SI leg length discrepency (Full Version)

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Crevidence -> SI leg length discrepency (November 24, 2007 2:22:58 PM)

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ehanso -> RE: SI leg length discrepency (November 24, 2007 11:41:10 PM)

These are all great questions. Have you asked the therapists at the clinics you rotate through? Do they have a "standard" treatment routine? How do the educate their patients about this Dx or home treatment?



jma -> RE: SI leg length discrepency (November 25, 2007 11:34:56 AM)

Here is a link that provided an article on LLD: http://physicaltherapy.rehabedge.com/m_4566/mpage_1/key_leg%2clength/tm.htm#4566



apolipo -> RE: SI leg length discrepency (November 25, 2007 10:20:31 PM)

First, I usually do not even mention a LLD, unless it is very noticeable (10mm or more).  Even then, I will tell my pts. that it is there, but it might not matter.  It could have nothing to do with the pain.  If you are working w/ a pt. one time and are questioning whether the LLD is important, ask the pt. if their symptoms are changing.  If their symptoms are decreasing, then you can focus on the positive and de-emphasize the LLD.  Try to keep the pts. focused on what matters.  If they feel like they are getting better, than that is what is important.

mike t 



Tom Reeves DPT ATC -> RE: SI leg length discrepency (November 26, 2007 12:26:54 PM)

I see and treat LLD all of the time.  If it is greater than 5mm people are much more likely to have symptoms because of it.  theoretically, if there is any amount of LLD then the forces through the lower quarter and therefore into the SIJ and the spine should change.  A 15 year old with a 1/8 inch LLD would not likely have symptoms because of it, but a 60 yo with the same, would be more likely to develop symptoms at the foot, knee, shin, hip, SIJ, or spine.  there was a very long thread I think in the poll section a couple years ago on rehab edge.  Look for a patellofemoral poll. 

Friberg, O is an author that looked at members of the army and correlated 5mm as the number where if you are over it you are much more likely to have back pain.

Sorry this is disjointed, million things going on.  I keep losing my train of thought with interuptions.



jesspt -> RE: SI leg length discrepency (November 26, 2007 1:44:36 PM)

Crevidence,

I float around from clinic to clinic and get some of the same reposonses froms patients that you seem to have recieved. That look of horror in their eyes when they have the dreaded "leg length discrepancy." It's almost as frightening as the awful "rotated pelvis" that some patients are told they have.

I can't say that I tend to treat LLDs very much, but if I am treating a patient that a colleague has diagnosed with one, I give them an explanation very similar to the one you provided in your last post.

I tend to think that focus on LLD or rotated pelvises or spinal malalignments contributes significantly to the fear avoidance beliefs that we all should be working to minimize. In my experience, once a patient is exposed to these biomechanical explanations for spinal or pelvic pain, they are much more likely to perseverate on the supposed impairment of a leg length discrepancy or other malalignment than they are to focus on the status of their original complaint, which is most often LBP.

Having said that, I still occasionally give out a heel lift if a patient has a true leg length discrepancy nad they haven't made much progress iwth a classification based approach.



Alex Brenner PT MPT OCS -> RE: SI leg length discrepency (November 27, 2007 10:23:18 AM)

     When I was new therapist I used to really look at LLI and would place a lot of "clinical weight" on this finding during my clinical decision making process. Now as a more seasoned therapist this finding very rarely makes any impact in my clinical decision for treatment options. A compliance study that was published by Don Goss in JOSPT in 2004 (Vol 34 No 3) made me change the way I looked at this.

    The only way that I can think to treat a LLI is with a heel lift because I don't buy into the "rotated pelvis" crap. After reading this study I really started to question whether or not my patients were really wearing these orthotics, especially women who typically have several types of shoes varying in size and shape. Are we to really believe that our patients will exchange the orthotic and place it in their shoe that they are wearing that day, every day? If West Point Cadets, who are highly disciplined and are trained to take orders are not compliant in wearing a heel lift then how can we believe that our regular patients would be? 

    I echo the point that JessPt made about fear avoidance and LLI. I too have treated patients who were seen by other providers and were told that one leg was longer than the other. It is very difficult to move them away from this line of thinking. Some patients have even inquired about surgical procedures to correct a 5mm LLI. Yikes.



jesspt -> RE: SI leg length discrepency (November 27, 2007 3:26:53 PM)

Alex,

You and I are on the same page. Why is it that so many therapists feel the need to fill the heads of our patients with some irrelevant labels that sound so ominous? I mean, sacral torsion sounds almost as bad as degenerative joint disease!

I guess we still have to clean up our own house and abandon some of these practices.



Shill -> RE: SI leg length discrepency (November 28, 2007 11:09:37 AM)

Alex, Jess, I am with you.  Let me know when and how we can clean up this house, and I will bring my Shop Vac. Pelvic asymmetry is the norm, not the exception.



Tom Reeves DPT ATC -> RE: SI leg length discrepency (November 28, 2007 11:48:33 AM)

I don't think it is  the norm, but the common.  Like back pain.  IF a joint has moved in one plane, it will move less in a second plane. Joint stasis causes discomfort.  If there is a LLD which causes pelvic assymetry, then the patient will have pain until it is corrected.
 
What do you people do?  treat symptoms?  fix the problem, the biomechanical problem.  that is what we were taught to do.  that is where we are the experts.  How do you treat chronic back pain? by modulating the neuronal response to pain, by therapeutic touch, continuous mobilzation yadda yadda yadda.  Do you not believe that there can be a biomechanical movement fault that can be corrected with mobilzation or a lifting technique that can be corrected or taught???
 
I don't get where you are going with this.  Seriously, how do you treat chronic back pain??  I know there are a lot of different subdivisions of back pain, but it sure seems that you are quick to dismiss an entire area of biomechanical dysfunction that has certainly been an important tool in many PTs toolboxes for years.
 
I am getting worked up sorry,  I will check back to see what your answers are.
 



Alex Brenner PT MPT OCS -> RE: SI leg length discrepency (November 28, 2007 12:53:59 PM)

Tom,
Read post #74 by Steve on page 4 in the "Classification Scheme versus Biomechanical Model" Thread. That may help answer some of your questions.



Shill -> RE: SI leg length discrepency (November 28, 2007 1:24:14 PM)

Hey Tom,
You asked  "Do you not believe that there can be a biomechanical movement fault that can be corrected with mobilzation" 
Yes, this is what I do not believe, as pertaining to the pelvis. 
I do not believe:
1. That we can tell if something is out of alignment or out of place.
2. That anything is out of place, or alignment.
3. That we can put it back in place or alignment.
4. That if we could put it back in place or alignment, that it would stay there.
So there we have it.  Mind you, this is not a knock on you, just a response to what I believe.



jesspt -> RE: SI leg length discrepency (November 28, 2007 5:14:21 PM)

Tom,

Ironically, a patient with chronic pain may be  one that I would consider using a heel lift for, if they had a true leg length discrepancy. There is some evidence that shows this may be beneficial. I'd be very careful that the patient didn't focus on this as the primary cause of their pain because of the reasons I presented above.

Changes in pain and disability secondary to shoe lift intervention in subjects with limb length inequality and chronic low back pain: a preliminary report.J Orthop Sports Phys Ther. 2007 Jul;37(7):380-8. 


Conservative correction of leg-length discrepancies of 10mm or less for the relief of chronic low back pain.Arch Phys Med Rehabil. 2005 Nov;86(11):2075-80 You also state that you"...fix the problem, the biomechanical problem.  that is what we were taught to do.  that is where we are the experts. I'd counter that just because we were taught to do something isn't much of an argument for continuing to do it when current best evidence runs counter to what we were taught. I think that current best evidence re:acute and sub-acute LBP steers us away from looking at a LLD as significant. 



Tom Reeves DPT ATC -> RE: SI leg length discrepency (November 29, 2007 1:49:44 PM)

I am not saying that something is out of place, i am saying that it is living at end range rather than mid range.  Next question, to you believe that a hypomobile joint can have motion restored by mobilization?  ABnormal movement patterns occur and can be modified.  If you don't believe that, then you must simply be a symptom treater.



Tom Reeves DPT ATC -> RE: SI leg length discrepency (November 29, 2007 1:52:16 PM)

quote:

ORIGINAL: jesspt

Tom,

Ironically, a patient with chronic pain may be  one that I would consider using a heel lift for, if they had a true leg length discrepancy. There is some evidence that shows this may be beneficial. I'd be very careful that the patient didn't focus on this as the primary cause of their pain because of the reasons I presented above.

Changes in pain and disability secondary to shoe lift intervention in subjects with limb length inequality and chronic low back pain: a preliminary report.
J Orthop Sports Phys Ther. 2007 Jul;37(7):380-8.
 



Conservative correction of leg-length discrepancies of 10mm or less for the relief of chronic low back pain.
Arch Phys Med Rehabil. 2005 Nov;86(11):2075-80
 
You also state that you"...fix the problem, the biomechanical problem.  that is what we were taught to do.  that is where we are the experts. I'd counter that just because we were taught to do something isn't much of an argument for continuing to do it when current best evidence runs counter to what we were taught. I think that current best evidence re:acute and sub-acute LBP steers us away from looking at a LLD as significant.
 



Jess, I don't think that the best evidence is clear.  The methods used to test leg length discrepancies used in the studies you cite are not valid in my view.  Leg length is a three dimensional measurement and most use two dimensional measurements.  I disagree with your assertion.



jesspt -> RE: SI leg length discrepency (November 29, 2007 3:27:24 PM)

Tom, How do you measure leg length?



Tom Reeves DPT ATC -> RE: SI leg length discrepency (November 29, 2007 4:24:04 PM)

Jess,

Since nothing we do is reliable by itself, I do a 10 point checklist.

1. iliac crest height in stance
2. foot pronation ( the more pronated foot suggests the longer side)
3. "towel test"  I have the patient put one foot on  the towel and shift their weight from side to side.  the side that feels more level is the short side - similar to the book test that was discussed earlier)
4. Hip hike test.  knees straight in stance, hike the hip.  the side that hikes the least is the longer side
5. Asis position in supine
once asis position is normalized through inferior glide pelvic mobs or unilateral LE traction, I look at the following:
6. apparent leg length in supine
7. tibial length - hooklying, feet side by side, eyeball or use a small level
8. femur length - same position, which tibial tubercle is more forward.
9. ASIS to medial malleolus measurement
10. shoe wear pattern - again if one suggests more pronation than the other, it suggests a longer leg.

I have a short form with each of the above and a R  L  = across from each factor.  If the score is long R = 8 long L = 1 and R=L = 1, then I conclude that they probably have a LLD.  If it is equivocal, then they don't get a lift.  If they do get a lift, it is a full length one and they are given instructions on how to inferiorly self mobilize their pelvis and advised to do it nightly.  I personally have a 5/8" LLD and if I skip my self mobs for 2-3 days, I ache in my Long side SIJ. 

If I had an MRI that I could use, I would measure three dimensionally from the femoral head to the medial malleolus.  Even a standing AP X-ray is not perfect.  It is only remotely valid if everything outside of the film is the same.  i.e. both knees at the same degree of flexion, both feet in the same amount of pronation.  Like algebra, you have to subtract the same thing from both sides.  if someone is standing with one knee flexed or one foot pronated more than the other side, it is an invalid test.



steve -> RE: SI leg length discrepency (November 29, 2007 5:09:15 PM)

Hey Tom,

Why dont you do a pilot inter rater reliability test on your cluster? Easy enough to do - you could look at the reliability of each test in isolation and as a cluster.

Steve



Tom Reeves DPT ATC -> RE: SI leg length discrepency (November 29, 2007 5:27:09 PM)

Good idea.  I think I will do that. How many subjects do you think it would take to make it meaningful,  I'm not a statistician.

Thanks for the push.




steve -> RE: SI leg length discrepency (November 29, 2007 6:34:57 PM)

Pilot study doesnt need to be many, its just to get an idea if further study is warranted. It gives you a chance to explain some of the previous literature around SI/LLT and then based on a small sample suggest for future testing. Just need another therapist in the clinic to go through and assess patients after you.

The even better way to do this study is to give a heel lift to your next 100 consecutive patients, run every test under the sun on the patients and see which tests correlate with those patients whos low back pain improves.


Steve



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