Pelvic Sagittal Torsion Caused by Induced Leg Length Discrepancy: Geometrical Illusion May Influence Measures Based on Superior-iliac Spines Positions.

OBJECTIVE: To investigate whether a common measure of sagittal pelvic torsion based on the superior iliac spines behave similarly to predictions of a rigid (non-torsioned) plane, when leg length discrepancies (LLD) are induced. METHOD: Twenty-four young asymptomatic participants were subjected to pelvic posture measurements that use the anterior-superior iliac spines (ASISs) and posterior-superior iliac spines (PSISs) as references, while standing on level ground and with a one-, two- and three-centimeter lifts under the left foot. A special caliper with digital inclinometers was used. The following angles were measured: angles of the right and left PSIS-to-ASIS lines; right-left relative angle (RLRA), as the angle between the right and left PSIS-to-ASIS lines, which is a traditional lateral-view measure intended to detect sagittal torsions; angle of the inter-ASISs line; angle of the inter-PSISs line; anterior-posterior relative angle (APRA), as the angle between the inter-ASISs and inter-PSISs lines. According to trigonometric predictions based on the geometry given by the lines linking the superior iliac spines (i.e. a trapezoid plane), a pure lateral tilt of the pelvis, without interinnominate sagittal motion, would change RLRA in a specific direction and would not change APRA. RESULTS: Repeated-measures ANOVAs revealed that RLRA (p<0.001) and right and left PSIS-to-ASIS angles (p≤0.001) changed, and APRA did not change (p=0.33), as predicted. CONCLUSIONS: At least part of the sagittal torsion detected by measures that assume the PSIS-to-ASIS angles as the sagittal angles of the innominates is due to pelvic geometry and not to the occurrence of actual torsion, when LLDs are induced.

Incidence of foot rotation, pelvic crest unleveling, and supine leg length alignment asymmetry and their relationship to self-reported back pain.

OBJECTIVE: To determine the incidence of pelvic unleveling, foot rotation, and supine leg length alignment asymmetry in a nonclinical population and to examine the validity (sensitivity, specificity, positive and negative predictive values) of these visual tests and their relationship to self-reported back pain. DESIGN: Volunteers answered a questionnaire regarding back pain and were then examined by a chiropractor who was unaware of the status of their back pain. PARTICIPANTS: Seventy-four unscreened volunteers answered the questionnaire. MAIN OUTCOME MEASURES: The association of visual tests with back pain and their validity indices; Visual Analogue Scale ratings. RESULTS: Fifty-one percent (n = 74) of volunteers examined had supine leg length alignment asymmetry (LLA). Pain intensity on a Visual Analogue Scale was significantly higher (P <.001) for those demonstrating supine LLA than for those without LLA. Those with back pain and recurrent back pain were significantly (P <.001) more likely to have supine LLA. The validity indices of the supine leg check showed acceptable levels for sensitivity (74%), specificity (78%), and positive predictive value (82%) [corrected] in recurrent back pain. Findings also indicated a high incidence of supine LLA in volunteers with chronic back pain (85%). CONCLUSION: The results indicated that, in this group of volunteers, the supine leg length alignment check had clinical validity as a stand-alone test for recurring back pain. Further testing on a larger, statistically defined cross-section of the population is recommended.

[Reduction of the period of treatment for leg lengthening. Technique and advantages]. / Réduction de la durée du traitement dans les allongements osseux progressifs. Technique et advantage.

PURPOSE OF THE STUDY: We assessed an adaptation of the Ilizarov method aimed at a considerable reduction in the period of treatment for leg lengthening in order to limit complications related to the duration of the external fixation. This technique associates multiple segment lengthening, automatic high-frequency lengthening, and stimulation of bone regeneration by extemporaneous compression at the end of traction. MATERIAL AND METHODS: We analyzed 78 cases of automatic fémur lengthening in 40 patients and simultaneous fémur and tibia lengthening in 38 patients. There were 51 men and 27 women, mean age 13.2 years (6 - 43 years). Mean length deficiency was 4.3 cm for the fémur and 3.5 cm for the tibia. Femoral and/or tibial deformations were observed in 32 patients. Minimal follow-up was 1.5 years. The automatic traction device was composed of the conventional Ilizarov fixator and complementary elements. Different assemblies were used depending on the associated deformations allowing their progressive correction. For 17 patients, radioimmunoassay of thyrocalcitonin and parathormone was performed to compare the time courses. RESULTS: Mean femoral lengthening achieved was 49 mm (8.5 to 20%). Mean tibial lengthening was 42 mm (7.2 to 18.8%). The consolidation index was 18.1 to 21.3 days/cm for single-segment lengthenings and 11.5 days/cm (mean) for two-segment lengthenings (taking into account both the femoral and tibial gain in length). The ideal moment of compression was 5.6 N/cm(2). Acceleration of the bone repairing process was evidenced by activation of the osteotrop hormone system. According to the SOFCOT classification of complications (1990), 60 patients (76.9%) were in category I, 15 (19.3%) in category II, and 3 (3.8%) in category III. DISCUSSION: Improvement of lengthening procedures with external fixators remains an important issue. Treatment periods are often long with consolidation indices for the femur ranging from 39.6 d/cm to 45 d/cm, which can lead to many types of complications. Use of a high-frequency progressive lengthening procedure based on the Ilizarov method considerably reduces the rate of complications compared with progressive lengthening methods and has allowed achieving more satisfactory results in a shorter treatment period. CONCLUSION: Multiple-segment lengthening using an automatic lengthening procedure set at 1 mm per day in four times provides an important reduction in the treatment delays since distraction is performed more rapidly and fewer steps are needed. Automatic high-frequency lengthening with the Ilizarov method provides optimal conditions for tissue regeneration: Treatment periods are shorter and anatomic and functional outcome is very satisfactory. Stimulation by extemporaneous compression of the regeneration zone allows a significant reduction in the duration of consolidation. Shorter delays to consolidation help avoid device-related complications.

Palpable unilateral sacral prominence as a clinical sign of lower limb anisomelia: a pilot study.

OBJECTIVE: To examine the role of oblique-axis sacral torsion in the presence of true or apparent short leg. DESIGN: Prospective blind trial of eighteen subjects. SETTING: A suburban chiropractic practice, a hospital and a university campus. SUBJECTS: Of 33 subjects selected, 27 completed the study, 8 exhibited elimination criteria, and 1 X-ray was nondiagnostic. MAIN RESULTS: 3 x 3 contingency table showed the presence of unilateral sacral prominence as statistically significant (p > .001) in subjects with LLI. The incidence of unilateral sacral prominence on the short leg side was also significant (p > .05). Weighted kappa confirmed both (alpha > .001). CONCLUSIONS: Oblique-axis sacral torsion may play a role in intrapelvic adaptation to anisomelia of the lower limb; further examination of this prospect is warranted.

Optoelectric measurement of changes in leg length inequality resulting from isolation tests.

OBJECTIVE: a) Establish a precise, standardized method to assess prone leg alignment changes (functional "leg length inequality"), which have, until now, been reported clinically to occur as a result putative chiropractic subluxation isolation tests [neck flexion (C5) and extension (C1)]; and b) describe differences in leg alignment changes in a group of healthy subjects and patients with chronic spinal complaints. DESIGN: Two group, two isolation tests, descriptive, repeated measure analysis of variance. SETTING: Exercise and Sport Research Institute, Arizona State University. PARTICIPANTS: Eight healthy controls, eight patients with a history of chronic spinal complaints and observable leg alignment reactivity. INTERVENTIONS: Active cervical flexion/extension maneuvers. OUTCOME MEASURES: Optoelectric markers affixed to heels and occiput, as subjects lay prone. Marker locations sampled at 100 Hz for 10 sec during: a) three no movement trials, b) three cervical extension and c) three flexion trials. Data transformed to local reference frame approximately each subject's longitudinal axis prior to analysis. RESULTS: Heel position movement occurred during trials and were highly individualistic. Patients exhibited more asymmetrical movements than the controls during the head-up trials. No differences existed between controls and patients for range of heel displacement or net displacement. CONCLUSIONS: The results of this study allow the following to be concluded: 1) small leg displacements (< 1 mm) were recorded by the optoelectric measurement system; 2) heel position changes during isolation tests were identifiable; 3) as a result of head-up maneuvers, patients exhibited more asymmetrical heel movement than controls (t = 8.743, p < .01); 4) The heel range of motion was not different between the groups; and 5) The net change in heel position was not different between the groups. Patients exhibited more asymmetrical heel motion during head-up isolation tests, suggesting that some phenomena may separate these two groups, warranting future study.

Excessive pronation: a major biomechanical determinant in the development of chondromalacia and pelvic lists.

Based on statistical analysis of 97 chronic low back patients, a pelvic list model has been proposed explaining the correlation between leg length discrepancies (LLD) and sciatica. This model suggests that asymmetrical pronation patterns (one pedal arch dropping more than the contralateral pedal arch) initiates a forward downward rotation within the sacroiliac joint. Entrapment of the sciatic nerve between the piriformis muscle and sacrospinous ligament occurs. Clinically, paresis is observed: numbness, weakness and eventually paralysis of the affected limb. Based on this work, the authors have comprised a classification dividing LLD into two main categories: functional and anatomical. Functional LLD have been subdivided into two types of lists: static and dynamic. Treatment based on a combination of chiropractic and podiatric therapy is presented with a 6-month follow-up. Analysis of the success in this tandem approach is very promising. Concurrently, a chondromalacia model is proposed explaining the pathomechanical events associated with oblique tracking patellar syndrome. The authors suggest that excessive pronation is the causative factor directing asynchronous rotation between the shank and femur. This forces the patella out of its normal tracking groove, which, in turn, generates erosion between the inferior margin of the patella and femoral epicondyles.

Clinical assessment and treatment of leg length inequalities.

Controversy persists regarding the significance of leg length inequality, the diagnostic approach to the use of heel lifts, and the implementation of proper orthopedic support in treatment of anatomical leg length inequalities. The purpose of this paper is to review the literature and formulate a sequential examination for a patient with leg length discrepancy, then outline a formula for the treatment of the patient. The initial problem a practitioner faces in examining a patient with leg length inequality is to determine if a true (anatomical) leg deficiency exists. Through a series of measurements and pelvic assessments, an effective screening process can be accomplished before radiography (scanogram) is required. An understanding of the mechanics along the kinetic chain, anywhere from the foot to the lumbar spine, coupled with the information gained from radiographs, can provide a treatment plan detailing the size of the lift and location.

Chiropractic concepts of the short leg: a critical review.

There have been relatively few subject areas within the chiropractic profession which have led to such widespread misunderstanding, confusion and controversy. This paper will attempt to examine the research surrounding the development of our current state of understanding concerning the many factors affecting the short leg. Traditionally, research surrounding the short leg has moved in several discreet directions. The first has been toward determining a reliable radiographic method used for measuring structural short legs. Many papers have been published here; included would be the work of Heufelder, Farinet, Giles, Nylander, Manganiello, Marstander, Wettstein, Schilgen and many others. Most tend to center upon use of new instrumentation or use of precise radiographic methods, usually involving femoral head views in some form or other. Another direction the research has taken is into an examination of how the presence of short leg affects biomechanics in both stance and ambulation. Further, investigation here have also centered upon how short leg may alter spinal growth and growth of other bones. I would include here the work of Giles, Pokorna, Moseley, Shapiro, Freiburghaus and Friberg. Other areas of research include diagnosis, therapy and correction. I leave for last a discussion on reliability studies. A major tenant of some chiropractic therapies involves the use of measurement of "functional" short leg. Though procedures for making such measurement are in the public domain, there is no proof within the literature that such exists. There have been done reliability studies attempting to show repeatability of measurement. Results have been mixed at best. I would note here the work of De Boer, Venn and Wakefield, Nichols and others. In all, this is an area under rapid and fairly extensive examination, with a wealth of previous papers available for perusal.