resourcesABOUT MT AUTHOR GUIDELINES CLASSIFIEDS EDITORIAL CALENDAR MEDIA GUIDE MASSAGE MART SCHOOLS & EDUCATION FEEDBACK
Rethinking Musculoskeletal Pain – A Public Health Perspective
The American Public Health Association (APHA) is the world's oldest and largest association of its kind, founded more than 140 years ago and boasting over 25,000 members.
Breath: The Movement of Oxygen and Energy
I remember with surprising clarity the first time a patient started crying during an acupuncture treatment I was giving. This is now quite a long time ago, back in 1999, when I was a student.
The Nectar of Plants: Essential Oils and Chinese Medicine
Essential oils are a very hot topic these days, especially with the likes of the Ebola virus and the resurgence of measles lurking in our awareness, but when I first became interested in Chinese medicine, essential oils weren't on the radar screen for acupuncturists.
Giving Vets the Care They Deserve
The Department of Veterans Affairs (VA) administers the largest integrated health care system in the United States.
Our Biggest Challenges to Compete in Wellness Care
In the first article in this four-article series [May 1 DC], I made the case that chiropractors should either embrace offering lifestyle wellness in their practices or face the possibility of losing their place in the wellness care marketplace.
Reducing the Autogenic Inhibition Reflex: Making Weak Muscles Strong
The autogenic inhibition (AI) reflex is a sudden relaxation of a muscle in response to excess tension.
We Get Letters & Email
A House Divided? (May 1 issue) provoked significant response from readers. Here are several of the surprisingly similar comments we received.
Calculating Billable Units
I recently learned of an office that was audited based on the number of acupuncture sessions performed in one day. Is there a maximum number of sessions that can be performed in one day?
Spieth Thanks His Chiropractor After Historic Masters Win
Jordan Spieth didn't just capture the hearts of golf enthusiasts worldwide with his record-setting, wire-to-wire victory at the 79th Masters Tournament.
How One Little Symbol (#) Gets You More Patients
Are you struggling to get more fans or followers for your acupuncture practice? Or are looking for ways to simply connect with your patients? Or do you just want to know how to keep them engaged (comments, retweeting, liking and sharing)?
What Does Success Mean to You?
Recently, I was asked to speak to young, budding businesswomen about running a successful business — and at first I thought, "Me? You want me to speak to others about success?!"
Green Tea Improves Cognitive Function in Elderly Subjects
Publishing their results in the journal Nutrients in May 2014, researchers showed that drinking the equivalent of 2-4 cups of brewed green tea (or bottled tea) daily improved cognitive function or reduced the progression of cognitive dysfunction in elderly subjects.
Acupuncture in the U.K. Today: A Personal View
When asked to write a short piece on the current state of the U.K. acupuncture profession, my first response was to say it has all been relatively quiet.
Use Technology to Gain New Patients and Improve Efficiency
From the smartphone in your pocket to your microwave oven, advancements in technology have made almost every aspect of our lives easier.
The Source-Luo Point Combination
The luo collaterals are part of the acupuncture channel system presented in the Su Wen and the Ling Shu (The Nei Jing). The function and clinical application of the luo mai are primarily presented in chapter 10 of the Ling Shu, however, they are also found in others chapters in the Su Wen and the Ling Shu.
TMF 2015 Scholarships
The Trudy McAlister Foundation (TMF), a nonprofit organization established to support students who are on track to make contributions either to clinical practice and/or to the understanding of the role of Traditional Oriental Medicine, has announced the 2015 scholarship recipients.
The Year to Make Things Happen
It is hard to believe that the Year of the Ram – 2015 is half over. Time seems to be moving especially fast. This is the year for things to happen for the acupuncture profession.
Marijuana, Apathy and Chinese Medicine, Part 2
A talented young woman presented herself with emotional mood swings, which included being nervous, anxious and jittery.
Acupuncture and the Pulse
In 1991, I attended a martial arts workshop hosted coincidentally by Sung Baek, a martial artist and the head of his lineage as a Korean trained acupuncturist. I was enamored by the details Sung could attain from the pulse, as told to me by some of his apprentices.
A Poor Choice for Pain Relief
Acetaminophen is the most popular pain reliever in the U.S., accounting for an estimated 27 billion annual doses as of 2009. With 100,000-plus hospital visits a year by users, it's also the most likely to be taken inappropriately.
The Modern Acupuncturist
You studied ancient Chinese medicine, but I'll bet you don't practice it! Contrary to popular belief, our medicine has evolved A LOT over the years. Let's take a brief walk through history and discover the differences between ancient and modern acupuncturists.
Green Tea Improves Cognitive Function in Elderly Subjects
Publishing their results in the journal Nutrients, in May 2014, researchers showed that drinking the equivalent of 2 to 4 cups of brewed green tea (or bottled tea) daily improved cognitive function or reduced the progression of cognitive dysfunction in elderly subjects.
Professional Credentialing and Board Certification: An Ethical Faux Pas
Because of the Affordable Care Act, health care systems are coordinating care through accountable care organizations (ACOs) in order to reduce the cost of care and improve quality of care.
Leg-Length Inequality and Pelvic Fixation: A New Approach to the Negative Derifield (Part 2)
As we noted in our previous article, with a positive Derifield (+D), the doctor observes the reactive (shorter) leg in the prone position that becomes longer or "crosses over" in the flexed position.
First Do No Harm?
There's no questioning the frightening nature of breast cancer, which strikes one in eight women in the U.S. – eclipsed only by skin cancer in terms of prevalence.
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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