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News in Brief
Major Organizations Announce Joint Conference; Fighting for Section 2706; New Vice President of Chiro. Program at Parker; Two Families, One Chiropractic Dynasty.
Defending With Vitamin D: Helps Prevent Progression to Diabetes
A 2014 clinical trial published in the American Journal of Clinical Nutrition provides additional evidence that optimal vitamin D nutritional status may be important in preventing the progression of prediabetes to diabetes in prediabetic adults.
Image Is Everything: The Power of Branding
Successful businesses use color and design to attract people to their service. They understand how important image is and hire experts to create an attractive package. Starbucks works hard to create an atmosphere that is warm and inviting.
A Guide for Talking to Doctors about Acupuncture and Brain Chemistry
Before I begin any discussion of how to talk about the effects of acupuncture on brain chemistry, nervous and endocrine function, it is essential to understand just what physicians most need help with.
Are Your Work Orders in Order?
There are times when a patient's occupational duties will delay or prevent them from recovering. These circumstances create the need for the doctor to recommend modified duty or remove the patient from work.
A History Worth Telling
The popularity and the use of acupuncture for the treatment of animals in the United States is at its peak.
We Get Letters & E-Mail
Not All Evidence Is Equal; An Abundance of Misinformation; A Well-Researched Decision; Far Too Dangerous.
Overcoming Barriers to Exercise Compliance
One of the most common questions other practitioners ask me is, "How do I get patients to do their exercises?" I am not frustrated by my patient compliance, as many doctors are; in fact, I am actually happy with my patients' involvement and commitment.
Is the EHR Ship Setting Sail Without Us?
The numbers are in: As of July 2014, 10,253 doctors of chiropractic have received $123,059,868 in EHR stimulus funds – and yet that represents less than 15 percent of our profession.
The Art of Day-to-Day Assessment and Treatment: Clinical Pearls
Let's focus on the day-to-day process of assessing and treating the patient. I am proposing a particular attitude; a way of looking at the patient. This often evolves over a few treatments and then changes as you figure out what is significant.
Finders Keepers: The Secret to Relationship-Based Marketing
Becoming a successful practitioner has less to do with what you learned in school, and more to do with your ability to find new patients and keep them!
Building From the Bottom Up
I caught up with my dear friend Honora Wolfe, in her Colorado painting studio where, if she is not praying in Bhutan or doing charitable work in a Nepali free clinic, she spends most of her time now.
The Wisdom of the Second Office Location (SOL)
There are some things I never want to do again, like riding a motorcycle 100 mph. I call these things my "negative bucket list." Other things I have on that list include water skiing, riding a roller coaster and eating habanero peppers.
New Medical Technologies You Need to Know
We're all familiar with how fast computers become obsolete, as well as the rapid pace of development in the field of cell phone technology. The latest smart phones are far more powerful than desktop computers were only a few years ago.
Love a Nurse – and They'll Love You Back
According to various sources, there are about 3 million registered nurses in the U.S., and according to the American Nurses Association, they are under serious pressure in today's health care reality.
A Dream Come True for Chiropractic: Funding Prevention and Public Health
Back in 2005, Sen. Tom Harkin (D-Iowa) said: "Let's face it, in America today we don't have a health care system, we have a sick care system.
Medical Qigong for the Heart: Part III
Part 1 and Part II of this series focused on the physical aspect of the Heart and mental emotional aspects of the Heart respectively. Now, I would like to focus on the spiritual aspect of the Heart.
State by State: Comparing Chiropractic Scope of Practice
"The issue of 'scope of practice' has been a bugaboo ever since our early quests for legal recognition for chiropractic," according to Dr. Claire Johnson, editor in chief of JMPT and National's other two chiropractic journals.
Billing for Same-Visit Extraspinal and Spinal Manipulation
Q: I have always been under the premise that when billing 98943, extraspinal chiropractic manipulation, on the same visit as spinal manipulation, 98940-98942, that the extraspinal manipulation requires modifier 51.
Women's Health: Herbal Formulas to Help Patients With Dysmenorrhea
Chiropractors have long treated women for menstrual pain (dysmenorrhea). Since roughly 60 percent of all chiropractic patients are women and 30-50 percent of women have a history of menstrual cramps, the vast majority of doctors of chiropractic will inevitably see patients with dysmenorrhea.
Peer Points: Always Seeking To Grow
Ellen "Kiki" Geary has spent the last decade honing her craft. As a specialist in integrative holistic care, she went straight from completing her master's degree in acupuncture and chinese herbal medicine from Bastyr University to building a successful and thriving practice in the small community of Anacortes, Washington.
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.
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