resourcesABOUT MT AUTHOR GUIDELINES CLASSIFIEDS EDITORIAL CALENDAR MEDIA GUIDE MASSAGE MART SCHOOLS & EDUCATION FEEDBACK
What the Science Says About Magnesium Stearate
It's often been said that scientific studies can be used to support just about anything. But discoveries are never made one study at a time.
Happenings in Our Evolving Profession
Good things seem to be happening for our profession and recent developments show we are all on board. Talking about being on board, this September The Veterans Express-Purple Heart Tour is expected to make its way out of the station.
Energy is a hot commodity. Society pays dearly for it and for the expertise of those who know how to cultivate it.
Herbal Medicine: Go Mainstream
When it comes to practicing herbal medicine in a mainstream setting, there are a number of important points to understand when it comes to prescribing formulas. Some important questions to ask are - what method of prescribing and dispensing is most effective in this setting?
Why You Should Get to Know the National Vaccine Information Center
Barbara Loe Fisher has been a diligent advocate for providing parents with the information necessary to make informed decisions regarding the usage of vaccinations for their children.
News in Brief
Controversial Florida PIP Law Under Review; D'Youville Chiro. Students Learning Art of Co-Managing; And the Award Goes To...; F4CP Recognizes Major Contribution by ChiroTouch.
What They Don't Say Could Hurt You
I have written previously regarding the difficulties of drawing information from patients who are poor historians, forgetful or just plain uncooperative. The thought to revisit the topic occurred recently during preparation for an upcoming seminar.
Medicine Presents: A Great Opportunity
The changing nature of health care presents both opportunities and challenges. While we tend to focus on our profession, we can sometimes forget the impact other health care professions can have on us.
Economics of Complementary/Integrative Care
Although this column doesn't usually feature a book review, we're going outside of our usual public health format to discuss a new book written by Patricia Herman ND, PhD.
The Potter's Wheel: Reflections on Practicing in a Technology-Driven World
In my very early years of practice, an older patient named Cora would call me at home, usually late Sunday night after she had consumed an unknown quantity of beer.
Going Shoeless: The Pros & Cons of Barefoot Running
With the subculture of barefoot runners and the products catering to them growing daily, just about every chiropractor has been asked at one point or another about their opinion regarding barefoot running.
SOAP Notes: It's Time for a Cleaning
I have been planning for some time to write an article about how traditional SOAP notes do not fit chiropractic practice, and the unfairness of holding DCs to a model clearly created for and primarily applicable to medical physicians.
You are What You Eat Part II: Integrative Protocols
In the previous installment of this article I discussed important ideas concerning gastrointestinal health and foundational ideas from TCM, which can provide key insights into creating effective protocols for healing the gut.
Correcting Kid Logic in Health Care and Research Design
A recent broadcast on public radio described a fascinating phenomenon known as kid logic.
Research Abstracts From the Journal of Manipulative & Physiological Therapeutics
Effect of Pain Relief on Lumbar Muscle Function and Activation; Effects of Thrust Amplitude and Duration of HVLA Spinal Manipulation; Immediate Effects of Upper Thoracic Manipulation on Cardiovascular Response.
Helping Infertility Patients with the Spirit Essence
As many of you know, when it comes to treating infertility, we are dealing with a patient population that is, generally speaking, in emotional turmoil. These patients often experience fear, anxiety, despair, hopelessness, grief and anger.
We Get Letters & E-Mail
Patient Perception and the Farce of "Fast Relief"; A Fly in the Ointment; Persecuted for Choosing to Practice Chiropractic.
Some Thoughts on the TMJ
The temporomandibular joint is an interesting and dynamic articulation that can cause a lot of problems.
Are They Finally Fixing Medicare Reimbursement?
Even with federal sequestration cuts taking effect in March, including a 2 percent reduction in Medicare reimbursement to health care providers, hope may be on the horizon in the form of a much-anticipated, perpetually suggested overhaul of Medicare's Sustainable Growth Rate formula, which serves as the basis for determining physician reimbursement.
Have a Heart: Say No to Soda
It's not enough that soft drinks and other sugar-sweetened beverages have been linked to cavities and weight gain, among other negative health consequences.
Let's face it – patient evaluation takes time. Unless you are really into the diagnostic evaluation game, you probably have found the formal exam protocol tedious if not downright annoying.
A Building Block of Healthy Aging
Coenzyme Q10 has gained enormous attention in recent years, and with good reason —it's the Energizer Bunny of the cellular world.
Chiropractic: The Right Choice for Relieving LBP
"Low back pain (LBP) is a common threat to medicine and a reasonable threat to all national health care systems. ... Reducing ineffective treatments is necessary to decrease the LBP associated costs."
Helping Patients Through Pregnancy Loss
There is a lot of focus in the acupuncture world on fertility and helping women get pregnant. It's exhilarating to hear the news that a patient is expecting a baby. The other side of that is pregnancy loss. That includes abortion, miscarriage or stillbirth.
Remembering Joe Weider (1920-2013)
With the death of Joe Weider, the world's most famous body-building visionary, crusader, fitness magazine publisher and icon, on March 23, 2013, chiropractic has lost one of its greatest friends and supporters.
Side Effects From Big Pharma: Wellbutrin – Dangerous for You and Your Baby
Are some of your pregnant patients taking Wellbutrin? If so, it could be a danger to them and their baby. This drug is extremely popular, but it has a serious history.
There Are No Secrets: Treating Complicated Conditions with TCM
Including standardized extra points, there are just over 400 acupuncture points on the body. You get 400 and I get 400 - same. Yet, time and time again treatment protocols are coveted as if they were some secret formula only intended for the right and privileged.
Peer Points: Stories of Practice Success
When patients go see Arizona-based acupuncturist Jing Liu, it is to get top care from an practitioner well versed in all aspects of Traditional Chinese Medicine.
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 more information about Erik Dalton, PhD.
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