|
|
Re: leg length question
|
Logged in as: Guest
|
|
Users viewing this topic:
none
|
|
Login  | |
|
Re: leg length question - February 17, 2006 4:38:00 PM
|
|
|
eam
Posts: 291
Joined: February 5, 2004
From: New York, NY 10028
Status: offline
|
Hi Tom,
To answer the question- nothing surprises me anymore. Sometimes after I perform an evaluation, I review it and some things just don't add up ( I repeat the tests and they still show the same!). I would check the pelvis for a torsion, rotation, upslip etc. Any falls? 1 cm does not seem like a lot. How are the ischial tubs -are they level?
Erica
|
|
|
|
|
Re: leg length question - February 19, 2006 12:32:00 PM
|
|
|
truthseeker
Posts: 148
Joined: June 23, 2005
Status: offline
|
As promised, here are some more references regarding how leg length discrepancies affect multiple musculskeletal syndromes:
Radiculopathy is associated with LLD
Spine. 24(7):684-686, April 1, 1999.
plantar fasciitis and shin splints
med sci sports exerc. 1988 Oct; 20(5):501-5
tarsal tunnel
foot ankle int. 2002: mar 23(3):212
achilles tendinitis and patello-femoral syndrome
Am. Journal of Sp Med, vol 12, issue 3 179-184
Med sci sport exerc., vol 31, no 10, pp 1374-1381, 1999
Clinical Journal of sports medicine. 11(1): 2-9, Jan 2001
tibial stress fracture
med sci sport and exerc. 32(2) Supplement: S27-S33, march 2000
clinical orthopedics and related research. (360):182-190, mstvh 1999
Morton's neuroma and tibial stress fracture
Foot ankle int. 1994 May;15(5): 256-62
plica syndrome
physician and sportsmedicine vol 32, no 7, july 2004
lateral compartment knee OA and Lateral and medial meniscus degeneration
J AM Acad Orthop Surg, 1999
Knee surgery, Sports Traumatology, Arthroscopy, Vol 10, issue 3, May 2002, pat3s 177-183
patellar tendinitis
clinics in sport med vil 11, 4, Oct 1992
ACL or MCL injury
Am J or phys Med Rehabil 2005; 84: 122-130
JOSPT 1996 Aug; 24(2):91-97
Orthop Clin North Am. 2002 Oct;33(4):637-651
Med Sci in Sp and Exerc. 28(5) supplement: 27, May 1996
medial knee compartment OA
J Am Acad Orthop Surg, 1999
ITB friction syndrome
Med Sci Sports Exerc. 1988 Oct;20(5); 501-5
patellar instability
Am J or Sp Med 30:447-456, (2002)
trochanteric bursitis
Med Sci in Sp and Exerc. 30(5) supplement: 224, May 1998
Hip OA
Skeletal Radiology, Vol 30 issue 11, Nov 2001, P 659
abnormal iliac position/obliquity
Lancet. 1984 Nov 3;2(8410): 1039
does management of LLD affect LBP?
Arch Phys Med Rehabil. 2005 Nov;86(11): 2075-2080
How much of an LLD is significant?
Some say 3/4 inch - Chiropr Osteopat. 2005 July 20;13:12 and 11
Some say less (5mm) Spine. 1983 Sep;8(6):643-651
I hope I have supported my position.
|
|
|
|
|
Re: leg length question - February 19, 2006 1:10:00 PM
|
|
|
truthseeker
Posts: 148
Joined: June 23, 2005
Status: offline
|
So, the point is, if someone has a LLD, and they have any one of a number of symptoms, investigate it and teach them to manage it so that they don't develop symptoms in the future. Retrospectively, there are a ton of things that are associated with LLD. If we don't try to prevent them, what are we?
I am not saying that treating individual consequences of the LLD is not necessary, its just that if someone develops patello-femoral problems or has chronic SIJ pain and we treat the knee or SIJ, we haven't really addressed the cause if the onset of symptoms was not associated with trauma.
Solve the problem
|
|
|
|
|
Re: leg length question - February 20, 2006 10:58:00 AM
|
|
|
MPT
Posts: 161
Joined: April 4, 2004
From: Syracuse, New York
Status: offline
|
Can we reliably determine if someone has a true LLD? From what I have read, it is even hard to be reliable when using x-ray.
tf8: Literature is not the end all be all but it should be the start. Studies help us be efficient and allow us to identify the treatments that are most likely going to help a certain population. It is all about playing the odds and the literature tells use what those odds are.
Can we reliably determine if someone has a true LLD? From what I have read, it is even hard to be reliable when using x-ray.
tf8: Literature is not the end all be all but it should be the start. Studies help us be efficient and allow us to identify the treatments that are most likely going to help a certain population. It is all about playing the odds and the literature tells us what those odds are.
Tom: Do we ever really know what the underlying problem is. The human body is so complex it would seem very difficult to pin down the problem. Maybe we should be more focused on the solution to the "problem". That is why studies like the lumbar manipulation CDR are so exciting. Lets face it, we have a very hard time reliably finding "the problem". If we can identify certain measurable characterizes that predict an outcome, we will be much more effective and efficient.
_____________________________
Where am I
|
|
|
|
|
Re: leg length question - February 20, 2006 11:28:00 AM
|
|
|
truthseeker
Posts: 148
Joined: June 23, 2005
Status: offline
|
AR15,
I agree with nearly everything that you wrote. No, we cannot reliably assess LLD with Xray but it is the best test that we have. Barring that, since I cannot order Xrays or be sure that the rad techs are ensuring subtalar neutral(another arguably unreliable position) and full knee extension, I do my clinical screening. Since I am looking at multiple indicators I am doing a sort of meta analysis which improves the validity of my findings. If it is close, I don't mess with a lift.
No we rarely know exactly what the problem is. However, it is our job to try to figure it out or at least construct a theory that is likely to explain a set of signs and symptoms.
We are the experts in function. If we find things that are not functioning properly, then we need to try and figure out why. We use the best evidence available and our clinical judgement. Payors are starting to look more at outcomes. Patients always look at outcomes. When research starts (and I believe that it is starting) to look at outcomes then evidence will come faster and better support our interventions.
|
|
|
|
|
Re: leg length question - February 20, 2006 11:56:00 AM
|
|
|
JLS_PT_OCS
Posts: 1684
Joined: January 30, 2005
From: USA
Status: offline
|
Hi Tom.
Just got a look at your list of references. Let's start with the first one, on radiculopathy:
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10209798&query_hl=1&itool=pubmed_docsum
Here's a quote from the abstract: "CONCLUSION: The results of this study showed a statistically significant association between leg length discrepancy and the side of radiating pain in a case series of patients with lumbar herniated discs. The relation was more pronounced and statistically significant in women only."
So, how does this support your point? Since the finding was only statistically significant in women, does that mean that your biomechanical theory only holds for women? Does statistical significance equal clinical significance?
Does correlation equal causation?
Think of all the knee injuries you've seen this month? Were an equal number of them right and left legs?
Correlation is not causation. This study is a perfect example of that phenomenon.
This study does nothing to support the theory that LLI is a causative factor in radiculopathy, nor does it show that addressing the inequality helps the symptoms. If you feel this supports your position, then I'm afraid to read the other citations....
Tom, I know you and I go back and forth pretty hard, but I respect your knowledge and point of view. Sometimes it's nice to find someone who seems as opinionated as me, 'cause then we can really have some fierce converstaions!
Too bad my current school schedule doesn't allow me to do more of this stuff...
J
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
|
|
|
|
|
Re: leg length question - February 20, 2006 12:19:00 PM
|
|
|
truthseeker
Posts: 148
Joined: June 23, 2005
Status: offline
|
I agree with the love of fierce conversations.
No I am not saying that correlation is the same as causation and no I am not saying that clinical significance is the same as statistical significance. Statistical significance demands a higher standard. In the radiculopathy study that you referenced, If it is statistically significant in femalesit is likely to be clinically significant in males and females.
The point is, that there are NO studies that prove causation. It takes a mighty big study with a large number of PTs doing the same exact type of treatment in order to cancel out the variables that the study is not examining. As we have proven at this website alone, its hard to get 2 PTs to agree on the best treatment plan, let alone 20. Thats the part of evidence based medicine that we need to improve upon. the docs have it a bit easier since many of the things they treat are measurable with numbers and much more objective than "my pain improved with stair climbing from 7/10 to 4/10" Is that objective or sort of objective. Heck, we can't even get the nurses to switch from a 0-5 pain scale to a 0-10 pain scale. How many times to you have patients give you "oh, 5 1/2" If we gave them a 0-100 scale, they would be giving us decimals.
In epidemiological studies regarding cancer, they don't really say the smoking causes cancer, it simply says that smoking is a factor that greatly enhances the likelihood of getting cancer. Some people have a totally screwed up LLD and don't have any type of symptoms. But, those who have LLD and tight iliopsoas, and tight gluteals are much,much,much more likely to develop facet pain, especially on the long side. Some of that is clinical judgement, some of it is simple anatomy and kinesiology, and some of it is inference.
When are you going to give up and just recognize everything I say is gospel???? (wink wink, nudge nudge) ;)
|
|
|
|
|
Re: leg length question - February 20, 2006 8:51:00 PM
|
|
|
Randy Dixon
Posts: 744
Joined: August 6, 2004
Status: offline
|
Charles,
I wasn't even aware of the CPR you are mentioning about pelvic landmarks. On this list it seems the CPR for spinal manipulation refers to the second one you mentioned by Childs et. al. I mentioned it because one of the tests is comparing hip rotation ROM, with a discrepancy being a positive sign.
Did you question why this test was one selected? This is one of the tests I've always associated with testing for a rotated pelvis. I assumed this was why it was included. This was mostly conjecture on my part but the following studies seem to support my conjecturing:
|
|
|
|
|
Re: leg length question - February 20, 2006 8:58:00 PM
|
|
|
Randy Dixon
Posts: 744
Joined: August 6, 2004
Status: offline
|
Sorry, these buttons have a mind of their own. Here is the links to the pubmed abstracts:
[URL=http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15195038&query_hl=5&itool=pubmed_DocSum]link 1[/URL]
[URL=http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12909437&query_hl=8&itool=pubmed_docsum]link 2[/URL]
Please note the authors.
|
|
|
|
|
Re: leg length question - February 20, 2006 9:13:00 PM
|
|
|
Randy Dixon
Posts: 744
Joined: August 6, 2004
Status: offline
|
I could probably add at least ten references to both Jason's and Tom's list. This issue is not decided by a long shot in either direction. It is currently in a very similar state to the spinal manipulation issue, with those believing it able to support their argument and those who don't able to support theirs. The Child's study of course was a huge feather in the cap of the pro-manipulation group. It is certainly far too early to make statements like
I think it's time we put to rest the imbalance=pain myth, it has plagued our profession for far too long as it is...JASON
anything other than personal opinions. I admit my bias in the direction of favoring the pelvic rotation/LLD theory since my personal experience with it has left me with little doubt, of course, I believe the problem lies in identifying what we should be measuring, in what population and with what treatment. The same issues that plague SIJ and spinal manipulation studies. Anyway, I'll only post one reference, not as proof or evidence either way, only as a new addition:
[URL=http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16449891&query_hl=33&itool=pubmed_docsum]link 1[/URL]
and this one since it also is rather new, I haven't actually looked at it:
[URL=http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16226625&query_hl=46&itool=pubmed_docsum]link 2[/URL]
Ooops, wrong one
And this one might have something to say.
[URL=http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11896379&dopt=Citation]link 4[/URL]
[URL=http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16271551&query_hl=5&itool=pubmed_DocSum]link 3[/URL]
|
|
|
|
|
Re: leg length question - February 20, 2006 10:11:00 PM
|
|
|
Alex Brenner PT MPT OCS
Posts: 1057
Joined: February 29, 2004
From: Kentucky
Status: offline
|
Tom R,
It appears from your posts that on your physical exams you put a lot of weight on the LLI (leg length inequality). I personally believe that the literature is all over the place in regards to LLI and related pain and I am pretty sure that I can dig up as many articles to show that it is not a factor in musculoskeletal pain. Because of this I agree with Jason. Treating the LLI is a lot further down on my intervention priority list when a soldier comes in for my care. If my first line of treatments are unsuccessful then I can see myself addressing the LLI, but it's just not the first thing I go to. Does every patient that you examine get screened for LLI?
Last question. Just like people with herniated lumbar discs, why do you think people with large LLIs many times have no symptoms?
_____________________________
Alex Brenner, PT, MPT, OCS
|
|
|
|
|
Re: leg length question - February 21, 2006 1:27:00 AM
|
|
|
truthseeker
Posts: 148
Joined: June 23, 2005
Status: offline
|
I screen most people who have: unilateral LBP, Chronic LBP without apparent provocation, unilateral LE symptoms without trauma ie hip bursitis, plantar fasciitis, patello-femoral syndrome, shin splints, ITB friction syndrome.
It strikes me that if someone does not participate in unilateral activities yet develops unilateral symptoms does so for a reason. One possible reason is LLD, other reasons are maybe they jump a lot and their plant leg is the symptomatic side, maybe they sit funny for long periods of time, maybe their 6 year old daughter always wants to sit in the recliner with them on the same side when watching SpongeBob.
My THEORY on why some with large LLD do not have symptoms is how they accomodate it. Optical righting reflex wants the eyes to be level (lizard brain)and does so by one or more of several "strategies". To shorten the long side: pronate the foot, flex the knee, posteriorly rotate the pelvis, and/or pelvic upslip. To lengthen the short leg: supinate the foot, extend the knee fully, anteriorly rotate the pelvis.
If someone "corrects" themselves all in the foot, they will be more likely to have symptoms than someone who does a little at all joints on both sides. Other possible explanations are that some people have thicker articular cartilage, are stronger, have better proprioception and are better able to deal with the LLD. Vague I know, sorry
|
|
|
|
|
Re: leg length question - February 21, 2006 5:18:00 PM
|
|
|
Randy Dixon
Posts: 744
Joined: August 6, 2004
Status: offline
|
LLD is found in the majority of the population, depending on how it is measured and how accurate you believe those measurements to be, up to 95% of the population. "Testing" for it then appears to have little point. Even if 100% of, let's say, LBP pts. presented with it what would you learn? Also some LBP pts. would present with no LLD. Does this mean that it should never be considered a factor. I think you can ask the same question of most things, hypo- and hyper-mobility of the spinal segments for instance. Most people will present with either or both on examination, some with LBP will present with neither, yet it is a factor that should be considered when designing a treatment plan.
LLD is one of those things which is probably variable in people's ability to adapt to it. It may at different times in different people be a causative factor, a contributing factor, a non factor or a result of dysfunctions. (one thing I wanted to address also was the correlation between pain, injury and dysfunction not being particularly high). If it is easily observable, as in this case, the complaint is in the hip, as in this case, and other findings are consistent with pelvic dysfunction, as in this case, then looking at the pelvis seems in order. A leg lift is probably about the last thing I would want to suggest, unless you find there is an anatomical LLD.
|
|
|
|
|
Re: leg length question - February 22, 2006 3:02:00 AM
|
|
|
certMDT
Posts: 154
Joined: April 5, 2004
From: Durham, NC
Status: offline
|
I know that Dr. Wagner has been trying to encourage more incisive (sp?) journal review, and this seems like the ideal topic for a big old meta-analysis. Perhaps we could set up a separate thread, where each person agrees ahead of time to read one or two articles, and report back in 2 weeks with the relevant results. We could set the parameters on inclusion criteria and exclusion criteria, power numbers of the study, etc. We could also start with a couple of review articles such as the one in JOSPT from 3-4 years ago. I would imagine we could get at least 50-100 people reviewing articles this way (if you include all of the people that read but never post), and it would be a good exercise for everyone. I don't know how to set this up exactly, but I guess post here if anyone is interested, and maybe we could get an organized thread going.
If this is a ridiculous idea, please feel free to let me have it. My feeling going into it is that it would be pretty much a wash, as we just can't measure all of the relevant factors. But as my instructor used to say, it's fun going through the mental gymnastics.
_____________________________
Charles Sheets PT OCS Dip MDT
|
|
|
|
|
Re: leg length question - February 22, 2006 3:37:00 AM
|
|
|
truthseeker
Posts: 148
Joined: June 23, 2005
Status: offline
|
Randy,
I was with you all the way through your last post. I won't put a lift in either unless I think that it is a structural LLD. I never put a lift in a shoe on a functional leg length, only a true one.
|
|
|
|
|
Re: leg length question - February 22, 2006 7:07:00 AM
|
|
|
JLS_PT_OCS
Posts: 1684
Joined: January 30, 2005
From: USA
Status: offline
|
Randy-
Nice sparring with you again. I stand by my statement that imbalance=pain is a myth. The two are NOT equivalent. There seems to be some evidence that in some people, sometimes, it can be a factor, but that's about it. Their equivalence is certainly not, as you suggested, a personal opinion. We can only say they are or may be related. That is not equivalence.
I agree with what you said that a heel or shoe lift is way down on the list of things to try.
Tom R-
Back to our fierce conversation.
Your statement "Statistical significance demands a higher standard. In the radiculopathy study that you referenced, if it is statistically significant in females it is likely to be clinically significant in males and females."
Either you do not understand the meaning of these terms, or you have mistyped. As shown in our literature review, we are very far from even determining when and to what degree an LLI is clinically significant, yet you claim that it's likely to be, even without reaching statistical significance. However, you also state that that's a higher standard. What?
Your last post is a classic. We admit that we cannot reliably determine a functional from a structural LLI by exam, and even with radiography there is an element of uncertainty. Yet you "never" put a lift in a shoe for functional leg length, only a "true one".
What does this mean, then?
I'm not against trying shoe lifts or looking for LLI. But like most of us, it's rather far down the list of things to try. In fact, it may be dead last.
Charlie-
Great idea on the SR, but I think that given the overall (once again) poor quality of most physical medicine research, we are likely to find the SRs much less useful than a few quality trials with good control groups and a large N. The Israeli low back pain LLI study's a good example - no true control group, small N, short followup, and no way to determine whether the intervention was superior to placebo or if we were witnessing Hawthorne effect. This is not the type of study that would help us when placed in a SR.
J
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
|
|
|
|
|
Re: leg length question - February 22, 2006 9:34:00 AM
|
|
|
truthseeker
Posts: 148
Joined: June 23, 2005
Status: offline
|
Think of the jury verdict in a criminal trial to be like p< .005 or statstically significant, must be unanimous, and the verdict in a civil trial, non unanimous, to be clinically significant. p<.15
If we do several sort of reliable tests and they all agree doesn't it increase the power and validity of our findings?
A patient comes in and you suspect an ACL tear. You take a history and sure enough you suspicions are supported by the mechanism of injury. They have not had an MRI. What tests to do you do? Do you do the pivot shift test? Lachman's test? Anterior drawer test? Probably you do all of them in spite of the relatively low, statistically speaking, of the reliability of each one. If they all agree, you may then send them for an MRI or ortho exam probably both. BUT, if the tests confound each other, you may treat them a bit to see if they improve.
"Your last post is a classic. We admit that we cannot reliably determine a functional from a structural LLI by exam, and even with radiography there is an element of uncertainty. Yet you "never" put a lift in a shoe for functional leg length, only a "true one".
What does this mean, then?"
If someone comes in and I begin to screen them for LLD, and one ASIS is elevated and one leg looks short by comparing their medial malleoli, and I am able to get their ASIS level with mobilizations or muscle energy techniques and their LL now appears normal, then I do not put in a lift. That would be a functional LLD or not really a LLD at all.
I respectfully say that if it is dead last on your list of things to look for, then your patients are coming for too many visits. Do the screenings and see if they get better faster.
I have been treating people for 15 years as a PT and have had excellent success. Maybe I am fooling myself and my patients but I don't think so.
The diagnoses that people come to us with have causes. Sometimes they are traumatic and you deal with that, but if there is no apparent cause, and no real change in their activities, and their symptoms came out of nowhere then why??
If it is acknowledged that many people have LLD, and it seems so, just that some don't think it matters, then I propose that it creates asymmetrical forces through tissues and causes overload which some bodies can handle and some cannot. If we see something imbalanced and we fix it, it costs very little but the potential benefits are enormous.
One thing that the DOs and DCs hold to be true is that the body has a profound ability to heal itself. Now do not misunderstand, I do not believe in subluxations or any of that drivel, however if you restore abnormal motion to normal and get out of the way, a lot of symptoms go away.
Why for example would tight hamstrings be a potential cause for discogenic pain? They restrict hip flexion and require excessive trunk flexion when picking up an object. Is that not treating an imbalance??
if someone has tight iliopsoas and complains of pain when standing is it not treating an imbalance of sorts to stretch them and improve abodominal tone to reduce facet compression??
If a desk jockey has daily headaches that begin at 3 pm and don't happen when on vacation and they sit with terrible forward head and protracted scapulae are we not treating imbalance by helping them fix their posture??
I disagree wholeheartedly with you assumption that imbalance does not equal dysfunction. It may not equal symptoms immediately but at some point it makes the person more likely to experience symptoms or at the very least, makes them less able to recover from some type of trauma. for example the desk jockey with the crappy posture is symptom free, but it takes them 3 times as long to recover from a whiplash injury than someone else with good posture. Why? because they had a pre-morbid IMBALANCE that was an abnormal load but tolerable to them. Then when they get whacked, they have to reduce loads on their upper traps etc . . . to recover.
Rant.
PS. look at the Friberg reference I posted, it is a good study that supports my thesis that LLD is bad.
|
|
|
|
|
Re: leg length question - February 23, 2006 4:00:00 AM
|
|
|
Randy Dixon
Posts: 744
Joined: August 6, 2004
Status: offline
|
Jason,
I don't really have much time to debate this further, but what about the CPR, you use it, at least part of it appears to be based on measuring for assymetry. How can an evidence based guy like yourself use such unsubstantiated crap.
|
|
|
|
|
Re: leg length question - February 23, 2006 4:06:00 AM
|
|
|
Shill
Posts: 1092
Joined: February 13, 2003
From: Madison WI USA
Status: offline
|
Tom, and Jason,
Just for curiosity, what was your schooling like in regards to the SI joint/pelvis. Was it an emphasis by your orthopedic instructor(s)?
Thanks,
Steve
_____________________________
Steve Hill PT
|
|
|
|
|
Re: leg length question - February 23, 2006 4:17:00 AM
|
|
|
Randy Dixon
Posts: 744
Joined: August 6, 2004
Status: offline
|
Ok, imbalance=pain, I don't think anyone is actually arguing that taking this literally is defensible. Imbalance may lead to pain in some instances. The question really is, is pain the only thing that makes something significant. Eating loads of fat doesn't cause me any pain, I rather enjoy it. Some would say the linkages here are clear, but they definitely aren't, a large percentage of the people who eat high fat diets will not have CHD, many who don't eat high fat diets will. This is an area that is extremely well studied.
|
|
|
|
 New Messages |
 No New Messages |
 Hot Topic w/ New Messages |
 Hot Topic w/o New Messages |
 Locked w/ New Messages |
 Locked w/o New Messages |
|
 Post New Thread
Reply to Message
Post New Poll
Submit Vote
Delete My Own Post
Delete My Own Thread
Rate Posts |
|
0.109
|
Printable Version
