resourcesABOUT MT AUTHOR GUIDELINES CLASSIFIEDS EDITORIAL CALENDAR MEDIA GUIDE MASSAGE MART SCHOOLS & EDUCATION FEEDBACK
Pediatric Asthma: A Case Study
I have had very good success with pediatric asthma, combining acupuncture with Chinese herbal products. Treatment is given over four to eight months, twice monthly, with herbal formulas rotated every month.
Power to the Patient
Against a backdrop of splintered political parties, polarizations within nations, civil unrest, and distrust of established government (such as the growing anti-Washington, D.C. sentiment) comes the not-so-surprising finding that health care authorities and practitioners (with perhaps the exception of insurers) are turning over more and more powers to the individual patient.
U.S. Olympians Have a DC in Their Corner
It's probably old news to you that doctors of chiropractic play an increasingly prominent role in treating athletes, from youth sports participants to weekend warriors, to elite / professional competitors.
Using the Lens of Chinese Medicine
One of the most common medications I see in clinical practice on a daily basis is fluoxetine or Prozac. Consequently, I hear many complaints concerning the side effects of this medication and am frequently asked by patients to help manage these side effects with acupuncture and Chinese medicine.
First Annual ICD-10 Updates Take Effect
Yes, there was an update to ICD-10 codes on Oct. 1. It was a regular update to the diagnosis coding system and will take place every Oct. 1, just as it did when the ICD-9 system was in place.
Getting Paid by Medicare Is Getting a Major Adjustment
The 2015 Medicare Access and CHIP Reauthorization Act (MACRA) was signed into law to implement a new approach to clinician payments and replace the Sustainable Growth Rate formula.
Treatment Success at the Won Institute
According to the World Health Organization's 2003 report titled, "Acupuncture: Review and Analysis of Controlled Clinical Trials," acupuncture has been shown to improve many physical, emotional, and mental conditions.
Update from the International AIDS Conference
The 21st International AIDS Conference in Durban, South Africa, brought together more than 15,000 of the world's leading scientists, activists, funders, policy makers, and consumers from 153 countries.
ITB Syndrome: Treat the Tensor Fascia Latae
Iliotibial band syndrome is usually the result of repetitive knee flexion, such as in runners or cyclists. Pain may be experienced in the knee and/or the hip. The patient may express a sense of the hip dislocating, popping or snapping.
Going Beyond Just Feeling Good
We all know that most patients come to us for some pain complaint: neck pain, back pain, sciatica, carpal tunnel, etc. We also all know that acupuncture is a great first-line care for these issues, as well as supporting overall health and wellness.
Six Things Every DC Should Know About the Zika Virus
The Zika outbreak continues to spread across the continental United States and U.S. territories. We offer this brief overview on this important public health problem for the practicing doctor of chiropractic.
Pediatric Footwear: Function Over Fashion
As practitioners, it is not uncommon for parents to bring us their children to treat or ask us questions related to the pediatric population. Children's feet tend to be a perplexing region for parents and practitioners alike.
Integrative Cancer Care: Chiropractic for Chemotherapy-Induced Hiccups
Hiccups (singultus) are a frequent occurrence during cancer treatment. The cause of the hiccups may be the chemotherapy drug itself, such as Cisplatin; or the prophylactic use of corticosteroids such as Decadron, which is used to prevent nausea and/or vomiting.
Decoding the Mystery of Medical Insurance Acceptance
In the constantly evolving profession of acupuncture, one of the least understood areas is medical insurance acceptance. The profession is filled with controversy surrounding this topic: Is it ethical?
Workers' Back Pain: Causes, Costs & Solution
You will want to share two important papers published in the past several months. Why? When read separately, each provides valuable information relevant to your patients, community and practice; together, they tell a compelling story.
Treating Peripheral Neuropathy: Multi-Faceted Approach Including Laser Therapy
Peripheral neuropathy affects at least 20 million people in the United States1 and nearly 60 percent of all people with diabetes suffer from diabetic neuropathy. Many suffer from the disorder without ever identifying the cause.
Four Ways to Attract Patients
Acupuncturist A has been in practice for six years and has struggled since day one. She spends as much time and money on marketing as she can, but since her practice is slow, her budget isn't that big.
Natural Cancer Prevention: Pomegranate for the Prostate
In recent years, the ingestion of pure pomegranate juice (8 ounces per day) has been shown in clinical studies with human subjects to slow, and to some degree, reverse, the progression of prostate cancer – the second leading cause of cancer death in North American men.
Upgrade to "Parker 2.0" in Las Vegas
Continuing your education and refining your practice: two key elements of a successful chiropractic career. Parker Seminars promises both as it celebrates its 65th anniversary in Las Vegas next February, according to Parker University President, Dr. William Morgan, and seminar consultant Dr. Mark Sanna.
Dysautonomia: The Medical Condition You May Already Be Treating
TCM practitioners have spent thousands of years healing patients without knowing or needing the names of their diseases as defined by allopathic medicine. We have syndrome names that are both poetic and efficient.
National Board Apologizes for Testing Issues
The National Board of Chiropractic Examiners (NBCE) has issued a formal apology following a series of computer-based testing malfunctions that impacted two separate examinations (March and June 2016) and caused "widespread confusion and frustration" to the nearly 1,500 examinees taking the tests.
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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