FnLLD allowing failure to cure to be accepted.

As you are a Chiro/C. ped, I am very curious to hear after making your diagnosis what your short and long term therapy would be, lets say if the rectus femorus and iliopsoas were the "culprits"?

In addition, all of the references sited here as well as those I have personally referenced additionally conclude that Limb Length is poorly understood, impossible to measure, has no effect on structure and function unless large (20mm +) and so your assertion that at the end of the day, "who uses lifts" asserting that lifts are dangerous (Re: your "concern") has no validity in Evidence and one that you seem to have no clinical experience regarding.

I end with my yet unanswered question regarding LLD/FnLLD and that is if any of you have asymmetric shoe wear, unilateral stress fractures, unilateral heel pain, unilateral bunion, unilateral neuroma, asymmetric callus and/or corn display, unilateral ankle, knee or hip pain or L-4 L-5 low back pain, how often are you treating these patients for LLD or FhLLD concomitantly in your practices?

 

Dennis I don't see where Simon made any such statement, Simon did you or did you not merely provide Kerrie with some information and studies that were pertinent to her original question? Dennis again you are basing your responses on your own assumptions, as you always do and without a shred of proof. Your EBM Level proof rhetoric is tired and loathsome on a professional board. Especially when no one I can recall agrees with your fantasies and fallacies.

I too refer to other providers. All professions can claim great personnel within it's ranks as well as abject lunatics. You are proof of the latter.

Or perhaps you lost numerous patients due to their overwhelming satisfaction with the chiropractors that you referred to? A recent 5 year Medicare study on the safety, efficacy and patient satisfaction for musculoskeletal complaints would blow this line of attack of yours out of the water Dennis. Don't go there, you will lose even more credibility attacking an entire profession unjustly, it is your opinion and your assumption again Dennis and a straw man argument and not relevant to the discussion and Kerri's original questions.

Dennis I could post an entire new thread (possibly a text) on physical medicine and rehabilitation. I won't bore the rest of the readers here but as a weight training enthusiast, martial artist, cyclist and chiropractor my entire personal and professional life has been devoted to functional medicine, treatment and rehabilitation from injury. In the past I have provided numerous injured workers, motor vehicle trauma patients and weekend warriors specific rehabilitation plans to mediate their complaints. My professional paradigm is to decrease pain initially and increase function and a return to work or activity and release the patient, as any reasonable provider would do. I seriously doubt you have any background whatsoever in physical or industrial medicine so drop it. As my father always said "never bring a knife to a gunfight".

To appease you though initially a patient in pain would undergo passive physical medicine (PIR, PNF, electrical modalities), manipulation and activities of daily living modification to reduce pain. Once gains were experienced, we would shift responsibility to the patient and introduce active exercise to improve function and maintain correction. This could include neuromuscular reeducation, Core exercises on a ball, concentric pelvic, hip and lumbar sets etc. It's not rocket science Dennis.

I agree that FnLLD assessment and treatment is less well understood than anatomic LLD. I provided Kerrie with a brief routine evaluation that I would perform to determine what was causing that patients inequality. Her patient has no pain or dysfunction that we know of so the question is why open Pandora's Box and possibly cause iatrogenic injury to an otherwise healthy patient?

Unlike yourself I (we as a profession) utilize standard and accepted orthopedic evaluation protocols to locate the source of the problem. To suggest that I have no personal clinical experience in dealing with these issues is the most pusillanimous and insulting comment from you yet. I have evaluated and treated more FnLLD than you can imagine and more than you ever did while you were in practice, guaranteed. I have helped a great number of these people and drawing on my personal intra examiner experience have found no value in lifts for a FnLLD. Perhaps this is because in my experience much of it is caused by pelvic, vertebral and muscular influence and treatable with the tools I employ daily in clinical practice.

Dennis where are the studies that validate any of your claims or theories? You have already established a "wellness" mindset (for which you deride my colleagues when convenient - quite hypocritical) and probably because you like many who come here with the Holy Grail theory of foot treatment want to sell a product and wellness is an excellent medium for providing 'what if's'. I notice Kerri thanked me for my response and not you, something to think about.

Dennis, Perhaps once and for all it is time for you to seek another hobby or get a pet, if the pet will have you. I wager not.

I apologize Kerri for this squabble on your thread. I hope you have some reference and answers to go on from our responses.

 

​

pusillanimous

I had to look that word up! You never stop learning.

Sorry Kerrie. This happens a lot.

 

Dr. Wedemeyer:
You and I are not "peer" DPM's or Chiro's. Do you argue that?
FYI: I do not use the letters for personal reasons but I am a C.Ped, probably longer than you, so I guess we are even there.

I have proclaimed the bulk of my profession (extrapolated from personal experience and opinion) to be biomechanically inept but that they are foundationally trained and poised to upgrade with a relatively small investment.

Likewise, in my experience and opinion, Chiropractors are inept at focused clinical assessment and care (as you are not) and I guess (you said it not me) that makes the bulk of your profession inept.

I have bookmarked your exam for LLD/FnLLD and plan to use it in my EBP, thank you for that. I use lifts because I lack the training and experience that you possess and I refer to others with similar skill and passion as you for motor control and manual therapy.

I could have said in my posting "As well pointed out by Dr Spooner's Evidence" instead of giving him authorship but The Arena microscope would have found some other word to focus on to call me a "Tool".

When it comes to The Chiropractic testing for LLAA (yet another acronym):

The examination for unloaded leg-length alignment asymmetry as a sign of "neuromuscular dysfunction" is a clinical test commonly used by chiropractors [2,3]. Given the frequent use of this test as an indicator of a functional problem, it is important to know whether the unloaded leg check test is an indicator of an anatomic short leg, or whether the test is reliable and valid as an instrument to measure functional "short leg" and whether LLAA findings are contaminated by anatomic LLI.

Petrone et al found excellent intra and inter-examiner reliability, and validity (ICC, 0.89–0.90) relative to anatomic leg length inequality determined by x-ray measurement in asymptomatic subjects [8]. However, the correlation between the pelvic level and femoral head heights was "substantially lower" in a low back pain group. This indicates that some sort of functional pelvic tilt or torsion was present in the low back pain population that was unrelated to their anatomic LLI. While the decreased correlation between pelvic tilt and LLI in the back pain group was not examined relative to a functional short leg, the connection between back pain and the biomechanically unusual pelvic torsion stands out.

This type of permanent compensation to pre skeletal maturity LLI was also found in subjects with pelvic unleveling. Young et al [11] found that placing a lift under the foot of a subject with no pelvic unleveling resulted in greater lumbar lateral flexion towards the now high iliac crest side. In subjects with pelvic unleveling, when the lift was put under the foot on the side of the low iliac crest in order to level the crest, lateral flexion was increased towards the formerly low crest side. If the body remodels and adapts to the pelvic unleveling/torsion caused by anatomic LLI, then by putting a lift under the side of the "low" iliac crest, one is actually raising what the body has adapted to as level. In other words, the unlevel pelvis of those with anatomic LLI has been adapted to and is now "normal", and putting a lift under the low side has the same effect as putting a lift under the leg of an even pelvis.

The studies noted above provide indirect evidence that the pelvic torsion associated with childhood-onset anatomic leg-length inequality is adapted for and incorporated as normal. It follows then, that when an average person with an anatomic LLI and structurally compensatory pelvic torsion moves from a loaded (standing) to an unloaded (prone/supine) position, the torsion of the pelvis remains intact and the leg length at the feet/shoes would appear "even" on a visual check. The pelvis – joints, ligaments and muscles – have adapted to the anatomic LLI, making any torsion structural. It is this putative biomechanical adaptation that makes unloaded leg-length alignment asymmetry tests – the functional "short leg" tests – unreliable as a measure of anatomic LLI [14].

It further states:
The nervous system also appears to compensate as demonstrated in the study by Murrell et al [12] in which there was no loss of stability in subjects with LLI, prompting them to point to "long-term adaptation by the neuromuscular system".

This leads to my thought that the nervous system needs to be stimulated by (temporary) lifts in order to re-educate them.

As to the use of lifts in LLD/LLAA:

Now we can return to the dilemma of how lifts may have a positive effect on back pain and muscle activity given that most anatomic LLI is not clinically significant. Torsion of the pelvis as an adaptive structural compensation in anatomic LLI has been shown to be limited. If a person has pelvic torsion due to anatomic LLI near the limits of the body's ability to adapt, and QL hypertonicity with its ability to cause pelvic torsion is superimposed, muscular bracing reactions and pain could be the result. Indahl et al [22] found that stimulation of the sacroiliac joint capsule (in pigs) caused reflexive muscular responses, depending on what area of the joint (dorsal/ventral) was stimulated. They note that, "Irritation of low threshold nerve endings in the sacroiliac joint tissue may trigger a reflex activation of the gluteal and paraspinal muscles that become painful over time". Interestingly, stimulation of the ventral area of the SI joint produced reflexive contraction of the quadratus lumborum. It may be that a positive feedback loop could be established where QL hypertonicity leads to lumbar curvature and pelvic torsion which stimulates the SI joint leading to more QL hypertonicity, more lumbar curvature and pelvic torsion. It will be interesting to see if a similar muscular reflex to SI stimulation is found in humans.

Based on their research, Allum et al [23] proposed that rotation of the trunk excites joint receptors in the lumbar spine triggering muscular contractions – paraspinal muscles – for balance correction. While these receptors likely have adapted to any pelvic/lumbar rotation caused by anatomic LLI, further pelvic torsion caused by QL hypertonicity may stimulate the balance receptors causing reflexive muscular contraction. A lift would reduce the pelvic torsion and lower the proprioceptive balance triggers below threshold, eliminating chronic, painful muscular contraction.

In a case of additive effects of anatomic LLI and QL/suprapelvic hypertonicity on pelvic torsion, a lift used to level the pelvis would take the strain off the sacroiliac and associated joints and ligaments and decrease potentially painful muscular bracing. Thus, lifts can work to decrease back pain in people with what seem to be clinically insignificant amounts of anatomic leg-length inequality. Of course, it would be important for the clinician to explore reasons for any quadratus lumborum and other suprapelvic muscle hypertonicity and eliminate them to provide a complete correction. On the other hand, pure anatomic LLI in the range of and above 20 mm – the upward limit for adaptive compensation – may stimulate sacroiliac and/or lumbar proprioceptors causing reflexive and ultimately painful muscular contractions that will only be relieved by a lift to level the pelvis.

I agree with the conclusion that:

In this authors opinion, while it is necessary to be able to detect a functional asymmetry above a baseline amount, the LLAA is more of a go/no-go test relative to a clinical decision. As such, accuracy in magnitude is not critically important past that lower limit amount. In other words, as an example, clinicians would only have to agree that an asymmetry above 1/8" exists, and not whether the asymmetry is 1/2" versus 3/16". Studies designed to examine intra- and inter-examiner reliability should keep this in mind.

I don't know what gives you the ability (other than bias and personal defense) to call the use of lifts (of concern).

 

Gosh what a lot of information. Being a Podiatrist not a chiropractor I skipped to the conclusion of that article. Which was:-

Seems pretty clear in its view there. Eliminate FnLLD before you Treat SLLD. But as I say, I'm no expert on LBP so what do I know? I'm a simple man, I like simple tests. Its much easier to guage outcomes if you're trying to move patients from Pain -> no pain. If it looks ****** from the back in gait, or IS ****** on a pelvic level on static, try them with a raise for a week or two. If it stops it hurting, cheer and leave it in.

Much harder if you are chasing the "ideal" position from a position of no symptoms as you have no objective and reliable indicator of good outcome. If there are no symptoms I don't presume to know enough about protective structural adaptations of the spine to know when it is wise or effective to try to staighten something which has been curved for years.

Article here BTW http://www.chiroandosteo.com/content/13/1/12.

I'll leave you two to it.

 

Agreed. I’m not sure what your point is here Dennis but I believe that I understand your inference. I will say that being a C.Ped. is probably redundant for a DPM. I do not question that DPM’s receive a high level of training with regard to foot orthoses and pedal biomechanics. Likewise, DC’s receive also receive a high degree of biomechanical training, mostly spinal. The leap to pedal biomechanics is not insurmountable for the chiropractor’s level of education and understanding of the structure and function of the human body.

I strongly disagree with you Dennis. I don’t think you’ll find many “peers” open to your ideas and theories when you disparage them in this manner. I also believe that DC’s are ‘foundationally trained and poised to upgrade with a relatively small investment’ in podiatric biomechanics.

I never called my profession inept Dennis, you did. Please show me where I have stated this? With regard to foot orthoses I feel as a whole we (chiropractors) are not the best profession to deliver this service given the current climate of training. I also feel that could change given the proper education. The bulk of my profession is more than adept at focused clinical assessment, we all took the same courses and passed the same boards. How one chooses to practice is what is highly individual, as are diagnostic and treatment skills. It is the same in your profession I am sure.

Unfortunately, that is only the tip of the iceberg. Any quality orthopedic assessment text (McGee) is useful here. The problem I see is a divide in training between podiatry and chiropractic (and physical therapy, I’m an eclectic) that could serve as useful if these professions worked together for the benefit of the patient and kept an open mind. Almost all of what I have learned clinically related to the foot I have learned from your profession. I admit that and I am not ashamed of it, on the contrary I encourage it.

I removed your post of the body of the article but anyone reading along can see it in your post or read it if truly interested (and perhaps bored to tears)

Dennis, Kerri was very explicit that this patient is asymptomatic. Your response to her confuses me because you point out that Kerri stated the patient is asymptomatic and then go on to deride Micheal’s post because the patient is asymptomatic and then begin to offer your process for TIP evaluation. The rest of us appear to agree this patient requires no treatment. Who is being pedantic now?

You wrote:

You use the word “MY” frequently I want to add. I merely offered Kerri a brief, orthopedically sound (and evidence based), accepted method of evaluating this patient’s concerns and validating them based on a fnLLD. I then offered treatment options based on the various possible differentials. Your assumption that this patient’s symmetrical differences and FnLLD is caused by his foot (TIP) is something you’ll just have to prove to us because I have never heard of this method of evaluation being taught in any medical, chiropractic, podiatric or physical therapy program. The onus of proof is on you Dennis. It has met exhaustively with criticism by your “peers’ at least here on PA. If you honestly feel that you can effect a positive change in a FnLLD at the foot in a reliable and repeatable manner ignoring the more reasonable approach that I have outlined, then we have nothing more to discuss.

Kerri’s original question was “Can muscular symmetry be achieved in the presence of a LLD?”. I feel the question was misunderstood, at least I admit to this on my initial reading (since we are discussing a FnLLD I will not address anatomic LLD in my reponse). Because this patient is asymptomatic I ask why on earth would you treat this patient with a lift (or a centring based on TIP)? I am offering my experience that I do not use lifts for functional LLD’s. I base this on excellent clinical outcomes for symptomatic patients with FnLLD using a combination of manipulation and physical therapy (and at times orthoses).

Robert wrote:

Spot on Robert. The people that seek me out are symptomatic, most have low back, hip or sacroiliac pain. I still do not use a lift if there is a FnLLD. I try to evaluate them and determine the etiology of the inequality; osseous, muscular or both and to treat them functionally because it is a functional problem. Our professions approach these patients based on what is in our tool bag. I have found that some patients with gross pronatory findings suffer low back pain and a FnLLD. I cannot explain it but this is what I have experienced and now evaluate the lower extremity as well as the spine as the source. Much more work needs to be done in this area by both professions, I think we can all agree that FnLLD is not as well understood as it should be.

 

David:

I told Robert the same thing.....this is what you are currently doing:deadhorse: .....and this is what you will be doing if you continue.....:bang:

By the way, David, you really need to pay me a visit sometime up here in Sacramento....I like the way you think.:drinks

 

The examination for unloaded leg-length alignment asymmetry as a sign of "neuromuscular dysfunction" is a clinical test commonly used by chiropractors [2,3]. Given the frequent use of this test as an indicator of a functional problem, it is important to know whether the unloaded leg check test is an indicator of an anatomic short leg, or whether the test is reliable and valid as an instrument to measure functional "short leg" and whether LLAA findings are contaminated by anatomic LLI.

Petrone et al found excellent intra and inter-examiner reliability, and validity (ICC, 0.89–0.90) relative to anatomic leg length inequality determined by x-ray measurement in asymptomatic subjects [8]. However, the correlation between the pelvic level and femoral head heights was "substantially lower" in a low back pain group. This indicates that some sort of functional pelvic tilt or torsion was present in the low back pain population that was unrelated to their anatomic LLI. While the decreased correlation between pelvic tilt and LLI in the back pain group was not examined relative to a functional short leg, the connection between back pain and the biomechanically unusual pelvic torsion stands out.

This type of permanent compensation to pre skeletal maturity LLI was also found in subjects with pelvic unleveling. Young et al [11] found that placing a lift under the foot of a subject with no pelvic unleveling resulted in greater lumbar lateral flexion towards the now high iliac crest side. In subjects with pelvic unleveling, when the lift was put under the foot on the side of the low iliac crest in order to level the crest, lateral flexion was increased towards the formerly low crest side. If the body remodels and adapts to the pelvic unleveling/torsion caused by anatomic LLI, then by putting a lift under the side of the "low" iliac crest, one is actually raising what the body has adapted to as level. In other words, the unlevel pelvis of those with anatomic LLI has been adapted to and is now "normal", and putting a lift under the low side has the same effect as putting a lift under the leg of an even pelvis.

The studies noted above provide indirect evidence that the pelvic torsion associated with childhood-onset anatomic leg-length inequality is adapted for and incorporated as normal. It follows then, that when an average person with an anatomic LLI and structurally compensatory pelvic torsion moves from a loaded (standing) to an unloaded (prone/supine) position, the torsion of the pelvis remains intact and the leg length at the feet/shoes would appear "even" on a visual check. The pelvis – joints, ligaments and muscles – have adapted to the anatomic LLI, making any torsion structural. It is this putative biomechanical adaptation that makes unloaded leg-length alignment asymmetry tests – the functional "short leg" tests – unreliable as a measure of anatomic LLI [14].

It further states:
The nervous system also appears to compensate as demonstrated in the study by Murrell et al [12] in which there was no loss of stability in subjects with LLI, prompting them to point to "long-term adaptation by the neuromuscular system".

This leads to my thought that the nervous system needs to be stimulated by (temporary) lifts in order to re-educate them.

As to the use of lifts in LLD/LLAA:

Now we can return to the dilemma of how lifts may have a positive effect on back pain and muscle activity given that most anatomic LLI is not clinically significant. Torsion of the pelvis as an adaptive structural compensation in anatomic LLI has been shown to be limited. If a person has pelvic torsion due to anatomic LLI near the limits of the body's ability to adapt, and QL hypertonicity with its ability to cause pelvic torsion is superimposed, muscular bracing reactions and pain could be the result. Indahl et al [22] found that stimulation of the sacroiliac joint capsule (in pigs) caused reflexive muscular responses, depending on what area of the joint (dorsal/ventral) was stimulated. They note that, "Irritation of low threshold nerve endings in the sacroiliac joint tissue may trigger a reflex activation of the gluteal and paraspinal muscles that become painful over time". Interestingly, stimulation of the ventral area of the SI joint produced reflexive contraction of the quadratus lumborum. It may be that a positive feedback loop could be established where QL hypertonicity leads to lumbar curvature and pelvic torsion which stimulates the SI joint leading to more QL hypertonicity, more lumbar curvature and pelvic torsion. It will be interesting to see if a similar muscular reflex to SI stimulation is found in humans.

Based on their research, Allum et al [23] proposed that rotation of the trunk excites joint receptors in the lumbar spine triggering muscular contractions – paraspinal muscles – for balance correction. While these receptors likely have adapted to any pelvic/lumbar rotation caused by anatomic LLI, further pelvic torsion caused by QL hypertonicity may stimulate the balance receptors causing reflexive muscular contraction. A lift would reduce the pelvic torsion and lower the proprioceptive balance triggers below threshold, eliminating chronic, painful muscular contraction.

In a case of additive effects of anatomic LLI and QL/suprapelvic hypertonicity on pelvic torsion, a lift used to level the pelvis would take the strain off the sacroiliac and associated joints and ligaments and decrease potentially painful muscular bracing. Thus, lifts can work to decrease back pain in people with what seem to be clinically insignificant amounts of anatomic leg-length inequality. Of course, it would be important for the clinician to explore reasons for any quadratus lumborum and other suprapelvic muscle hypertonicity and eliminate them to provide a complete correction. On the other hand, pure anatomic LLI in the range of and above 20 mm – the upward limit for adaptive compensation – may stimulate sacroiliac and/or lumbar proprioceptors causing reflexive and ultimately painful muscular contractions that will only be relieved by a lift to level the pelvis.

You took more than a day to reply to my post thinking of a way to respond to Dr. Spooner's evidence which I referenced and obviously came up with absolutely nothing and so you totally avoided it.

Your limp and personal response fuels me.

IS USING LIFTS FOR LLD A DESERVED CONCERN WHEN YOUR OWN LITERATURE STATES THEIR BENEFIT?

Please take another day and research another astute word that Isaac et al can congratulate you on instead of confronting the evidence you asked for and I produced from your own sourcing.

Dr Sha

 

Seems to me that there are a number of questions that need to be answered here, but lets start with one that might help Kerrie:

If one gives a lift to an asymptomatic patient with a functional limb length difference what might the potential positive and negative effects of this lift be?

Here's the rules- only peer reviewed published evidence to be submitted, not personal pet theories.

Have fun gentlemen.

 

Thank you Kevin, a most gracious offer and one that I hope to take you up on.

 

This is why I don’t use the leg length check alone. I rely on functional orthopedic assessment and evaluation of motion at the lumbar spine, sacrum, and pelvis actively, passively and resisted; functionally. It is far too lengthy a subject to relate on a podiatry forum. There is a distinction between symptomatic patients seeking treatment and asymptomatic patients such as Kerri’s example.

Precisely my point. Heel lifts can effect a dramatic change in the lumbopelvic structure so their use should be judicious with regard to a functional difference (let alone an asymptomatic patient). Blindly using a heel lift without benefit of examining all of the factors related to the presenting problem is folly and may cause iatrogenic injury. For that reason alone and barring any real evidence that lifts are of value under a 20mm LLI I do not use them. You look at studies Dennis and I look at my clinical experience, an acumen which you previously praised me for I remind you.

Pelvic unleveling is defined as the rotation of the pelvis around the anteroposterior axis. You cannot have significant A-P unleveling of the pelvis without significant compensatory changes in the lumbopelvic complex, as the above illustrates. If you change the ground beneath the feet (heel lift) there is more to consider than just leveling the hip. We do not know enough about the neurologic effects in play except to say that they exist.

So again Dennis, why would you put a lift in the shoe of the patient that Kerri described without having full knowledge of the potential effect or a full understanding of the effect beyond:

I do not rely on this test and was never taught to rely on it for an anatomic LLI. Yet again you’re discussing oranges (anatomic) and I am discussing apples (functional). My responses are in reference to functional LLI, why do you continue to quote findings about anatomic ones and what does this have to do with Kerri's patient?

This takes the cake for all time. You claim to be an evidence-based practitioner but offer no explanation for these mechanisms, no valid proof, not one iota of evidence. I on the other hand don’t attempt treatments that are if come and maybe on patients. I certainly do not recommend them for asymptomatic patients. Again, you roasted Michael for simply offering an explanation of the work involved in a leg length inequality in response to Kerri’s original question related to symmetry, calling him pedantic. Then you take a shot at Simon and segue into your own theories and methodology (unproven) on an asymptomatic patient.

You already stated that everyone else is inept. I am beginning to understand you much better with each post Dennis and would wager anyone who knows you personally would reveal that you claim that you are never wrong. I can only conclude that you like to argue and no one can reason with you.

Dennis I have a lot going on at the moment in my personal life. I also maintain a full schedule in my office so if taking a full day to respond to you seems somehow suspect or inappropriate, consider that you’re being a hypocrite. Let’s not be ridiculous about this. I have responded and I have answered Kerri’s original query with an examination procedure not based on the unloaded leg length assessment “commonly used by chiropractors” but on accepted orthopedic examination and treatment “commonly used by chiropractors”.

I feel that you have confused the difference between an anatomic vs. a functional leg length difference (LLD or LLI vs. FnLLD or LLAA), the interaction between the two, Kerri’s original question and the articles that Simon provided. All of your references discuss anatomic leg length and its compensatory sequlae. The conclusion of the second article, which is the one that discusses functional LLI does not arrive at the opinion that heel lifts are recommended for a functional LLI under 20mm (and it goes without saying on an asymptomatic patient and one who's true inequality measurement is in question). It says in fact:

What I related was that I have excellent clinical success with these patients without the use of lifts and I do not rely on the test in question to determine a functional difference.

I feel that Kevin, whose advice has always benefited in the past, is correct. Therefore this will be my last response to you regarding this subject. I had a colleague come and view the thread to get his opinion and he tried to respond but somehow it didn’t appear. He said I was dead on and was of the same mind as Kevin. I’m completely done wasting brain cells on you Dennis.

 

This is an exercise in EBP revealing how two interpractitioners can review the same literature and come up with greatly diverse reactions as to how they affect practice.
We are polarized when it coomes to FnLLD, one never using lifts and one always starting with them. Everyone else is somewhere in between and just as the bias for our own practical protocols, there is a bias that lives in the investigators, those that support the investigations, those reviewing them and those looking to apply them into practice.
That is the reason that I put less emphasis on The filtered and biased Evidence of The Arena than dictated by it's heavy hitters.

Dr. Wedemeyer admits that his practice draws patients in pain and that he doesn't tread to care for assymptomatic patients. I, on the other hand, for the past 40 years, have treated in addition to as many patients in pain as he (I would wager) have treated assymptomatic, lopsided, assymetrically deformed, poor performing patients and I have applied 20,000+ lifts in my career to combat TIP.
Althgough I have never been sued for placing a lift, I have stacks of anecdotal removals of canes, AFO's, space shoes, " I walked for a mile for the first time in 5 years" in my interpractice and I get refferrals from 185 physicians in my community for such care.
I admit (as you who say I consider myself infallable while not knowing me) that I do not claim to be able to manipulate or massage away FnLLD but you who acknowledge a lack of experience with lifts talk of their use as if an expert in using them.

Amongst the goals of the Arena is to convert all naysayers to the kirby/payne/spooner/isaac philosophy and theory with huge bias and to destroy the personality, reputation and work of all others by design.

Let's complete the mantra that you posted and keep all the current and future Kerries in the fold sheepishly moving in the right direction.
"I feel that Kevin, whose advice has always benefited in the past, is correct" and that Dennis's (and Dananberg's and Glasers and all others) advice has always and will forever remain not worthy of inspection, trial or consideration.

Kevin has tried to blow me out of your waters, now he is attempting to advise his sheep to simply not reply to my postings.
The demotivational poster thread reveals the anger and contempt you have for a me even though none of you has ever had a 5 minute personal converstion or interview with me?

I have made many mistakes in my life and will continue to do so but for me, until proven otherwise, I (and others) have an exciting story to tell to those with a love and passion for diagnosing and treating complaints (not just pain) of the foot and postural suffering public in a practical setting that differs from yours and time will tell which of us will be banging our heads against the wall.

Fundamental biomechanical schools of thought, like fundamental religions are only interested in converts and unswerving loyalty. They aim to eliminate competition using any and all means.

I believe that Kerrie is afraid to express the positive and comforting words that she has delivered to me about my comments towards her case in private for fear of retribution.

I have had personal contacts with Dr's Isaacs and Spooner that are more comfortable than our on screen relationship and I have been avoided by Kevin, Menz and others rejecting a blending of philosophy. I have been likened to by Dr. Payne as Homer Simpson sitting at the button controlling the atomic plant's safety as the second slide when delivering his "unbiased" lecture on Neoteric Biomechanics. In oppositiion, I quote all of these men positively as to their contributions to biomechanics and impact on my work when lecturing and publishing.

I will be pleased to have an uninterrupted voice on The Arena if all of you would only listen to Kevin and stop responding to my posts. I will only have to worry about Craig editing my threads into nonexistence like religious zealots did to the religious works and artifacts of thosen they attempted to conquer and destroy "because they felt like it".

Kerrie, I am sorry that I have been one of the parties that metamorphosized your thread away from a simple request of a new practitioner in trying to help a patient with assymptomatic needs and a desire for professional care into what it has become.

I am hoping, as you have stated to me that you will try some of the bookmarked advice I gave you with this young man and followup with me personally.

Dr Sha

 

Dennis, One of the things that bothers me about your posts is your assumptions of our goals. Speaking for myself, I have never tried to destroy the personality of anyone. I have not tried to destroy anyone's reputation. On a forum such as this you make your own reputation. If you disagree with someone and are able to articulate clear arguments as to your position your reputation will improve. If you misstate what other people think then your reputation will diminish.

Dennis, your ideas were inspected, thought about and rejected. There are some quite long threads we can look at to see that this is true. You failed to convince many members of the arena of the validity of your ideas.

Dennis, do you include yourself amongst those trying win converts? I wouldn't say that asking questions, examining ideas and posting arguments stating the reasons that I disagree with you is any and all means.

Regards,

Eric

 

For the record, I received a private message from Dennis titled: "secret relationship with DrSha". The contents are copied below:

My response is copied below:

I have not been contacted by him since.

P.S. I happen to like Howard Dananberg as an individual and value his contributions to podiatry. Dennis, to categorise him along with yourself is (in my mind) incorrect.

 

David,
If you do post this or have any information or useful papers on this topic please let me know as I find that area greatly interesting and could read about it for hours so rest assured that you will never bore me with that topic
Also, going to try to do some sort of study on rehab so any papers which could help with the lit review would be GREATLY recieved :drinks
Thanks So Much
Kerrie

 

Kerrie:

Do you have follow up on this interesting and what turned out to be volitale case?

Either way,

Healthy, Prosperous and Loving Holiday Season.

Dr Sha