Why I stopped using short leg checks and a better way!

 

Are you being treated or have you been treated for a short leg that is potentially a factor in your low back or hip pain?

If you haven’t, that’s most likely a good thing. Leg checks are performed with the patient laying face up or face down, legs extended, and the clinician attempts to look at your heel/ankle area to determine if one leg is shorter than the other.  Sometimes they will also flex your knees to 90 degrees to check for a short leg.

 

 

THIS POST WILL COVER

1. Why symmetry is often overrated and unreliable.
   2. Why even if symmetry were important, leg checks still give us relatively poor and unreliable information.
   3. How to make a better clinical decision and understand if your doctor is making logical clinical decisions about your pain or dysfunction.

 

I used to use leg checks.  It was the first protocol I learned, and it was pretty neat at the time.  I scrapped them when I learned how unreliable they are and learned superior assessments that anatomically and functionally make more sense and also allow me to communicate more effectively with patients.

 

Functional Short Leg vs Structural Short Leg

First, it’s important to understand that there is something called a STRUCTURAL SHORT LEG and something called a FUNCTIONAL SHORT LEG.

• A STRUCTURAL short-leg is when one of your legs is anatomically shorter.  This could be due to a shortened femur, tibia, hip malformation, or a combination of these factors.  You can measure from the ASIS to the medial malleolus (ankle) and compare sides to get a close idea. X-rays would be needed to get a more precise measurement.
• A FUNCTIONAL short leg is not actually shorter than the other leg, it just shows up shorter in various positions, whether lying on your back, stomach, standing up, turning your head, etc.  It can appear short at times and appear long at times.

 

A STRUCTURAL short leg, if significant, should probably be corrected with some sort of a lift.  There’s no need to go around limping which, over time, could lead to tissue breakdown and damage.  For the sake of this post, I will be talking about FUNCTIONAL short legs.

 

Symmetry Just Makes Sense, Right?

A short-leg DOES NOT inherently mean that you will be in pain.  If you checked everyone, symptomatic and non-symptomatic, for the presence of a short leg, most people will be asymmetrical and have one leg shorter than the other. We don’t even have a base line to assume that a short leg is inherently a “bad” thing.  Generally we just accept the notion that humans should be symmetrical.

It’s easy to convince someone of the idea of symmetry being important; it seems like common sense.

We have two eyes, two ears, two arms, two legs, etc. You get the picture.  Symmetry often creates beauty and aesthetics in nature and biology, but that’s not what we’re talking about here.

Why do we have one heart (left), one vena cavae (left), and one liver (right)? Why does the right lung have three lobes while the left has two? Why is the right diaphragm larger (both the leaflet and crural attachments to the spine) than the left (which also can’t leverage the presence of the liver)? Why do we have better lymphatic drainage on the left side? Check out this link to see a little more on how the natural asymmetry of the body can potentially create a short leg. Apparently LL Cool J is the poster child for living asymmetrically. Check out the link under sources at the bottom to see what I’m talking about.(1)

When we actually look at human anatomy and function, we don’t find nearly as much symmetry as you might expect.

Many people also have STATIC adaptations that are corrected when doing DYNAMIC activities.  Here’s an example.  According to Mike Reinold and others who have performed research on scapular kinematics, professional baseball pitchers often have scapular (as well as glenohumeral) adaptations that show up as a static asymmetry but generally will correct into proper positioning when movement is required. (2,3,4)

Notice how the asymmetry at rest appears to correct when the muscles are activated.

Dynamic control/neuromusculoskeletal control appears to be much more important than static positioning when it comes to pain and injury.

 

 

A Short Leg seems Like a plausible mechanism for pain, right?

From a clinical perspective, there are several problems with trying to assess and treat a FUNCTIONAL short-leg.

1. The inter-examiner reliability for prone leg checks is overall NOT RELIABLE. (Meaning, two different clinicians get different findings using the leg check protocol on the same patient. (5)

-In research, you first need to determine if you have reliability, which essentially means, can different people use the same protocol and get very similar results?  From there, you still have the burden of showing that the test/protocol is valid.  As it relates to leg checks, showing validity would require showing that the leg check findings correlate with some kind of pathology, dysfunction, pain, etc.  Withoutreliability, you can’t even check the procedure for validity.

 

2. It might be completely NORMAL and completely OK to have a FUNCTIONAL short-leg – In other words there may be no dysfunction here. (6)

 

-We can’t conclusively say that a FUNCTIONAL short-leg is a dysfunctional entity. It would be like treating a redhead with brown hair dye due to thinking that their red hair was a dysfunction. In the study cited, there was no corellation between those who had a short leg and those experiencing low back pain.

 

3. Our bodies and movement are dynamic.  Assessing structure STATICALLY is usually incomplete without assessing DYNAMICALLY.

 

-For example, the situation with the baseball player’s scapula from above-  What happens when the person stands up? Does one leg stay short?

 

-We have no idea how long a person’s legs even stay balanced after treatment.  10 minutes?  An hour?  A day?  A week?  Who knows?  Who even knows what happens when you stand up and go weight bearing because we rarely measure that, if at all. And who knows what happens to your leg length once you start moving and walking?  It’s hard to meaure when it counts, when you actually bear weight and get some movement going in your hips and back.

 

4. Clinicians rarely assess a short-leg situation with adequate thoroughness.

 

-Different techniques teach that a short leg is caused by different factors.  Some say it’s a muscle issue, others a joint issue.  Some say it’s coming from the hip or low back while others acknowledge a neck contribution, and still others believe that a very specific correction to your very top vertebra will fix it.  Some techniques acknowledge that it’s multi-factorial.  I’ve also never seen a clinician that uses leg checks break out a tape measure to see if it’s structural, although I’m sure some do.  From what I’ve personally seen, I’ve never seen a clinician use a leg check thoroughly and check for all the possible components.  If you’re not going to do it RIGHT, why do it? For more on the various possible contributing factors, you can check out the links to Eric Dalton’s site below.

 

5. Is a FUNCTIONAL short-leg the LIKELY or plausible MAIN factor contributing to a person’s problem?      

-In forming a responsible clinical opinion, a doctor/scientist should first rule in likely factors and rule out unlikely factors.  If the LIKELY explanations don’t solve the problem then we can start to rule in the more UNLIKELY causes.

6. Just because a clinician treats a patient for a short leg and the patient got better doesn’t mean the patient got better because the clinician “corrected” a short leg.

-Not only are clinicians not following you around to see IF or HOW LONG your short leg stayed balanced, but most people will come back to the office every time with a short leg that “DIDN’T HOLD.”  Or maybe it is holding a little bit or getting a little better, but you can’t see it.  You have to take the clinician’s word for it, and I would personally feel foolish if I kept treating someone for a short leg that I could never get to “hold.”

-Unless the person is a runner or does a lot of walking, it doesn’t make a lot of sense to assume that a short leg is even going to have much opportunity to create injured tissue leading to pain.  Even if the person is a runner or walker, there are still all the previous reasons to not be overly enthusiastic about treating short legs.

 

So what does a logical and simple clinical thought process look like?

1. What are the possible pain generators of this condition?-It’s probably coming from irritation to some kind of tissue such as muscle, joint, disc, nerve. or connective tissue.

   -Most of the time you can figure this out by asking a person, “What makes it better, and what makes it worse?” followed by doing some confirmatory provocative tests.

   -If you tell a clinician that it hurts when you pick up your kids, lift things, or get up from a chair, and they’re treating you for a short-leg, all I can say is that I’m sorry. The placebo effect can be pretty strong, so maybe you can get that benefit just from going to anybody.  But this is just simply not how a competent clinician thinks.

2. What is the person doing, or what has gone wrong with this person to make their pain persist? (i.e., continue or get worse)-This includes things likeposture, faulty movement patterns, chemical components such as nutrient deficiency or toxicity, weakness, tightness, even psychological components can come into play.
3. Clinician’s role and patient’s role.-What can I do as a clinician that the patient can’t do for themselves such as an adjustment, myofasical work, or medication?  The clinician’s role is also to educate the patient on what they are doing that is harming themselves and how to make the necessary correction.

Generally, pain of a musculo-skeletal origin will heal relatively quickly if we can identify and stop doing what harms us, identify faulty movement patterns, and develop correct movement patterns and strategies while incorporating some treatment geared toward restoring mobility, stability, and proper movement patterns.

I know we all wish we could go to a physician with magic hands who does all the work, and we walk out healed.  Unfortunately that rarely happens.  I think we all know deep down that if we want to become pain free and stay pain free, the majority of the responsibility falls on ourself.

If you want to pursue having your legs balanced, there are plenty of chiropractors and various clinicians that will try to do that for you.  If you want a clinician who understands how tissues become damaged and irritated and gives you knowledge to get and stay pain free, that’s harder to find.

 

Additional Reading 

If you want to understand more about the theory of functional short leg checks, Eric Dalton, PhD, explains much of the theory, assessment, and treatment on his website. He does not address how Upper Cervical Specfic or Activator Method practioners use leg checks which is somewhat similar but also fairly different.

Short Leg Syndrome Part 1

Short Leg Syndrome Part 2

Clearly I disagree with him for all the reasons listed above as well as the fact that according to the vast majority of evidence, the STRUCTURAL model of pain and dysfunction is short-sighted and incomplete at best. For more on how the STRUCTURAL model fails us you can check out my post onSTRUCTURE vs. FUNCTION for a quick read, or for a longer and very thorough read, check out this great post: Your Back Is Not “Out” and Your Leg Length is Fine

 

 

Sources:

1.) http://www.t-nation.com/free_online_article/most_recent/what_i_learned_in_2010 (see #3 – Complete Symmetry is a Myth)

2.) http://www.mikereinold.com/2010/12/4-things-i-learned-in-2010.html

3.) Reinold M, et al. Current Concepts in the Evaluation and Treatment of the Shoulder in Overhead Throwing Athletes, Part 1: Physical Characteristics and Clinical Examination. Sports Health. 2010 January/February; vol. 2, no. 1, 39-50 101–115.

4.) Struyf F, et al. Does Scapular Positioning Predict Shoulder Pain in Recreational Overhead Athletes? Int J Sports Med. 2013 July.

5.) Schneider, Michael DC,PhD. Reliability and Validity of the Prone Leg Check. Dynamic Chiropractic. January 15, 2009, Vol.27, Issue 02

6.) Grundy PF, Roberts CJ, Does Unequal Leg Length Cause Back Pain? A Case-Control study. Lancet. 1984 Aug 4;2(8397):256-8.