resourcesABOUT MT AUTHOR GUIDELINES CLASSIFIEDS EDITORIAL CALENDAR MEDIA GUIDE MASSAGE MART SCHOOLS & EDUCATION FEEDBACK
Time for World-Wide Growth
Acupuncture is the organically growing around the world. The legislative body in Quatar has said acupuncture is "okay." The United States has five states to go to have every state recognized and regulated.
Bring on the Bitters
Out of all the possible flavor choices with foods, such as sweet, sour, salty, and umami (deliciousness), which would you choose first? Bitter, though not as enjoyable, is also a flavor.
Shoulder Rehab: The Gait Connection
Shoulder problems can be difficult to rehab completely for several reasons. The shoulder is made up of several joints that must function together smoothly to provide the extreme mobility that is possible and necessary for many activities.
Herbal Medicine Continues to Evolve
Product manufacturers, industry partners, distributors and practitioners work as a collective Traditional Chinese Herbal Medicine (TCHM) community to produce high quality TCHM prescriptions that bring low-risk healthcare to thousands of patients everyday.
Chiropractic Needs a Lesson in Education
The American Chiropractic Association has launched a campaign, The National Medicare Equality Petition, to enact federal legislation that would achieve full physician status for DCs in Medicare.
Diet, Nutrition and the Context of Risk (Part 2): Food Poisoning
Other than the morbidity and mortality linked to eating too much food, "all-natural" organisms that contaminate our food cause more illness, more hospitalizations and more death than food contaminated by heavy metals, plastics, preservatives, artificial colors, emulsifiers, artificial sweeteners and pesticides combined.
Who is Your Ideal Patient?
Being in a healthcare practice requires you to think critically about many things including your equipment, techniques, documentation, financial goals, and the retention of clients and staff.
Five-Element Reaches Out to Serve the Community
In 2006, a student at the Institute of Taoist Education and Acupuncture (ITEA) approached the administration about an idea for his senior project.
How to Bill Evaluation and Management Codes
Q: I am in need for guidance on how to bill evaluation and management (E&M) codes in addition to acupuncture the same date of service, I have never been paid for an exam when done with acupuncture and I believe I am doing it wrong.
Case Studies and Answer Analysis for NCCAOM Exam in Foundation of Oriental Medicine
Case studies are very common for acupuncture school students, either in class exams or during taking the national board exam. Most test takers feel they have no idea where they should start and how they should start to analyze those complicated cases.
The Good, the Bad and the Successful in Social Marketing
You might be thinking, "social marketing, don't you mean social media?" No, I mean social marketing. Every day, I keep reading, hearing and learning more and more about the changes happening in social media.
Day in the Life of an Advanced- Practice DC (Pt. 2)
Let's continue our Q&A with Stephen Perlstein, DC, APC, chair of the New Mexico Chiropractic Association PAC and president of the American Academy of Chiropractic Physicians. Part 1 of this interview appeared in the May 1 issue.
Acupuncture at a Pain Clinic
Introduction: Pain is the most comprehensive human experience. The experience of pain is associated with the somatic, emotional and social impact. Pain has not only somatic symptoms, but also psycho-social dimension, especially in case of chronic pain.
Immunotherapy: Where Molecular Medicine Crosses Into Holistic Thinking
Immunotherapy, and its promise as a cancer treatment, has been in the news a lot in the last few years, and for good reason. Real shifts are happening in oncology and exciting researchers, clinicians, and patients.
Are Herbs Useful for Chronic Pain?
The human nervous system is what makes us special, but our greatest strength also makes us vulnerable: witness the growing incidence of chronic addictions, anxiety, depression, sleep disorders and chronic pain syndromes.
The Eight Extraordinary Confluent Points
The eight extraordinary confluent points are a very popular set of acupuncture points in the modern practice of acupuncture. They are also called the intersection, meeting, command, opening, master, and the flowing and pooling points of the eight extraordinary vessels.
We Get Letters & Email
Another Slap in the Face for DCs; I Know Where to Find the Missing Chiropractic Patients; Clarification on Vitamin D Study.
Introducing the Dynamic Chiropractic Digital Edition
In response to the changing habits of our readers, Dynamic Chiropractic is proud to introduce a digital edition of the publication beginning with the July 2016 issue.
What Should You Call Your Patients (and What Should They Call You)?
When I walked into the exam room, the new patient looked uneasy, fumbling with his cellphone. He was a huge Polynesian man, probably in his 40s, with unrecognizable island tattoos.
Does Anyone Know You're a Good Chiropractor?
If you had a chance to read the recent article in Time magazine (April 6), you know it provided some good information about the efficacy of chiropractic to the magazine's substantial consumer audience.
Treatment of Type 1 Diabetes Mellitus: The Latest Breakthroughs
There are now more than 29 million diabetics in the U.S. and 10% of them have Type 1. The incidence has been increasing in recent years at an epidemic rate.
2016 Trudy McAlister Foundation AOM Scholars
This year, the Trudy McAlister Foundation (TMF) received a record number of excellent applications for the 2016 scholarship awards and has awarded five scholarships for $2000 each. More information is available on our website: AOMScholarship.org
F4CP Campaign Addresses Public Misperceptions of Chiropractic
In late 2015, results of the Gallup-Palmer College of Chiropractic Inaugural Report: Americans' Perceptions of Chiropractic were published. The report found that 33.6 million U.S. adults (14 percent) had utilized chiropractic care within the previous 12 months.
The Effectiveness of Chinese Medicine in Treating Infertility in the Philippines
Infertility is defined as the inability to achieve a successful pregnancy after 12 months or more of regular unprotected intercourse.
November, 2007, Vol. 07, Issue 11
Short Leg Syndrome: Part Two
By Erik Dalton, PhD
A highly debated postural issue begging for a logical explanation is the "short right-leg syndrome" (Fig. 1). Although an inferred awareness of right-sided limb-length shortness has existed for centuries, along with decades of published research, no one has provided a universally acceptable answer to two very important questions:
Let's begin by reviewing notable research regarding functional and structural short right legs and then discuss theories, assessments and corrections that help deal with this troublesome disorder.As Sir William Osler once stated, "In order to treat something, we must first be able to recognize it." Any attempt to tackle limb-length discrepancy and associated compensations, armed with inadequate evaluation tools, surely will lead to failure and frustration. In the absence of radiographic measurements, massage therapists must develop keen palpatory and visual skills for detecting osseous and soft-tissue dysfunction. Aberrant patterns are best identified and classified using the acronym ART: Asymmetry, Restriction of motion, and Tissue-texture abnormality. Although numerous tests and treatment modalities have proven successful in treating short legs and associated compensations, we'll focus on only a few fundamental myoskeletal techniques that add to your toolbox of touch.
Leg Length and Back Pain
In two exquisitely designed studies (1962 and 1983), Denslow and Chase measured leg-length discrepancy in 361 and 294 subjects presenting with low back pain.1 Using the most advanced radiographic technology currently available, their papers (published in the American Academy of Osteopathy) reported the following findings concerning limb-length discrepancy:
By comparing sagittal-plane femoral-head height and sacral base angulation (Fig. 3), the authors concluded that innominate bones rotate around the sacrum (iliosacral tilt). Transverse plane images revealed that the pelvis also can rotate as a block around the vertical lumbar spine. Denslow and Chase's pioneering work helped biomedical researchers understand how shortened limbs torsion the pelvis, creating painful lumbar compensations. Their data not only confirmed leg-length findings conducted by previous researchers but also prompted new, more sophisticated imaging studies. In 2004, John H. Juhl, DO, reported that 68 percent of 421 low back pain patients presented radiographically with short right legs.2
Functional Leg-Length Assessments
Through the years, manual therapists have developed many creative ways to differentiate functional (fixable) from structural (true) limb-length differences. Screening exams taught in educational programs often place too much emphasis on supine leg-length assessment in determining pelvic disorders. Commonly, one leg will appear shorter during visual observation of the supine client's medial malleoli (Fig. 4) when, in fact, the leg lengths actually are equal or just the opposite of how they appear radiographically when standing. For example, in the presence of a true (structural) short right leg, standing ASIS measurements should show an inferior slope on the short side. However, when the client lies supine (removed from vertical gravitational compression), the left leg may suddenly test shorter than the right. While many factors may contribute to this finding, one of the most common culprits is length/strength imbalance in deep intrinsic postural muscles such as the quadratus lumborum (QL). When unilaterally short and tight, the QL can 'hip hike' the left ilium as the client assumes an off-weighted supine posture. Confusion mounts as the left leg now appears shorter than the right. Figure 5 presents an effective contract/relax/assist maneuver to lengthen the hypercontracted left QL.
Although leg, hip and pelvic corrections shouldn't be based solely on supine test results, helpful information is derived by combining it with other exams such as prone leg-length tests. These oft-neglected prone assessments offer therapists additional clues for solving the limb- length puzzle. When prone, both ASISs are "pinned" to the table, thus preventing ilial rotation and allowing the therapist to isolate sacroiliac and axial skeletal joint dysfunction. Here's a quick reference for differentiating supine from prone limb-length assessment:
Supine: Tests leg-length differences resulting from iliosacral rotation, typically due to muscle imbalance.
Prone: Tests leg-length inequality as the lumbar spine attempts to adapt to sacral-base unleveling in the presence of SI joint dysfunction.
Depending on the degree of leg-length shortness, compensations may travel all the way up through the cervical spine and into the cranium (Ascending Syndrome). Conversely, "key" restrictions sometimes begin in the head or neck and travel down the kinetic chain (Descending Syndrome), causing pelvic obliquity and adaptive leg-shortening (Figs. 6A and B).
During the course of an examination, several simple tests help uncover the biomechanical root of the shortened leg. However, none are adequate to fully assess all possible causes. The Derifield (deer-field) Maneuver3 and others discussed below are useful in "weeding out" spinal and pelvic disorders.
The Derifield Maneuver
The neurological basis for body balance is found in the brain's reticular system, where the inhibitory and facilitory systems maintain muscle balance. Cranial or cervical fixations can affect lower-limb musculature via tonic neck reflexes, resulting in the appearance of one leg being short when viewed with the client in the prone position. Typically, comparisons are made by observing the feet, with knees in extended and flexed positions, noting any leg- length disparity (Fig. 7).
To determine if head/neck restrictions might be altering leg length, the therapist places the thumbs inferior to the medial malleoli. The client is asked to turn their head to one side and then the other. If cervical joint restrictions and/or bony spurs "snag" the dural membrane, head-turning can twist and torsion the sacrum, resulting in leg-length changes. Sometimes, the apparent leg-length discrepancy is resolved or even reversed during these cervical rotation maneuvers.
The second phase of testing begins with the client's head in neutral with the therapist's thumbs evaluating medial malleoli height. Once a visual measurement has been noted, the therapist's hands slightly plantar-flex the client's feet while slowly bending the knees to 90°, examining for any changes in heel height. Four possible findings may be noted during this test.
2. Short leg gets shorter. Sacroiliac and lumbar spine dysfunction can create muscle hypertonicity that shortens the leg in appearance as it is flexed. Figures 9A and B show effective myoskeletal springing maneuvers for derotating the pelvis to correct sacroiliac and lumbar spine asymmetry.
3. Short leg becomes longer. A posteriorly rotated and fixated ilium (usually left) shortens the leg. When accompanied by an adhesive right-anterior hip capsule, increased rectus femoris pull during knee flexion shortens the right extremity causing the left leg to appear as long, or longer, than the right. This is termed cross-over. The therapist should perform spring tests for a posteriorly fixated left ilium and anteriorly fixated, right hip capsule (Figs. 10A and B).
4. Heel Drop: With knees flexed 90°, the therapist allows both heels to drop toward the buttocks to see if one leg falls farther than the other. The heel falling farther usually is a positive indicator of a posterior sacral rotation on that side. This finding is noted as a positive Webster's sign.4 A variety of spring tests can be used to identify and correct the torsion.
Neurological Explanations for Short Legs
When a short-right-legged client stands with each foot resting side by side on bathroom scales, a measurable weight-shift typically occurs to the low side. The Leaning Tower of Pisa demonstrates this normal law of physics. However, the Tower does not possess a nervous system. Several researchers including Kappler, Previc and Pope5,6,7 believe that some individuals unconsciously resist this gravitational pull by sideshifting body weight to the left side, through a prenatal organizational system called cerebral lateralization. Their research theorizes that motor dominance overrides anatomical and gravitational factors in these individuals. It's thought that right motor dominance has roots in fetal positioning during the third trimester, resulting in the brain's lateralization process.8
In the brain, motor dominance typically crosses cortexes from left to right (left brain controls right side of the body). Conveniently, left vestibular dominance, which assists in balance, coordination and orientation, travels ipsilaterally down the left leg to allow left-sided weight bearing during right motor-dominant activities. For instance, a right motor-dominant person typically balances on their left leg to perform tasks such as kicking a ball (Fig. 11). Combining right motor and left vestibular dominance often results in a left-side-shifting maneuver of the pelvis over the vestibularly long left leg during standing (Fig. 12). This neurological postural shift helps explain many unusual pain patterns seen in clinic.
Short Leg Symptoms
Those with short right legs who bear more to the short right side usually report greater SI joint pain in the right hip and low back area. Examination of the sacrum often reveals a deep right sacral base, positive spring test for anteriorly fixated ilium and tender iliolumbar and sacroiliac ligaments. Conversely, motor-dominant clients who side-shift over the left leg usually experience greater left-sided SI joint pain and a positive spring test for a posteriorly fixated ilium. Symptoms worsen during prolonged walking or running, as overstretched abductors grind against the greater trochanter, creating bursitis, gluteus medius tendinosis and piriformis syndrome.
Since the human body rarely is symmetrical side to side, testing for loss of joint play often provides more reliable information than analyzing anatomical landmark findings. For decades, therapists have utilized spring tests to determine the presence (or absence) of joint-play in ankles, feet, hips and shoulders. Regrettably, spring tests are not as commonly used to evaluate spinal and sacroiliac joints. Therapists can benefit greatly by observing for common postural patterns during gait, checking anatomical landmarks, and spring-testing questionable structures to see if the findings have relative value.
Iliosacral, SI joint, and lumbar spine spring tests are valuable assessment and treatment tools that fit perfectly into a massage therapy format. Following the supine and prone leg-length tests, specific springing maneuvers can be used to verify findings and correct motion-restricted joints.
Since short limbs arise from biomechanical as well as neurological factors, therapists must take time to fully evaluate the client looking for common compensatory patterns such as the short right leg. Visual observation of the client's gait alerts the therapist to the possibility of cerebral lateralization and accompanying pelvic side-shifting. Supine and prone exams should be compared with other anatomical landmark findings to determine whether iliosacral, sacroiliac or head and neck restrictions are responsible for limb-length problems. Discrepancies greater than 2 cm can be associated with scoliosis, pelvic obliquity and alterations in the normal walking cycle. From a functional standpoint, there is strong, though not conclusive, evidence of an associated increase in the incidence of low back pain and hip joint osteoarthritis.
Click here for previous articles by Erik Dalton, PhD.
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