Leg length discrepency how do you measure clincally?

Hi Stanley,

Do you have a copy of this you could e-mail to me please? Japma online doesn't keep PDFs of articles this far back. Let me know if you have one and I will PM you my e-mail address.

Thanks

Ian

 

Sorry Ian, I don't.

Regards,

Stanley

 

Hi Stanley sorry for not getting back to you sooner I have been a bit better - I am very lucky and I work alongside a physio - I would highly recommend this and she will check the gluts, obliquus internus, tensor fasciae latae and the quadratus lumborum all of these can have an affect on the position of the pelvis and affect leg length - by manipualting these and stretching specific muscle groups and the use of a heel raise in the short term you can reduce the correctrion needed.

ps just realised where you live - I have a brother who lives in Cleveland in University Heights - where abouts are you?

 

Hi Claire,

I agree with what you are saying.
The quadratus lumborum that you see tight is actually caused by the opposite quadratus lumborum being weak. I find this in a postural pattern including a weak anterior scalene on the side of the tight quadratus lumborum (and thus a high ASIS). The high ASIS side acts short, and therefore has an equinus and sometimes a weak peroneal.
A weak gluteus maximus can cause an anterior innominate of the iliosacral joint, and a tight gluteus maximus can cause a posterior innominate. More commonly the quardriceps and hamstrings are involved. The tight hamstring will cause a posterior innominate in runners especially when they start speed work. A weak quadriceps will cause a posterior innominate, usually in lifters.
A weak tensor fascia lata will have a level pelvis, but the ASIS on the weak side will be rotated forward on the transverse plane. When you reposition the pelvis to even on the transverse plane, you will find the ASIS raises on the forward side as you move it backwards.
I haven't used a heel lift in a long time. I get my corrections on the visit. There are many ways to treat the problem from treating proprioceptive defects such as Strain-counterstrain, reverse counterstrain, etc; processing defects such as cortical cerebellar imbalance, dysponesis, ocular lock, righting reflex dysfunction, etc.; or fascial dysfunctions such as the lateral line of fascia.

Claire, I practice on the west side of Cleveland, about a 20 minute drive. If you ever come out to visit him, let me know.

Regards,

Stanley

 

Thanks Stanley - I would love to come and see how you guys work accross the atlantic I will let you know when I am coming over
Claire

 

Hi Claire,

Anytime you want to come, just let me know. Just not during the Christmas holidays.
I don't practice as most of my colleagues, but I can probably arrange for you to spend some time at the podiatry college, rotate with a podiatric resident, and visit some more representative podiatrists in additino to spending some time in my office.

Regards,

Stanley

 

I would normally measure navel to medial malleolus during a routine biomechanical evaluation, with the patient prone. I do this by asking the patient to hold the tape to his navel, tugging lightly on the patient's ankle and and reading the measurement at the vertex of the medial malleolus. If LLD is determined, I would measure ASIS to medial malleolus - this gives me actual vs functional LLD. If I would like to know whether Femoral or Tibial LLD, I would place the patient in a prone position, place medial malleoli together and with flexed knees compare the height of the knees - this is for femoral LD. For Tibial discrepancy place the paient supine and flex knees 90 degrees - compare level difference of vertex of medial malleolus. I never find the need to expose patients to X-Ray just to be 100% accurate what heel height to prescribe - the average body can take up to 9-11mm of LLD without altered gait.

 

Ivan,

I think you may mean supine rather than prone

Ian

 

Are any of you trying to intimate that this method of LLD measurement or any measurement that utilizes ASIS has one iota of being reproduced (or researched) by groups of practitioners on groups of patient?

That brings me back to my query on this thread that if LLD exists and is showing clinical signs of Wolf's and Davis's Laws accomodating most of us into assymetry of the feet and posture, why would you wait for breakthrough research (as you will continue to wait forever) when it comes to offering treatment to your patients for this rather common problem.

I pose questions that given the human body has the ability to compensate for uneven limbs, if the system utilizes that compensatory reserve when pushed to limits by increased weight, poor equipment, overuse and maximized performence, why would you not want to replenish those reserves by compensating some of that limb length elsewhere?

and

Is there not one level 1 EBM aspirating scientist member of The Arena whose family has a long history of low back problems, unilateral foot complaints (like a larger bunion on one side or unilateral heel pain) that would not want their children to share their inherited fate?.

The loudest of you continue to attemt to make the Art of Medicine that separates great clinicians practicing in their clinics with researchers and scientists practicing in their labs and try to make it vestigial.

I have come to realize that I am not gods gift to the foot suffering public as you proclaim I am thinking, instead, it is you that are less godlike because you have not learned to take your blinders off.


When it comes to treating the feet and posture, the pearls of your valuable work should be added to the pearls of work like mine in order to expand our levels of care.

Both Art and Science exist in Medicine and both are necessary in order to maintain balance.

"I'll let you be in my dreams if I can be in yours".
Bob Dylan
:drinks
Dr Sha

 

Quite right Ian!
Seems I confused the terms prone and supine there...sorry!

Ivan:wacko:

 

I'm feeling masochistic so I'm going to have another go at understanding where you are coming from Dennis.

If I understand you correctly you contend that measuring lld is a bit pointless because the intra / inter tester variability will be so high it indicates a pointlessly inaccurate measurement.

To a point, I'd agree with you there. It's certainly a defensible position.

Now here is the bit I don't fully understand. Unimpressed with using raises to correct lld based on measurement you instead advocate issueing them based on clinical signs you feel indicate a Lld. Have I got that bit right?

Let me know if I understand your argument correctly so far.

My next question will be, what clinical signs, symptoms or pathologies do you believe are indicative of a short / long leg. And if you will indulge me, since I am honestly trying to meet you half way, I'd appreciate if you could answer using standard terminology we're all familier with. Or use FFT terminolgy if you must but explain what it means.

Much ta.

 

Robert:
As you are too busy opinionizing my work without reviewing it, I quote another Arena thread that you participated on which has already answered this query.
The Confirmatory Signs and Tests for TIP

1. Weighing Scales
Observe the patient marching in angle and base of gait for 10 seconds and then ask the patient to freeze. The separation of the feet and the angle which they sit determine the angle and base of gait. Trace the patient’s footprints, and in those footprints, put two weigh scales. Then ask the patient to step on the scales. Since TIP causes a person to shift weight to the short side in stance, if the scales do not read the same, the greater of the two readings will be on the short side.


1. Gait Pattern Confirmatories

TIP shows predictable changes in gait that reflect the asymmetry in the feet and posture. There is a longer stride length on the long side with a longer foot plant. There is a relative external rotation of the hip and limb on the short side with a greater arm swing when comparing the short side to the long side. There is a relative flatter arch (pronation) when comparing the long side to the short (or a relative higher arcj on the short side (supination).


2. A Unilateral Postural Complaint, or a bilateral complaint that develops from a one sided complaint. i.e. unilateral Bunion, heel spur, plantar fascitis, ankle, knee and hip arthritis and pain syndromes. Unilateral nerve problems such as sciatica

The increased work accepted by the longer side with every active step and movement, in subjects with TIP, places greater stress upon the joints, muscles, tendons, and ligaments of the long side. Overuse syndromes and progressive degenerative syndromes attack overstressed locations in the posture with the most force and early. This results in additional compensation in these locations in the posture with early pathology and symptoms.

For example, when examining the feet of subjects with TIP, the long sided foot performs more work than the short sided foot in supporting and moving the posture. This increased demand exposes any biomechanical weaknesses to overuse and degeneration. Since the long side foot is pronated, more force is applied to that medial column. If other deforming forces such as a hypermobile first ray have predisposed this subject to develop bilateral bunions, a more pronounced Bunion (hallux abducto valgus) deformity develops on the long side. Similarly, the increased pronatory forces of the long side cause additional collapse of the medial arch and compensatory pull of the plantar fascia on the long side. Thus, plantar fasciitis and heel spur syndrome develop on the long side first.

3. Unequal Shoe Wear Pattern
With the increased inversion noted at the subtalar joint of the short side, bony adaptation in addition to contactures of the associated musculature, capsular, tendon and ligament soft tissue structures fix the subtalar joint in more varus than its mate. During the heel contact phase of the gait cycle the short sided heel is contacting the ground more supinated and this leads to additional lateral wear of the shoe.
The additional weight and time that the long side spends in active function in subjects with TIP leads to increased total shoe wear on the long side.

4. Excess Lateral Column Callus on the short side
The increased weight on the lateral column as a result of the varus loading on the short sided heel, in gait, results in the existence of a unilateral or a more extensive 5th metatarsal callus on the short side. In Flexible FootTypes, this can also lead to increased callus under the 2nd metatarsal.

5. Low Back Pain or one side dominated sciatica, A Pelvic Tilt in angle and base of gait, to the short side and/ or A Shoulder Girdle Tilt in angle and base of gait, to the long side
In TIP, at the level of the pelvis, one limb is functionally (or structurally) longer than its mate. This fact causes a downward tilt in the pelvic girdle from the vertical lopsided towards the short side (figure 1.) This can be measured or “eyeballed” by placing markers on both anterior superior iliac spines (ASIS’s) and noting the presence of the incline (i.e. The Leaning Tower of Pisa). This incline of the pelvic girdle with the short side lower causes L-5/S-1 and L-4/L-5 degeneration and low back pain and radiculopathy. In order to maintain the center of gravity and erect posture, the lumbar vertebrae shift towards the long side and form a concavity. This compresses the lumbar nerves on the long side and leads to compression and eventual sciatica on the long side. The curvature in the spine tapers and becomes less exaggerated as it extends all the way to the shoulder girdle. At the shoulder girdle, the compensatory need to keep the center of gravity causes a tilt with the long side lower.

6. The Long Sided Foot is Larger, longer and/or wider and reveals an Increase in Pronation when compared to the short side in angle and base of gait.
The long sided foot accepts a dominant role in stance and in function and performs more work than its mate. Over a lifetime, this is reflected with greater muscle mass, bone density, supportive tissue as well as a widening of the longer foot. This translates into the fact that the long sided foot, in TIP, is larger than its mate both in length and girth.

As stated previously, the long sided subtalar joint compensates by pronation in order to functionally shorten the limb. This additional pronation places more of the limbs weight on the medial column and drives additional stress into the midtarsal joint. In patients with a flexible forefoot, this force will unlock the midtarsal joint and create a hypermobility in the forefoot that will cause it to stretch and spread. Over time the long sided foot will become larger and wider.

7. Larger Mass on the Long Sided Limb (i.e. calf, thigh)
Since, functionally, the long side dominants in subjects with TIP, the compensatory increase in muscle mass, bone density and connective tissue strength leads to the long sided limb developing larger than its mate.

Measure the diameter of both calves 5 cms below the tibial tubercle to record calf girth. Measure the diameter of both thighs 5 cms above the proximal patella to record thigh girth. The side with the higher measurements is the long side until proven otherwise.

8. Walking Down Stairs
Observe the subject walking down a flight of stairs. Due to the compensatory abduction of the short sided hip, the angle of gait will appear windswept to the short side if TIP is present. If it is no t present the angle of gait will appear relatively straight.

Add to that an Assymetrical Lunge Test (A Test I learned from Craig here on The Arena)

and

Assymetric second metatarsal shaft thickness or periostal surface on AP X-rays.

Your patients are trying to tell you about their asymmetry and the need to treat it but you are waiting for them to give you research and all they have to give you is a clinical picture that you are not willing to review.


Dennis

 

Hi
I will add a simple two penny'th worth to this discussion. I looked into LLD and LBP as my dissertation last year and read extensively around LLD and musculo-skeletal disorders. My main feeling from all the papers I read is that it is very difficult to prove a direct correlation between LLD and M-S disorders and much of the corrective treatment is questionable.
Regards
Deborah

 

Thank you Dennis. As you say we did look at this all before but one tends to forget what one does not use. And to reiterate a point I've made before...

You don't know what anyone elses clinical processes are so to critique it is both unhelpful and illogical. You presume much.

However, too the point

You say :-

I've picked this out as an example although what you say, the principle stands for other things.

You say that the long side foot is more pronated. How did you draw this conclusion? What makes you beleive this?

Regards
Robert

 

I agree that LLD is hard to corrolate to M-S disorders.
I agree that LLD's corrective treatment is hard to prove.
very strongly.

What separates an artful doctor from a scientific one is what we do in applying these facts to patient care.

You are waiting for the proof and I am clinically applying tests to determine if LLD exists for each patient and what level of impact it is having clinically.
I am actively treating LLD for 35 years and I am well practiced clinically.
In my opinion, you are waiting for proof and failing your patients and you have less clinical knowledge about LLD than I.

If my child had unilateral heel pain, low back pain, thicker callous on the longer side and some dorsal arthritic bumping on the 1st MP Joint of the longer side, I would add a heel lift to the other sides shoe or orthotic without hesitation. Would you?

Dennis

 

Yes yes we understand. You feel these signs indicate an lld

But to pull you back to my question WHY do you believe that a more pronated foot (for eg) indicates a longer leg?

Put it this way. For the sake of argument I say that in fact a more pronated foot is the sign of a SHORTER leg. Because we know that pronating shortens the leg I say you are worsening the situation by putting a raise under the side which is already longer.

That's not my view btw. But for the sake of argument how would you refute this?

C'mon dennis. Finish the sentance. "I believe a more pronated foot indicates a longer leg because..."

 

That's what I was taught in podiatry school.

Those of us who have treated patients know that sometimes the foot is more pronated in static stance on the longer limb side and sometimes the foot on the shorter limb side is more pronated in static stance. Why is this? Well, lets start by looking at the factors that determine the position of rotational equilibrium of a foot - nice biomechanics corner here for you Robeer.

 

Dennis Replies:
You are taking my body of correlative tests and filtering it down to a pronated rearfoot because you can then argue that recent literature states that the long side is not always pronated and then you will say that relates to the rest of my testing. Craig did this so long ago and its sooo boooring for you to Pavlonially spit it out again.

Some feet compensate the short side on the sagital plane with relative equinus, some supinate the forefoot on the frontal plane. Some extend a knee, some lower a hip. Some rotate and lordose the low back, etc. If the long side doesn't compensate by pronating, your studies will prove that to be the fact but it is compensating somewherthey compensate some where or some way else. The pronation studies comfirm it. Please respect me enough to deal with bodies of work and not out of context trite like pronation and the long side Robert.

If you have a table with two short legs and the plates are sliding off the short side, I would take two plates and place them under the short sided legs elimiating the sliding plates.
You would wait for a study to find out why the plates are sliding and what moments and forces are in play making them slide and crash. Then you would need a study to determine if the plates are thick enough, long lasting, not producing any unwanted side effects, etc. before trying them under the table, etc.

I would be eating dinner for years using the same plates and you would be eating dinner surrounded by broken plates.

Treating the thousands that I have over 40 years for TIP with lifts, they often ask me a version of the same question.
I've been going to other DPM's and MD's for so many years, How come they never told me about this or offered me the treatment and relief that you have?

My only explanation is to say that I must care more about their feet than the others.
:drinks
Dennis

 

Wow. You're right. The plates thing made it all click. Broken plates, of course! My God how could I have been so blind!

So your argument is in essence that you're great and that everybody else hates their patients. That these things are self evident to you and you alone (on account of you're just cleverer than everyone else), and that you have no need to defend them rationally because they are JUST TRUE!

I give up. Again. You're gargantuan ego and lack of understanding of any of the principles of science is impervious to logic. How lucky for us all that you went into podiatry not emergency medicine.

One thing I will give you. You're analogy of artistic medicine vs scientific medicine is right on. Science is the search for facts. Art is the endevor of making things which look good. Your model is like a picasso. Pleasing to the eye to be sure and highly artistic, but a twisted distortion of its subject. And you can't argue taste. That's why these debates never work. We're trying to tell you the nose is stuck to the forehead and you're telling us it does'nt matter because it looks nice.

Byee.

 

Robert:
Nice rant...

Does that mean you do or don't treat LLD and if u do what treatment methods do you use?
Dennis

PS:
does byee mean 4 ever? I so value the contact.

 

We're probably not that lucky are we.

 

Hi

This is an interesting discussion and passionately argued on both sides!

Perhaps at this point for the sake of the discussion it would be beneficial to reflect on what you do agree on and from that common ground try to work forward again.

 

The problem is that these two may not agree on what day of the week it is.

 

Snarl. We'd agree it was Wednesday. Then Dennis would say that he was the ONLY person who knew it was wednesday and that we were all waiting for evidence that it was Wednesday before admitting it was. He'd probably then say that none of us ever bought newspapers because we could not admit it was Wednesday and that this proved he cared more about the news than us.

Fine, fine. We'll try to drag this car wreck of a discussion back out of the ditch.

I think we'd agree that:-

The tape measure or xray approach is unreliable due to the huge inherent error.

That one can help some patients with heel raises.

That clinical signs / symptoms can be more useful for deciding whether and where to use a heel raise than measurement.

We don't much care for each others posting style.

Thats probably it.

 

1. Small amounts of LLD (mm's) are common and can be compensated internally without sequelae. i.e. LLD exists
2. Structural (SLLD) when present in large amounts (1/2"+) can be diagnosed and treated with lifts.
3. Functional (FLLD) is where debate is focused since soft tissue relationships can reduce, increase or actually invert (long becomes short) during care.
4. The literature has not resolved the debate and may actually fuel it.
5. There is no EBM diagnosis of SLLD.
6. There is no EBM treatment of SLLD.
7. Heel lifts may benifit some SLLD cases but need monitoring for possible increase, decrease or removal.
8. Soft tissue manual and motor therapy may benifit some SLLD cases.
9. Podiatrists (and others) vary in their ability to diagnose, treat and monitor LLD.
10.Robert and I both have something to add into the debate
:drinks
Dennis

 

1. Agree
2. Disagree. I never treat LLD. Although I often treat pathology arising from LLD with heel raises. Very, very occasionally I will use a heel raise in a patient with a SLLD >10mm if I can see an obvious risk of pathology. But lets face it, how many people do you see with a SLLD of <1/2" and no symptomology?

It may seem like a small and pedantic difference, but from a treatment psychology point of view I think its significant. I don't treat to make people "normal" or "symetrical". I treat to try to make them comfortable or function better.

3. Agree
4. Agree. It will never resolve the debate because the debate is too complex. It can however prevent error and more to the point, tautology. Like the belief that the more pronated foot is always on the longer leg. Which as you rightly say Dennis, It ain't.

5. Agree
6. Disagree - as per the sackett definition of EBM which leaves room for empiricism.
7. Agree. Through raises can also be worth considering.
8. Disagree. If its Slld, its S. Can't stretch bone. If you are treating the discrepancy then you can only compensate.

Although manual therapy may assist some of the "sequelae" (great word, looked it up) of the SLLD. Brings me back to point 2. Thats why the pedantry is important.

9. See answer 2. Where I think many podiatrist vary is in whether they treat LLD or consequenses thereof.
We've no way to know if / how good people are at measuring LLD because we've no baseline. We've also no way of knowing how good people are at treating LLD related conditions because again, we have no baseline. For me to say "i'm better because I don't treat them when they're not there whereas you find them through a tautological system and thus treat them in error" is as meaningless as for you to say "I'm better because you don't treat them when they are there and causing the problem because you have no evidence." We are both right within the constraints of our own paradigm and neither have any objective yardstick.

10.I 'spose (grudgingly).

Big ole structural LLD's, the ones where the discrepancy is larger than what might be considered the error of measurement, which you describe as <1/2", no argument from me there.
As you say, the debate is around the significance, or not, of small ones and of course the whole murky issue of functional LLD. Which is why I want to know the basis for your propositions. I know what you believe. I need to know why you believe it. Take your point 3 for Eg (to be less pavlovian than to examine the longer leg, more pronated chestnut)

Why do you believe that the long side spends longer on the ground? And why do you believe that this will result in more wear? I'm not saying its not, or that it is, I just want to know why YOU think it is!

What if the short leg circumducts more and scuffs the ground, whereas the long leg strikes clean and solid?

 

Looks like you actually agree more than you disagree! Sorry!! ;-)

Re Roberts repudiation of point 2, I would have assumed Dennis meant the symptomology not assymptomatic LLD, if so then you both agree here

Re repudiation of point 6, empiricism relates to treatment without diagnosis, Dennis was referring to diagnosis. However may we assume that you agree SLLD exists and can treated empirically if not with measurement?

Re repudiation 8, Dennis said SLLD may benefit from manual treatment not be corrected by manual treatment would you agree with "benefit"?

Re repudiation 9, you both seem to agree on the existance and treatment of SLLD related pathology, you are both saying it is hard to measure, is it not reasonable to assume in the light of this lack of clarity there will be variability in many aspects of how SLLD is dealt with in clinical practice.?

Hah, you will now be more fed up with me than Dennis!

BTW I believe there was some research (quoted by Craig Payne) that the common gait strategy with SLLD is for the long leg foot to be on the ground longer.

L

 

and you truly don't understand why this is do you.

I proceed with the sure knowledge of one who is talking mainly to himself. But hey.

Here is the tautology. The longer side you say. To find the longer side you must have measured. Thus the observation that the longer side has longer load is based on a measurement. Fair enough. But if THAT measurement is a valid way to find the longer leg (in the lab) then it's also valid in the clinic right? Or if it is not valid in the clinic, it was also not valid in the clinic.

This Is why we need research. Because the alternative is to run on observations. I have a whole presentation on cognitive illusions and heuristics which shows how shaky they are. You consider the more pronated foot on the edg was the "good data" and that the lack of correlation in further studies is the abberent data.

Why should I trust your interpretation of your personal experiance over, say, professor Rothbart or dr butterworth who tell me different? Or indeed my own observations?

I use heel raises often. But I see no merit to switching to your system for when to use them. You offer no validation to your protocol and I find your thought processes to be too uncritical And lacking in introspection for me to trust your ability to overcome our natural tendancy for heuristic reasoning.

 

Robert is once again off on an angry tangent. I wish to remain focused on LLD (TIP) the subject of the thread.
I do not understand tautology, cognitive illusions or heuristics but I suggest Robert start new threads on these subjects for us to monitor if we have interest.

Although I am sure Robert is using tautology and heuristics to form his opinion as to whether to consider the importance of my work or to test any or all of it in practice but we already know his opinion on TIP and to explain why or how he arrived at it should be kept off this thread as ultimately, his opinions are no more valuable than my observations.

Comparing me to Rothbart has no other purpose than inflammatory and I ask Robert to lower his defenses and bias when continuing to debate LLD.

"Even the President of the United States Must Sometimes Have to Stand Naked".
Bob Dylan
:drinks
Dennis

 

Clearly :hammer:

The link is that both of you have a unique and patented model, both of you claim years of experience successfully treating patients with it, both of you claim academic credentials, both of you spurn the idea of testing it through research, both of you seem surprised and offended that others won't just accept what you say without questioning you on the basis for it and both of you overtly and arrogantly claim that everyone who does not accept your model are inferior clinicans who are neglecting / damaging their patients. Oh and you both cause me excess stomach acid.

The PURPOSE of comparing you to Rothbart is to try to make you think how all these things seem to YOU when somebody ELSE is doing them. You, I presume, care little for Brians work. He would say almost all the same things to you as you say to me (stop being defensive, open your mind, stop neglecting your patients etc etc). How would YOU answer HIM?

Here's the thing. You gave us your method for measuring LLD. Or rather deciding if its there without recourse to measuring. Fair play. I asked you to explain / validate your theories. Since when you have provaricated, accused, complained, cried foul and done everything but actually answer my questions.

I don't know how else to remain focussed on the topic! I'm trying to get you to explain your theories. You fail to do so. Moreover you appear to fail to see WHY you should need to do so (hence my trying to explain the need). And every time we get anywhere near a sensitive point you start complaining of bias and victimisation rather than answering the question as you have done in your last post.

So to please you dennis, by bringing the thread back to your model. Lets continue with some questions you've still not answered rather than discussing the need to ask them. Lets stick on topic.

You said

I replied

And you reply....

Here's another. You say:-

And I asked

And you reply....

And here is a 3rd to be going along with.

In your explanation you said

(italics mine)

In your treatise you state

So, to be clear, what does increase pressure under the second met head indicate, a long leg, as per your explanation, or a short leg as per your treatise?

3 questions. Lets try to stick to them then. They are not attacks on you personnally, nor your model in general. They are areas where I've read what you claim and cannot accept it without further explanation. Sadly I (and I suspect a few others) will not just take these things as fact on your say so.

Robert

PS.

Nah. I respect you rather more than that, you know that. :drinks

 

Can I just add one more question to Robert's list for Dennis: How do you measure the size of a foot accurately with an electrodynogram?

For those that don't know the electrodynogram was a primitive pressure measurement system which consisted of up to 7 force measuring transducers.

Oh and by the way, this is a Masters thesis:

http://digitool.library.mcgill.ca:80/R/?func=dbin-jump-full&object_id=68140&local_base=GEN01-MCG02

"This study investigated the reproducibility of test results of the Langer Electrodynogram (EDG) foot sensor system which quantifies discrete pressures and temporal episodes at the interface of the foot and appropriate surface. In phase one of the study, the effects of transducer placement errors were evaluated by manipulating sensors. In the single subject studied, results suggested that placement errors of a single transducer within ${ pm1}$ cm from its original location do not significantly affect the temporal components of gait, though errors as low as ${ pm0.5}$ cm from an initial position significantly affected pressures.
In phase two, ten healthy subjects performed 25 straight line barefoot walks on each of two separate days at an average natural cadence of 111.06 steps/min. with identical transducer placements on each day. Twenty-five gait variables were analysed for unilateral and asymmetries estimates. Analyses of variance revealed few significant differences among trials. Further, while there were no significant overall differences between days, there were significant subject-by-day interactions due to between-day differences in individual subjects, in part related to inherent subject-performance variability. Since clinicians are interested mainly in individual subject analyses rather than a mythical average subject, caution is advised in data interpretation when monitoring a subject on different days, even with as many as 25 trials per session and identical landmark placements. Pressures, while reliable within a single testing session, should not be used for inter-day comparisons and may not be appropriate for monitoring asymmetries because slight variations in placement will account for the measured differences between limbs.

 

:boxing:

Simon joins in once again with his Ph.D. arrogance and bravado with an angry and personal agenda aimed at me so now that he has opened up the door, the gloves are off.
I just googled Simon Spooner Ph.D and the first two responses were another Spooner Ph.D. Then his practice which quoted his Ph.D. thesis in 1997. Then a reference to his now famous paper on The Subtalar Axis Locator of which there are two with none in prooduction and current use, to my knowledge. Finally, a thank you from Steve Barrett DPM for consultation that Spooner provided him. THAT's IT! THAT's IT!
Nothing new, nothing valuable, nothing that justifies his bravado.
No double blind, randomized, longitudinal, journal published (or even concieved) research, EVER!

I answered Roberts question with my experience (that was what he asked). I became the third of twenty to have Dr. Langer take back my beta EDG as I felt that it was too flawed and he was using us to perfect his baby. That was thirty years ago and I must thank Simon for alerting me to its flaws with a masters thesis thirty years later. Does he have one proving the Model T vestigial as well (I mean, by the way, a MASTERS THESIS!)?

To Simon I ask:

What have been your recent research accomplishments (lets say the last decade)?
How does your plate currently look with research that you are involved with?
Can you list research that you are contemplating doing in the near future?
Who is funding you to do research for them?

Having you as a role model for Ph.D's and research pundits (I merely looked up titles and listed them for the readers was one of your replies to my query) justifies me living near the emirical side of the biomechanics curve.

I dare you to functional foot type twenty five patients in practice and let me know if it doesn't enlighten you as to plane of pathology (and therfore care) and does not provide a matrix for clinically organizing the mire that is biomechanics.
I'm sure you will reply that I am an egotist not worthy of your time or that you are too busy working on your current research project.

"The most insignificant people are the most apt to sneer at others. They are safe from reprisals. And have no hope of rising in their own self esteem but by lowering their neighbors".
William Hazlitt

"I'm gonna free fall out into nothing. I'm gonna leave this world for awhile. Now i'm free....Free Falling"
Tom Petty

:boxing:
Dennis

 

Do try to stay on topic Dennis. You're lapsing into ad hominems and agression again. You asked that we stay on topic (LLD), lets do that shall we?

You've answered nothing, unless your answer is "my experience of more than 30 years". Is that really it?! You expect other people, to accept your model purely on the basis of "it works for me"?

Ok. In my experience, people who can curl their tongues have ankle equinus and benefit from heel raises both sides. Do you accept that from me Dennis? If not, why not?

I'm not expecting anything as mucky as actual evidence. I just want to understand your thinking.

And you did'nt answer this one at all.

Or this one

To answer these questions requires no evidence nor hard data, merely rational thought. I'm not even asking you to prove your model is "true" or "proven" on this one, merely consistant with itself and with fundamental logical laws.

An overloaded 2nd met head can't indicate a longer leg AND a shorter leg.

It is not logically consistant to make an observation of something that happens in a longer leg based on a measurement... then deny the accuracy of that measurement but maintain the accuracy of the observation.

As I say, Tautology. That means circular logic Dennis. Circular logic does not need evidence to refute that it is circular, it is self evidently flawed. An argument you level freely and correctly at the Rootian definition of sub talar neutral so I know you understand it.

Please try to stay on topic.

Regards
Robert

 

Dennis, your deflection doesn't take away from the fact that you still haven't answered a simple question:

How do you measure the size of a foot accurately using the EDG?

Still unable to answer straight forward question so attempt to attack the questioner, hey Dennis?


Now my research activities over the last ten years, this isn't all of it, but you'll get the gist:

Currently working on a project on foot and lower limb stiffness measurement. Currently engaged in funding applications with the University of Plymouth for this to Department of Health.

I'm presenting two papers at Rx Biomechanics summer School August 2010

Co-author last year paper on in-shoe pressure measurement accepted for publication in JAPMA, awaiting publication.

Presented paper on finite element modelling of foot orthoses PFOLA 2007

Co-author published paper in Japma on centre of pressure and foot orthoses 2006

Co-author published paper in Japma on stj axis locator 2006

Co-author published paper in British Journal of Podiatric Medicine comparing efficacy of scalpel debridement and insole therapy for treatment of plantar hyperkeratosis 2005

Co-author of successful bid for funding from Age concern for footcare project 2004

Co-author of published paper on effect of wedging in JAPMA 2004

Co-author of successful bid to department of health for peninsula allied health collaboration project 2003-2004



And yours Dennis?

In fact don't bother Dennis, trying to discuss anything with you is like playing an old scratched record that the needle gets stuck on. I'd rather "scoop out my eyeballs and replace them with hot toffee apples" than contemplate ever entering into a discussion with you again. "Bravado"? "Personal agenda"? "Opened the door (by asking a simple question) so now the gloves are off". I feel you may need help, Dennis.

 

"Centre up your patient supine on the couch so hips, pelvis legs etc square.

Flex knees to a 90 deg angle and compare height of knees. The reasoning is that a short tibia will show as a lower knee and a short femur will show as a knee retrograde to the other."

Lawrence is right, but before we put the knee flextion we "pull" on the cal. and lift them 5cm of the bench then ask the client to "lift your bottom of the bench please"
whilst this allows for you to be certain that the pelvis is as straigth as possible, the test is not much good if the client has laid down a little crooked.

Now flex the knees, you can then put a wedge or two under the Cal. giving you and the ever doubtful parent a great veiw of what you are looking for and how you will go about fixing it.
(l just had a new client in with a 4.5cm LLD aged 6years and no intervention had been taken to this point)

Book reference if you would like one
"Assessment of the lower limb" second edition by Linda M. Merriman, Warren Turner page 207-209

Question; When measuring of your ASIS can you get the exact same measurement twice on the same client a week later? or can your college walk into the room after you have finished and get the same result as you just did on that client?


I actually agree with the above commments in that i usually get the patients to lie supine ffet and legs together. Get them to flex knees to about 90 degrees and then ask them to lift their bum off the couch 2-3 times. I then check the Knee heights. If one knee is higher than the other i could indicate a longer tibia, while if one leg is [positioned further forward than the other, this could indicate a longer femur.

I then check the medial malleolar levels. I also get them standing up and check their iliac crest level, ASIS, PSIS and greater trachanters. In some cases you could have one side ASIS higher and the corresponding PSIS lower, which could indicate a rotation. I generally use the block system with 4mm, 6mm or 8mm heel raises to balance the paitent as necessary.

Im not quite sure how acurate this is but i sometimes get the patient to stand with their arm out by their side. I then try pulling their arm down and ask them to resist. I tend to find that people find it more difficult to resist the pressure on the side with the shorter limb and when balanced with a heel raise, the"power"returns. Anyone tried or heard of that method??

 

"Hat's off to the man that said he could,

when he couldn't.

But he didn't get away with it,

never hurt anybody but his face did fit

the frame in which he was set up.

Running out of time, running out of luck.

So what on earth did he think his mouth was for --- ?



Don't talk to him about truth and lies,

if he's 6ft tall he's half the size.



And damn the man that said he was right, (I'm right)

(not quite)"

Stuffies- "No, for the 13th time"

 

Currently working on a project on foot and lower limb stiffness measurement. Currently engaged in funding applications with the University of Plymouth for this to Department of Health.

I'm presenting two papers at Rx Biomechanics summer School August 2010

Co-author last year paper on in-shoe pressure measurement accepted for publication in JAPMA, awaiting publication.
Simon Says (I love that):
Presented paper on finite element mCurrently working on a project on foot and lower limb stiffness measurement. Currently engaged in funding applications with the University of Plymouth for this to Department of Health.

I'm presenting two papers at Rx Biomechanics summer School August 2010

Co-author last year paper on in-shoe pressure measurement accepted for publication in JAPMA, awaiting publication.

Presented paper on finite element modelling of foot orthoses PFOLA 2007

Co-author published paper in Japma on centre of pressure and foot orthoses 2006

Co-author published paper in Japma on stj axis locator 2006

Co-author published paper in British Journal of Podiatric Medicine comparing efficacy of scalpel debridement and insole therapy for treatment of plantar hyperkeratosis 2005

Co-author of successful bid for funding from Age concern for footcare project 2004

Co-author of published paper on effect of wedging in JAPMA 2004

Co-author of successful bid to department of health for peninsula allied health collaboration project 2003-2004

Dennis Replies:
Any Level 1 EBM?
I have none to my credit either in the last ten years.

That means we both live on the lower levels of scientific research.

Lets use this common ground to rebuilt our tarnished relationship.
Dennis

 

Robert States:
Do try to stay on topic Dennis. You're lapsing into ad hominems and agression again. You asked that we stay on topic (LLD), lets do that shall we?

Quote:
I answered Roberts question completely and very quickly with my experiences of more than thirty years.
You've answered nothing, unless your answer is "my experience of more than 30 years".

Dennis Replies:
My answer actually is "my experience of more than thirty years".

Dennis