LLD - mechanical or structural?

[evosy1978]

Hello,

I went to see a physio the other day to get some help and advice with chronic lower back pain amongst other things which I have going on with my body. Prior to going I was aware that my right leg was slightly longer than the left and that I also have over pronated feet. The physio asked me to lie on the table on my back and he held my feet and commented that the right was longer and so he then asked me to lift my hips in the air whilst my feet were flat on the table and shake my hips about. Then held my feet again and said they are now level...... (I never really asked what he did and why it worked) But what i do know is as soon as I started walking and moving again I noticed my right leg was again apparently longer.

So does anyone know what he did, and also why it went back to normal after I stood up? Does this mean its a mechanical LLD? (I didnt ask him these questions as I was firing lots of other questions at him)

thanks

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[stewartgp]

Hi evosy

Your physiotherapist did the right thing, in my experience a LLD is an over diagnosed 'condition'. A poor therapist would get you to lie on table and measure without resetting pelvic position (using the simple technique you describe), meaning if you lay down on table with 1 leg/your hips not in the exact neutral position it could be incorrectly measured as a discrepancy. The accuracy of the measurement also depends quite strongly on the therapists surface anatomy/palpation skills and last i remember the basic LLD measurements we have at our disposal are quite crude with a very poor inter/intra-tester reliability, which is to say even with this pelvic resetting maneuver its is far from a reliable measure.

Long story short, on his first look at your LLD there would have been an 'apparent' LLD but when he got you to 'reset your pelvic postion' when lying back down this apparent discrepancy dissappeared. I would not worry about it!

[yelufem]

Your physio may also need to assess you for SIJ dysfuntion.You sought physio primarily b/c of your lower back pain.SIJ dysfn could throw an LLD and pain at the low back as well. This apparent LLD could be corrected by squaring both or one of the lower limb or by the method your physio adopted.Your physio has done well by determining the nature of your limb discrepancy but a probe to SIJ might be quite revealing on your way to getting solution to the pain at the low back .yelufem.

[evosy1978]

Thanks for the replies.

So just to clarify, you think SIJ dys might be the reason the LLD re-appears when I stand up. What could be the cause of SIJ dys.

thanks

[yelufem]

Yes,SIJ dysfn could cause your LLD and the pain at the low back.This condition is presipitated by degeneration of the sacro iliac joint with associated inflammation of the para-articular ligaments.This makes the ligament to lose their tencile properties and prevent accesory movement of the sacroiliac joint.affectation of any of the SIJ would throw an apparent LLD which can be corrected by those methods.
Sorry i could not help using those jagons.
Your physio would surely help u out of your current pain if it is found to be coming from SIJ.
Hope this helps.yelufem.

[Dr Damien]

dear evosy1978

Yelufem and stewart gp are quite right with the advice they have given. Stewartgp is correct in suggesting that your LLD is possibly "apparent" rather than real based on the assessment you describe. By real LLD we mean that one leg is actually shorter than the other such as you would have after a surgery to a lower limb long bone, a fracture to a long bone or sometime congenital hip problems. By apparent LLD, we mean that the legs are actually the same length and the problem is coming from faults in the pelvis or above.

yeluflem suggests that a possible SIJ dysfunction can offset the symmetry of the pelvis causing an LLD. This is quite true, and infact can cause back pain sometimes chronic back pain. there is more to the story and if Yeluflem will pardon me I will explain further...

Often enough, apparent LLDs are mostly caused by spinal dysfunctions or deformities. This causes an obliquity in the pelvis that can put some strain on the SIJ. True SIJ dysfunction without a faulty spine often comes from trauma i.e falling on your bottom, landing on one leg from a significant height etc. If you are having a true SIJ dysfunction without trauma, then arthritic changes should be considered... when people think of arthritis they often think of major joint changes however degenerative changes occurring in surrounding tissues indicates some onset of arthritis and these you would get with age...

So the question would be where is this stiffness coming from that would put unneccessary strain on the SIJ? This is still going with the hypothesis that the problem is from the SIJ

You mentioned that you have an overpronated foot...

I would suggest that an indepth assessment of your posture is needed, identifying areas of stifness in your lumbar spine, the shape of your lumbar spine, what happens when you load each limb, my guess is you probably have some scoliosis...or a rounded shoulder...

if the problem you have is postural then perhaps a shoe raise worn over a few weeks might make a difference to your chronic back pain...

[alophysio]

Hi - good advice from DrDamien and the others.

I just wanted to add that the SIJ can cause such issues but it is rarely the only reason...it can only move a few mm whereas you need at least 5-10mm to be a noticeable LLD. Trust me, if your SIJ was "out" that much, you would have a hard time walking.

What is more likely to be happening is that there are muscles that are working differently from side to the other. This causes asymmetry and an apparent LLD.

By resetting the pelvis as you describe, it would seem that the problem is in the "apparent LLD" category as the others above correct suggest.

As DrDamien has said above, get everything assessed properly

Cheers!

[Dr Damien]

To Alophysio

Your point is quite true, I just remembered seeing a lady with a fractured pelvis that was missed on xray...you would need quite a lot of distraction of the SIJ to feel the effects on LLD. In this womans case literally a fractured pelvis or pubis symphysis shearing, and in both cases the pain would not make it possible to walk easily as the assymmetry would be too great for the load...it would make more sense to look higher for the distortion that would give an apparent LLD

Good point there

[yelufem]

It is great reading thru your contributions.DrDemien,alophysio and others, u have been wonderful going into differentials . Agreeably, we may not be able to narrow down effectively on the incriminating tissue/condition without having the said patient on our plinth for one on one examination.
Reading thru those differentials gives me confidence that this forum is blessed with great physios.
It seems the patient is off the post he/she started.All the same,i wish him all the best.
Yelufem.

[alophysio]

Thanks DrDamien and Yelufem...

...interesting Yelufem that you raise the "incriminating tissue/condition". I have 2 of my staff going thru their physio training at the moment. I know we are trained to look for the pain producing structure but far too often we are not challenged to think about why it is the pain producing structure.

Obviously sometimes it is obvious why it is the pain producing structure. Just tonight i saw a lady who has had problems in the past with many things but came in tonight after 4 weeks of pain in the shin after running into a bench - guess what? it was a contusion injury to the tibialis anterior and peroneal muscles...a simple problem but i still checked her entire LLKC to ensure it was...

My passion is to encourage others to always ask "why is it the problem though?" until they can't go any further

Thanks again!