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Leg Length Discrepancy

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Chris Gracey, Aug 28, 2012.

  1. Chris Gracey

    Chris Gracey Active Member

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    Howdy Folks,

    I'm having a discussion with a professional colleague regarding a patient with what has been called a chronic rotated pelvis. He presents to me with a 3/8" leg length discrepancy (L>R) as noted by the asymmetric pelvic crest height but with no rotated illieum ant or post this day. ASIS, PSIS, and crest are lower on the R, angles of inclination between ASIS and PSIS are equal. He has laxity throughout the joints of his body (R>L) and historically his therapist "manipulates his 5th vertebrae and puts his pelvis back in place" and the apparent LLD disappears. His therapist has been treating him for several months if not years for the same condition.
    I issued him orthotics to address foot and ankle concerns which did not include a lift. His FA pain went away but he continued to complain about unilateral muscle tightness in his back and LE on the Right. Today, I placed a small 1/4" lift, with the orthotics under the R heel to attempt to provide a more level pelvis. His pelvis appeared level and he claimed a "Balanced Feel".
    When I reported this to his usual therapist she said he would need an x-ray to determine true structural LLD..blah blah..and she did not believe in heel lifts.

    OK, I would like to try the lift and see if it helps. I can talk the physics behind it but it may fall on deaf ears without a paper or two to support my assertions that, based on clinical findings (without films) a lift is an appropriate intervention. Please direct me to a thread that contains this info should one exist. My search brings up way too much to pour through.
    If it is not the right call, or you need more info, please correct me. Thanks for the help in advance. Cheers!:drinks
  2. Admin2

    Admin2 Administrator Staff Member

  3. Chris Gracey

    Chris Gracey Active Member

    Coolness, Admin2!
  4. Chris Gracey

    Chris Gracey Active Member

  5. RobinP

    RobinP Well-Known Member

    Good question Chris and thanks admin 2 for the links

    I'm with you on this one. How can you "not believe in heel lifts?"

    One has to question the therapist who doesn't believe in something that may give permanent relief in favour of the temporary relief of "putting the pelvis back into place"

    What will an X ray show? Is that any more clinically significant than clinical findings? Even if it does show a more level pelvis , what evidence is there that a pelvis has to be level to be pain free.

    There is a paper(i can't find it at present but it is probably in the list of threads above) that is a review of all current literature on LLD. Opinion on clinically significant LLD ranges from 3mm 22mm. In my humble opinion, there is no upper or lower limit. Clinically significant is based on symptom reduction, but that is probably not the most popular view

    Inform the patient and let them decide

    Good luck

  6. Chris Gracey

    Chris Gracey Active Member

    Check out the PDF I posted above. I found it after I posted here last night. Is that the one you are thinking of? It is Chiro-based but amazingly thorough and even provides guidelines for ishial lifts, age-related variables, nucleus propulsus theories, and reminds us of the 4:2:1 rule (which I don't know has even been proven but it sounds good).
    I too agree that there is no MIN-Max lift and that the patient's subjective outcome supersedes a physician's textbook s'posed-to-be methodology.

    ...oh, and your sugarlumps are the bomb-diggitty
  7. nmarman

    nmarman Welcome New Poster

    It always seems strange that practitioners want to find a single solution. in my mind and practice both work well in unison. but a heel lift is a passive support that if not re-evaluated can cause secondary problems if there is no structural abnormality.

    I see many patients who have had orthotics with heel lifts that don't need them any more. in fact many of them are causing them problems as the pelvic imbalance is no longer there.

    in short pelvic imbalance is caused by
    i) structural anatomical leg length discrepancy (needs x-ray to be evaluated) very rare.
    ii)joint fixation particularly the SI joint
    iii) myofasial complications/ tightness particularly the QL muscles on side of short leg.
    iv) combination of ii & iii (very common)

    Remember that ii., iii. and iv. are all reversible condition states, with treatments of course. but a shortening of the Achilles from excessive heel lifts can cause huge problems for professional runners. Therefore heels lifts should really only be used as a method of changing habitual gait. It should be reviewed every two weeks in my opinion and never used as a permanent solution.

    Some people may disagree but if they apply the heel lifts without a objective look at anatomical form through x-ray they are creating a leg length discrepancy, once the hip imbalance is corrected.

    NOTE: a tredelemberg test should always be used to rule out pelvic imbalance due to muscle weakness in glut med m.
  8. Blaise Dubois

    Blaise Dubois Active Member

  9. Sally Smillie

    Sally Smillie Active Member

    umm, and what about that therapists lack of any lasting effect? Surely that points to being a temporary band-aid relief without treating the cause. (not that is doesn't have a valid place in the holistic treatment of the patient, but to be used in isolation). Just sayin...
  10. David Smith

    David Smith Well-Known Member


    Here's my brief summary

    First is it necessary to 'put it right' i.e. are there signs and symptoms that would be improved.

    if you like symmetry then you could check these things out visually, biometrically, with Video slo mo and vertical pressure device

    mobilise joints, release tight muscles and recheck if there is an LLD NB sometimes and LLD appears where there was non apparent before Mobs and releases.

    review symmetry

    Fit heel lift, give range of motion and stretching exercise and review after 6-8 weeks

    Dave Smith
  11. RobinP

    RobinP Well-Known Member

    Someone will have to convince me that symmetry= good and, in addition that error in measurement values don't invalidate any pelvic obliquity/angular discrepancy
  12. David Smith

    David Smith Well-Known Member

    Robin: Not that I'm trying to convince you of anything just telling you what I think.

    There are postural symmetry, biometric symmetry, kinematic symmetry and kinetic symmetry (forces and moments) and energetic symmetry (power and work).

    Symmetry in a non symmetrical world seems like a nonsense however what other standard reference can you use.

    Tissue stress evaluation indicates what forces need to be reduced and without the necessary consideration of symmetry.

    However returning symmetry obviously by definition balances the bio machine and so intrinsically relatively reduces or increases internal forces, which may be favourable (or not).

    For repeatability, error in measurements must be relatively small compared to the differences in symmetry but they usually are aren't they? and if not do we need to consider them as significant?

    Regards Dave
  13. David Wedemeyer

    David Wedemeyer Well-Known Member

    Robin are these the papers that you mentioned?




    I read through Johanna Hill's paper, nice work. One thing I come back to again and again is that an anatomic leg length difference (LLD) is quite different than a functional leg length inequality (LLI). Treatment is different as well and it is exceedingly rare that I use one for a functional LLI in practice.
  14. Colleagues:

    Symmetry of gait function is a very important consideration when treating patients with mechanically-based pathologies since asymmetrical function is a cause of many foot and lower extremity problems. Yes, asymmetry of the foot and lower extremity is common and expected within the human species, but gross asymmetry is less common and can cause significant pathology over time due to the increase in pathological stresses these gross asymmetries cause over time in the bipedal human.

    Due to the bipedal design of the human locomotor apparatus, common asymmetries that may cause foot, lower extremity and lower back pathologies over time may include contralateral differences in leg length, subtalar joint axis location, medial longitudinal arch height, first metatarsophalangeal joint range of motion, foot length, metatarsal parabola, first ray and ankle joint dorsiflexion stiffness, and others. Unless the clinician is skilled enough to detect these asymmetries, then the etiology of the mechanical disturbance may not be appreciated by the clinician so that the patient's problem, and pain, may not be solved.

    Expert clinicians can appreciate subtle asymmetries in the foot and lower extremity that mediocre clinicians will never be able to detect. This is one of the factors that makes these clinicians an expert.
  15. Blaise Dubois

    Blaise Dubois Active Member

    Sorry Kevin,
    you don't convince me.
    Expert clinicians are first of all capable
    - to recognize that we have no idea if asymmetries are a cause of short and long term pain or pathologies
    - to know that the body will be adapted to asymmetry
    - to choice to do nothing! (most of "standard" "rookies" clinicians think they MUST do an intervention to justify their job)
    - to read the literature for decision making... ... ...
    - to recognize that our profession bias each of us on our approach that are most of the time NOT evidence based.
  16. Sorry, Blaise, you don't convince me. Having good research evidence is a noble ideal, but, in the patients and pathologies I treat, only about 10% of the conditions that I have treated very successfully for the past 27 years (30 patients a day, with a three week waiting list for an appointment) have research evidence to justify the treatments I use to make these patients better.

    Oh, and by the way, I commonly see patients of physicians who do nothing for their patients, and the patients don't get better. Then I may put a soft adhesive pad in the patient's shoe and they get better. After that demonstration, the patients think these other doctors who took their choice to do nothing, as you suggested, are ignorant and uncaring, but think I am knowledgeable and caring because I made them better with a simple pad in their shoe. And guess what, Blaise? There is absolutely no research evidence to support what I do, making in-shoe modifications, for the days, weeks, months and years I have been doing it. However, there is a biologically plausible and mechanically coherent reason for my treatments to make these people better (who suffer needlessly by seeing the clinicians that do nothing). This reliance on Newtonian mechanics and the physiology of the human organism is what drives my treatments.

    So go ahead, Blaise, and read the literature all you want, cite the literature profusely to attempt to prove your beliefs, give lectures all you want, and then, after all of that, you can certainly still have the right to disagree with me. However, as far as treating patients, expert clinical skill will win out over a knowledge of research literature and the accumulation of research evidence in treating foot and lower extremity mechanical pathologies any day of the week. Making patients better and causing no harm is my treatment goal.

    Blaise, I hope your treatment goal for your patients is not to only provide those treatments that have research evidence to support their use. If you pursue this narrow-minded, idealistic path, you will have very many unhappy patients that are sick and tired of you "doing nothing" for them.
  17. Blaise Dubois

    Blaise Dubois Active Member

    Is all your statements (that I agree for the majority) support the idea that you think that body need to be symmetrical? ... or that we need to correct LLD that are less that 2cm? ... or that pronation is a problem?
    you will need to have better arguments to convince me! ;)
  18. Chris Gracey

    Chris Gracey Active Member

    I love where this thread is going so here's an update: Patient with a 6mm LLD L>R. When the patient stood using my orthotics and a 3mm lift, both his PSIS aligned nearly perfectly (</=1mm). All innominate angles were symmetrical. The patient stated, "I feel more balanced". His usual therapist did not approve and had the patient remove the lift claiming a Functional LLD. Yesterday, I was able to observe the therapist perform a manual manipulation of the patients' spine and use a few different techniques to rotate the pelvis into alignment. When the patient stood barefoot after treatment, the PSIS were aligned to within 2-3mm (from roughly 6mm). When the patient stood using my orthotics without the lift, the PSIS aligned nearly perfectly. However, the innominate PSIS-ASIS angles were skewed (R>L). The patient claimed A "Balanced feel" and "I feel straighter".
    My orthotics for this patient primarily limit excessive medial migration of the STJ axis and limit navicular drop during weight-bearing to within a measurable specific range. This affects MLA height which affects lift up the chain resulting in an indirect lift of the pelvis on the R. While I am a fan of "symmetry of feel", I create orthotics for each individual foot as it relates to the human machine. They may look similar, but they most often perform differently. In this case it was left to me to decide what should be done. Simply advise him to use the additional lift or have him continue to receive weekly re-alignments? But before I tell you what I did, what would you have done? Use the orthotics plus a lift or the orthotics plus muscle action and manual therapies?
  19. Chris Gracey

    Chris Gracey Active Member

    I climaxed at this. just sayin'....
  20. Blaise Dubois

    Blaise Dubois Active Member

    Sorry guys, is less than your error of measure!!!
    AND 2 Reviews showed than it takes more than a 2 cm difference to have an adverse and significant impact on biomechanics, pain and function (2005-Anatomic and functional leg-length inequality: A review and recommendation for clinical decision-making. Part I, anatomic leg-length inequality: prevalence, magnitude, effects and clinical significance, Gary A Knutson AND 2002-Leg length discrepancy Burke Gurney)

    Sorry guys but that YOUR perception, with YOUR tools of assessment...

    Sorry guys, the manipulation of the pelvis have first off all a neurophysiological effect (release of myofascial tension...) NOT a real "reposition effect"

    Sorry guys, but 2-3mm is clearly smaller that what we are capable to precise with our measure

    Sorry guys, I can have the same effect by just speaking with them or touching them... I agree that the result is the important thing, but the way to arrive to this perception/condition can be done by MANY different ways. I think your intervention is maybe correct on short term, but the reason why you think your patient is better is absolutely wacky! ... However, if you are convinced of your treatment and you are able to convince your patient... that's 80% of the treatment :)

    is orthotics limite navicular drop? Is orthotics have really an effect on STJ?
    And if you tell me yes, is really a good idea to have this effect? What's the effect on long term? Is it not another medical intervention not supported and invented on very weak bases?

    Why not the most simple, cheap and natural one? ... especially on long term.

    Sorry guys, but Podiatry (and many other health professions like physiotherapy) needs to redefine is base of knowledge/concept/belief.
  21. Chris Gracey

    Chris Gracey Active Member

    We'll get right on it. Thanks for the input.
  22. David Smith

    David Smith Well-Known Member

    Blaise, what reference frame other than symmetry or standard reference position do you use to determine what your next move is or how your intervention has changed anything?
    Please don't say pain relief because you can't just fire an arrow off in any direction and expect to hit the bullseye or even the target area with regularity unless you have a reference frame.

    regards Dave
  23. Blaise Dubois

    Blaise Dubois Active Member

    Pain, Function, and yes for some cases ROM/symetry.

    Gaining range of motion of an ankle after an ankle sprain to reach the ROM of the contra lat side is one thing.

    Supposing that (something present since long time to someone) a movement (pronation, navicular drop, ROM of dorsi-flexion, ...) or a peculiarity (flat foot, LLD, big nose, ...) is a problem is another thing.

    How can we supposes that a minim difference of leg length (measured by non valid tools), present from ever... is the cause of a new low back pain?

    To my view, it's a pure invention of health professionals... I call this created his job (even if it was not by expected)... I repeat, we need to change our belief on that.
  24. David Wedemeyer

    David Wedemeyer Well-Known Member

    Blaise patients live with radiographically verified OA, spondylolisthesis, bulging discs and yes, leg length discrepancies often without complaint. Many have a previous history of back pain and a percentage will become acute or subacute. In your scenario above the man presents with back pain, why wouldn’t the doctor assess LLD if the patient is symptomatic?:confused:

    If you suspect an anatomic LLD not ordering this scan may be the difference in resolution and avoiding disability in this patient and delaying timely, appropriate care. I know, I know, “It’s not natural” right? I suppose you would recommend this patient go barefoot? :D

    Gonad shields. Of course there are risks inherent in imaging. I would hope that the use of scanograms is reserved for anatomic LLD only and that the risk-to-benefit has been considered. Slit scanography exposes the patient to much less exposure. I agree that routine imaging should be questioned but only when outside of standard practice.

    What is standard practice then you’ll ask next? What is the rationale to order slit scanography? A good history and ruling out congenital and developmental factors, trauma, arthritides, scoliosis, Leg-Calve-Perthes, Blounts Disease, infection, dysplasia and tumor. In the presence of any of the above I feel justified to order radiographic tests as the benefit outweighs the risk.

    By the way Blaise, how many radiographs have you taken in your clinical life? Are you even trained/licensed to take plain film or do you just base your opinions on what you read on the internet?

    Blaise, just where do you find these obscure studies that you always reference that go against all of the good ones saying the opposite?


    Slit scanogram measurement is the preferred method for assessment of limb length discrepancy. Slit scanogram significantly reduces error and exposure.

    I could find many more but what’s the point?

    Here we find a modicum of agreement and again some debate. I actually observe a greater number of leg lengths which are symmetrical on informal evaluation than functional differences. But, we’re really discussing apples and oranges here as an anatomic LLD nearly universally cause symptoms and the larger the difference the greater the complaint. On the other hand a good number of people are walking around with functional differences and no symptoms. When a patient has symptoms it should be assessed and addressed accordingly.

    Blaise, Blaise, Blaise, you are at it again selectively interpreting the data to arrive at a conclusion you favor.

    This was written in another paper by one of the same authors:

    You are referring to functional differences correct? Either way you’re dead wrong Blaise. I see 2 cm functional differences (and greater) all of the time in patients with a tight iliopsoas, quadratus lumborum, disc wedging due to trauma etc. Pelvic and muscular influence is common and I hope no one would question this in functional differences. My approach though is not to use a lift even temporarily unless absolutely necessary.

    Again, functional leg lengths? I would agree more work needs to be done here but the outcomes for anatomic leg lengths treated by lifts is well documented, widely practiced in all professions represented and clinically useful.

    Nice pitch for your seminars :rolleyes:

    I don't feel that any one profession has all of the answers to functional leg length difference complaints and each appears to evaluate and treat according to their unique training; podiatrists tend to evaluate the feet and chiropractors tend to evaluate the pelvis and spine. I feel that it is somewhere in between and see both as causal; our professions can learn a great deal on this subject from one another.

    Then there's Blaise....:empathy:
  25. David Wedemeyer

    David Wedemeyer Well-Known Member

    Here we agree Blaise.:drinks
  26. David Smith

    David Smith Well-Known Member


    While I agree that symmetry in itself is not the ultimate goal, it is a good reference to work to or from. So far your argument in terms of symmetry seems to be rooted in whether or not LLD can be reliably and repeatedly measured and that heel lifts are not generally a useful intervention. Symmetry is not just a physical measurement or metric it is also an observation of motion.

    Here's is a common observation; a rocking side to side gait progression often called Trendelenburg gait. I see this and fix this regularly, for example the subject rocks over the right leg at left swing thru. Both ankles are equinus, the right hip abductors are weak. Hip levels are even in terms of pelvic crest and G. Troch heights. The hamstrings are tight especially right.

    Mobilise the ankles and release the hamstrings and then the right hip abductor regains strength but now the right hip is low and they still rock side to side but less than at first, now fit a heel lift right side and they have a symmetrical gait progression.

    The presenting problem was some painful symptoms due to uneven forces caused by the uneven or asymmetrical gait progression and of course vice versa.

    Once this aspect of unbalanced progression has been addressed one can then concentrate on the more specific painful foot pathology. I believe that, in this case the return to a more symmetrical gait progression will have a far greater impact on the final outcome than only addressing the local foot pathology.

    If we had measured leg length or used long bone xrays or pressure mat of force plate scans we could have had physical measurements to back up our observation and then we could also argue about how repeatable and reliable these metrics were, however they still may be a useful clinical indication.

    Regards Dave Smith
    Last edited: Sep 3, 2012
  27. Blaise Dubois

    Blaise Dubois Active Member

    ... and a MRI for his nose to know how big it is?
    ... there is no limit to investigation.
    ... give me good reason... you seems doing a link between our case and is lower back pain...

    Prove me that... any GOOD prospective article showing the causality of LLD and the incidence of injuries and LLD?

    Agree with that... What you point? You never do a scanography if you don't have this type of patient?

    It's not because I'm not making orthotics, prescribing XR, giving cortisone shot that I cannot criticize those that promote and make money with that type of treatment. Any problem with that?:wacko:

    It was one of my reference ;) ... Did you read it? ... or just throw an article to show that yo are EB?
    In the case of Chris, in this post, he correct with blocks a 3/8" (1cm) of LLD. The mean difference of the Interobserver Variance measure are 1.01cm in this study... so in his case is result is not valid:empathy:
    More ref below

    Do you know how many LLD scan are made with the Slit Scanogram and how many with a standard XRay and the radiolucent ruler between the legs? Just curious if in your area everybody use a slit scanogram? Interesting article on that (availability of different methods in USA : #1) Also

    1. Clin Orthop Relat Res. 2008 Dec;466(12):2910-22. Epub 2008 Oct 4.
    Methods for assessing leg length discrepancy.
    Sabharwal S, Kumar A.

    2. J Bone Joint Surg Am. 2006 Oct;88(10):2243-51.
    Computed radiographic measurement of limb-length discrepancy. Full-length standing anteroposterior radiograph compared with scanogram.
    Sabharwal S, Zhao C, McKeon JJ, McClemens E, Edgar M, Behrens F.
    Skeletal Radiol. 2012 Feb;41(2):187-91. Epub 2011 Apr 14.

    3. Arch Phys Med Rehabil. 2001 Jul;82(7):938-42.
    Measuring leg-length discrepancy by the "iliac crest palpation and book correction" method: reliability and validity.
    Hanada E, Kirby RL, Mitchell M, Swuste JM.

    4. J Manipulative Physiol Ther. 1995 Sep;18(7):448-52.
    Comparison of leg length inequality measurement methods as estimators of the femur head height difference on standing X-ray.
    Rhodes DW, Mansfield ER, Bishop PA, Smith JF.

    5. Gait Posture. 2002 Apr;15(2):195-206.
    Leg length discrepancy.
    Gurney B.

    I could find many more but what’s YOUR point?
    The error of measurement of lower limb is considerable for all measurement system!!!
    Maybe it's better to say : The error of measurement of lower limb is considerable (UP TO 1 cm inter-rater on X-rays image reading in addition to the error of the machine itself) AND as is the error of measurement of health professionals using a measuring tape (UP TO 2 cm intra-rater and 2.5 cm inter-rater)

    :D Show me the evidences from 0 to 2cm!

    Can you explain your point...don't understand your comment ???

    Chiropr Osteopat. 2005 Jul 20;13:11.
    Anatomic and functional leg-length inequality: a review and recommendation for clinical decision-making. Part I, anatomic leg-length inequality: prevalence, magnitude, effects and clinical significance.
    Knutson GA.


    Gait Posture. 2002 Apr;15(2):195-206.
    Leg length discrepancy.
    Gurney B.

    NO... Anatomical... See my to ref above (2 reviews)
    Please show me your reference

    We don't read the same lecture AND don't know the same friends/professionals... but I agree, like Everything : more work needs to be done.
    In 2012, there is no scientific reason to prescribe a lift and doing this intervention on long term with a LLD <2cm!!!

    Hope to see you and one of your friends one day... just 600Can$ for the best course in the world!:drinks
  28. Sorry, Blaise. From the quality of the content what you have written here on Podiatry Arena so far, I think that you would need to pay me 600 Canadian dollars to force me to sit through one of your seminars.:sinking:
  29. Blaise Dubois

    Blaise Dubois Active Member

    OK, for you it will be free :empathy:

    Also, tell me if you (or one of your friends) give a course/seminar somewhere... it will be a PLEASURE to follow it and listen your thought...

    Just hope that it will not not just :
    - telling people to wear orthotics and big bulky shoes to prevent injuries,
    - correcting LLD of 1cm measuring with blocks,
    - doing X-ray to everybody,
    - proposing treatment like in your video (you never comment on my comments http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=79871&highlight=blaise )
    - doing cherry picking on articles
    - criticize scientific articles just by reading the abstract
    - telling people to heel strike
    - also you never answered to my answers to your 10 points to barefoot :sinking: http://www.therunningclinic.ca/blog...la-chaussures-moderne-modern-shoes-defenders/

  30. Blaise:

    I think you don't know very much about the way I practice from what you say that I tell my patients. You assume you know too much. And as far as cherry picking articles.....people who live in glass houses shouldn't be throwing stones (sorry, I don't know the French equivalent) for this saying).:drinks
  31. Blaise Dubois

    Blaise Dubois Active Member

    I'm leaving in a 1828 house. The walls are 2 feet width build with stones... very strong, natural, solid bases... ;)
  32. David Wedemeyer

    David Wedemeyer Well-Known Member

    Does anyone here speak Quaalude, I can't decipher 1/2 of Blaise's nonlinear narrative?

    I wrote (and you conveniently ignored):

    Blaise you are commenting on a subject from the weak vantage point of misinterpreting some reviews and studies with no training or clinical experience in xray (correct?). You have zero training or experience ordering and interpreting plain film (correct?). You have zero training or experience formulating a diagnosis (correct?). Plain film is often used to confirm suspected pathology, so my point is that if plain film of any kind is used to confirm a diagnosis AND can provide valuable information for the treatment of that patient that it is justifiable. It is also justifiable to rule out other pathology. If you cannot agree with this then I don't know what to tell you as your recommendations are not the norm of clinical practice.

    Now in the case above the patient presented with low back pain and an apparent LLI. I would not order films on this patient. I have already stated that I am cautious in dispensing heel lifts for a functional LLI or for low back pain. There are always exceptions. So on this we agree but when you began discussing anatomic LLD's and your 2 cm rule I commented. There is a distinction and I see patients with < 2-3mm LLD who are symptomatic (low back) and who resolve with lifts or shoe correction. I've done this with hundreds of LLD patients over the years, I cannot recall one where their condition worsened. I call that solid clinical evidence and a lot of medicine is based on just that, not just statistical and literature review studies.

    I'm with Kevin in that "expert clinical skill will win out over a knowledge of research literature and the accumulation of research evidence in treating foot and lower extremity mechanical pathologies any day of the week." We don't initially need to confirm the causality of their complaint but correlating their complaint with an LLI or LLD is typically pretty straightforward Blaise.

    I don't need to comment on your apparent inability to comprehend what you read Blaise, The same author admitted the findings were "anecdotal".

    More of your “evidence” which again shows a pattern of selective comprehension, cherry-picking etc:


    Case series, Level 4 literature search, no controls

    This is actually a good study. Not surprising, chiropractors have been using FS AP films for a century but try getting them past certain insurers. I took the liberty of calling the local hospital radiology department this morning as I refer all of my films out to them and one other facility. The tech stated that slit scan and FS AP produce about the same exposure FYI. In the past I have shot, marked and evaluated FS film and I can tell you that there are a lot of errors inherent that are not with lower extremity slit scan, meaning a higher than average number of retakes.

    This study was of apparent or functional differences.


    Also Level 4 from what I can see.

    Forget the controversy over which method is best for radiography and let's get to the point of Chris' post (sorry for wandering off Chris):

    You still have not answered David's question as to what you would do differently (although David did give us a reasonable treatment plan) Please, enlighten us? And let’s differentiate between an anatomic and a function/apparent difference shall we?

    If you disagree with lifts whether in shoe or built into an orthotic or shoe additions than you need to submit to a piss and blood test to determine first if we're dealing with a reasonably straight individual! :craig:
  33. Blaise Dubois

    Blaise Dubois Active Member

    I agree My Quaalude is not very good, so I will be brief.

    You propose a treatment... but you cannot justify it.
    You do a statement about the cause of a problem... but you cannot support it.
    you over-medicalized a condition that is universal
    You propose testing that are not available everywhere or not enough sensible or not valid
    You reject study I propose to you but don't give other one to support your assumption.


    You probably sell the testing and the intervention, ;)...

    SO, provide me better evidence that the articles I gave you. You DO an intervention : justify it! I don't care of your hundreds of patients that feel better... My patients feel better to with no Xray, no heel lift and no Big bulky shoes... even with LLD.

    Interesting to see you all speaking about science until you cannot provide evidence and at that point you start to speak about your clinical experience... I find this very funny

    Aslo fisnrt sleidn lduviev pour al tast de singd :drinks
  34. Chris Gracey

    Chris Gracey Active Member

    This thread did not finish where I thought it would.

    So, when faced with the dilemma of lifting that last 3mm or continuing weekly manipulations, I said "NO, the lift is not necessary". Not for any published reason but that it clearly wasn't providing a tactile difference that interested the patient enough to desire a trial of it. He liked the results of the manual therapy and he liked simply using the lift. But it was clear by his responses he felt more in touch with his body through the hands-on modalities and eagerly looked forward to his therapy sessions each week. He described his sessions as mentally relaxing. And at that moment I knew what the correct call should be. Perhaps he had found a balance in his life after all and I wasn't going to let my good advice or expert device ruin a perfectly good leg length discrepancy. :)
    Thanks everyone!
  35. David Smith

    David Smith Well-Known Member

    I like your thinking ;)

    Dave Smith
  36. RobinP

    RobinP Well-Known Member

    That's the rub. You can be as informed as you like. You can educate your patients to the end of the earth but the bottom line is that you are treating a person with a brain and emotions.

    With the error in measurement, he may not even have a discrepancy and the weekly adjustments are some kind of psychological crutch. Regardless, if the patient is pain free and happy then the result is a good one.

    You made the right call and that is what is separates a good, rounded clinician from the one trick pony.

    Thanks for keeping us informed

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