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Clinical Reasoning Typical cases are discussed there. The cases are brought by practioners.

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Old 14-06-2008, 03:42 PM   #1
marcel
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Default "Sudden" discrepancy in lower limb length

Hi,

I ask you for some input (thoughts) here.

Last week I saw a 65 yr old woman, reffered for arthrosis in knees and hips. Major complains are pain lower back and in both knees.
Remarkably in her story is her question : she noticed a relative shortening of her right leg which had to occur within a timeframe of one year; next to this she mentions to fall at least 3 times a year always landing on a knee, she never had severe pelvic or backpain after a fall.
X-rays of both hips and knees show mild arthrosis. In testing her right leg seems to be at least 1,5 cm shorter. A bit difficult to test due to obesitas is the orientation of SIAS and SIPS however it does show an indication of pelvic torsion where the left ilium is in relative anteversion opposed to the right wich is in retroversion. (i.e tilted forwards & backwards)
I consulted the reffering orthopedist about his findings if that might explain the relative "sudden" discrepancy in lower limb length.
He mentioned a slight valgus change of the "longer" leg and a torsion in the pelvis, but no opinion if that could explain this discrepancy in lower limb length.

Has anyone seen something similar before? Where a patient mentions a discrepancy in lower limb length that became noticable in a relative short period of time.

I appreciate your input.
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Old 14-06-2008, 04:04 PM   #2
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Hi Marcel,
The supposed leg length issue could be coming from the pelvis. If she is compensating for something lower down the chain-she could have developed a muscular imbalance which would affect lumbo-pelvic mechanics. From what I know, an anterior rotated ilium could be a "soft" cause of a longer leg. Check psoas and see if it's stiff.

Also, if her gait is a little off from the knee problems, she could limit her stride length, which could indirectly affect the lumbar spine and pelvis. The gold standard is the x ray for leg length issue-does it disappear in sitting?
Anyway, just my thoughts.
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Old 14-06-2008, 11:28 PM   #3
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Hi Erica,

psoas is symmetric, limb length test supine full flexion in hips & knees , full extension shows 1,5 cm discrepancy doesn't alter after repetition and exorotation of the legs and put in neutral.

I have suggested her to ask her physician for a detailed x ray.

Haven't tested length in sitting, might be a clue.

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Old 14-06-2008, 11:49 PM   #4
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Reverting for a moment to my slightly ortho-esque and ancient past, I would suspect upslip of pelvis on that side.

It's usually treated like an ortho problem but is probably more just a motor control issue. Clues are if the lower "cheek bones" feel uneven to palpation from a caudal approach with patient in prone, and if the sacrotuberous ligament (supposedly that is what one is palpating) feels slack on the suspected upslip side compared to the other side, also in prone.

In any case, the treatment I learned (and found worked well), is put the patient prone, traction the leg caudally and maintain steady pull while asking them to cough sharply, once. Repeat three times, just to make sure this novel input gets everywhere it needs to go in the brain.

Recheck the ITs and (supposed) ST ligs. Should feel nice and level and even after. Nice manual magic trick. Legs should look even and feel even to patient when they stand back up. If they don't , suspect ilial "flare", another motor control problem disguised as an ortho problem.
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Old 15-06-2008, 12:28 AM   #5
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I don't think leg length can change 1.5 cm over the course of a year unless there is major trauma or pathology. I suspect something is "tight" somewhere and it just feels different. I'd watch the patient walk and probably get most my information from that. But I suspect I'd be working with the iliosacral and sacrotuberous ligaments as well as the gluteal muscles.

Does anyone here believe we are able to change the position of the ilium relative to the sacrum?
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Old 15-06-2008, 11:58 AM   #6
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Hi Diane

Quote:
In any case, the treatment I learned (and found worked well), is put the patient prone, traction the leg caudally and maintain steady pull while asking them to cough sharply, once. Repeat three times, just to make sure this novel input gets everywhere it needs to go in the brain.
I'd guess you put traction on the shorter leg?
Quote:
If they don't , suspect ilial "flare", another motor control problem disguised as an ortho problem.
What do you mean with ilial "flare"?

Thanks,
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Old 15-06-2008, 12:16 PM   #7
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Hi Oljoha,

Quote:
I don't think leg length can change 1.5 cm over the course of a year unless there is major trauma or pathology.
I don't think that either.

Quote:
Does anyone here believe we are able to change the position of the ilium relative to the sacrum?
I don't really believe that's possible in humans with normal anatomy, physiology etc., research in SI joint movements show a max. of a just few degrees.

Fact remains that the story of this patient makes it plausible that a pelvic torsion might have occured somewhere in time. If I look at her problem just from a ortho-"mechanical" way there's definitly a torsion in her pelvis.
On the other hand unfortunatly there's no point of reference (previous exams for example) to state this torsion occured in a relative short time frame.

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Old 15-06-2008, 03:58 PM   #8
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Hi Marcel,
You would traction the "upslipped" side in this case. I learned it in supine but it probably doesn't make a difference, other way. As Diane mentioned, the IT's and other "higher" landmarks should be level with the other side after that.
Another thing worth looking at is , does she sit with her legs crossed? Also, when she sits does she sit with more weight on one buttock than the other? Over time, this can cause chronic muscle imbalances that will give the appearance of pelvic obliquity.
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Old 15-06-2008, 05:08 PM   #9
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Quote:
I'd guess you put traction on the shorter leg?
Yes.

Quote:
What do you mean with ilial "flare"?
Flares of the ilium, either side, either in or out.

Usually you'll find an outflare on the longleg side, but occasionally an inflare on the shorter leg side. Maybe she has both. Flares make the legs look strikingly different lengths, yet it's just an illusion. Again, it's just a motor control problem, not an SIJ thing.

To find, lay patient supine and do a standard leg length test. (Have patient bend up her knees, feet standing, she lifts her pelvis in the air, sets it down, then you pull her legs down and check discrepancy at the med. malleoli.) There can be an inch difference sometimes, very striking. But it's just an illusion. The ASIS's will be uneven; have your patient put her index finger on her belly button so you can visually triangulate the ASIS's with it. Your thumbs should be on the exact same spot on both ASIS's. Both ASIS's should be equidistant from the umbilicus normally.

Outflare: On the short leg side the distance between ASIS and umbilicus will be ordinary, but the distance between ASIS and umbilicus on the long leg will seem huge.

To treat the outflare side, use ordinary contract relax. Get the leg up to 90 degrees flexion at hip and knee, take the leg passively into internal rotation, just to tissue tension, then resist at ankle and knee while they try a light contraction into external rotation, 10 seconds max. Ask them to let go, then see if the leg can go into more internal rotation. Repeat three times. Always three times not because it's ritual ortho magic or something, but because the brain seems to have to make three efforts before it will "get good" with new motor output.

Inflare: Same assessment. Ankles look even, but this time one illium looks too close to the umbilicus.

One treats an inflare with the same set-up, but ask for and resist contraction into external rotation instead.

If you find flares, treat the outflare before looking for an inflare, or you might miss the inflare.

I rarely bother treating this way anymore. I found out that dealing with pain first usually gives the brain all the help it needs to get rid of all the rest of its own illusions. But it's a good trick still, as long as you don't inadvertently talk too much out loud about bones being "out" of "place" ... it's ok to say that some landmarks seem distorted, that's it's just a motor output problem, that you think you can help the brain get back on top of.
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Last edited by Diane; 15-06-2008 at 05:10 PM.
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Old 15-06-2008, 07:01 PM   #10
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Marcel,
I've had many a patient assume that their leg length was off and had become so only recently. a

Some of the things I used to look for in leg length really contributed to my escape from the bone out of place paradigm.

So many things contribute to leg length and pelvic positioning. Hip rotation, tibio-femoral rotation, pelvic rotation, varus/valgus at the hip or knee, etc.

I started noticing 2 things when I used to check for this. 1st, I noticed that often the apparent alignment would change or "correct" in the manner I had been taught to expect, but it would do so in response to indirect treatments such as strain/counterstrain, or with movement intervention such as with Sahrmann's approach. In other words I'd check, find the obliquity, perform movements or s/cs only, re check, and find symmetry.
The 2nd thing I noticed was that often I'd find obliquity, then I'd treat as above. Pain would resolve. I'd recheck landmarks. Obliquity remained.

I was taught the cough maneuver with a pull added. I stopped doing that after I felt as though I almost dislocated my wife's hip once. That probably also contributed to my leaning towards less and less coercive methods.

I don't know if that contributes anything at all to your situation, but it made me think back and I thought I'd share.
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Old 15-06-2008, 08:00 PM   #11
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Quote:
I was taught the cough maneuver with a pull added. I stopped doing that after I felt as though I almost dislocated my wife's hip once. That probably also contributed to my leaning towards less and less coercive methods.
The bigger and stronger you are the more careful you must be when learning any motor treatment skill. And if you are a patient, and need your leg held, pick someone who will just hold it steady while you cough, not add any pull. (Sometimes a treater who looks old and feeble and out of shape can be a reassuring thing to a patient. At least that's what I tell myself nowdays... )
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Old 15-06-2008, 08:27 PM   #12
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In all of these "findings" of altered illial position we must beware of pareidolia. Not that knowing about this will ever eliminate it entirely.
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Old 15-06-2008, 09:46 PM   #13
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Good one Barrett.
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Old 15-06-2008, 11:18 PM   #14
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Hi Barrett,

Quote:
Originally Posted by Barrett Dorko View Post
In all of these "findings" of altered illial position we must beware of pareidolia. Not that knowing about this will ever eliminate it entirely.
Quote:
pareidolia, a psychological phenomenon involving a vague and random stimulus (often an image or sound) being perceived as significant.
When refferring to altered illial positions in general, yes I can agree to your point here.
In this case the presentation of the patient wasn't vague, when my interpretation of her story was correct. Physical exam was not vague but remarkable if I have to believe such a thing would occur in one year.

Perhaps there is a logical explanation for this : maybe she had this "condition" for years but not noticable, say this being normal for her physique. Then there's the thing she mentioned : falling on a knee at least 3 times a year. For some years.

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Old 17-06-2008, 10:25 AM   #15
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reading the history case, my first thought is an upslip too.
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