Anoop (pronounced ‘Anoop’ like ‘Snoop’) from Miami responded to the last blog and suggested I put the conversation we’ve had that’s at the bottom of the last blog… up as another blog… so it’s a blog of a reply to a blog?…I have a feeling he’s trying to help me get more ‘air’ time? Anyway, I’ve edited it and added a bit about sex at the end because that puts you right off but leaves you wondering what it could be all about.
The trouble is I get side tracked from writing the book… and now I’ve found out that one or two Mckenzie supporters are off at me again in the depths of the CSP website… So, perhaps there’s a sensible blog piece to come soon on some recent thoughts on centralisation and how it might happen, any takers?? I tried to explain it once, but no one listened… They just say that I think that all McKenzie is extension…(well to most of the world, I’m sorry, but they do have an extension meme problem floating around…and I’ve explained that too…) .. I did one of the original UK courses with Robin McKenzie, at Royal Free Hospital in 1982..and even taught a few McKenzie courses until it stopped working for me…I liked the self management bit… Now, if they’d only read what I said and follow the reasoning..
Right now though, I really should try to be more non-confrontational, so …..back to: Sex and leg length discrepancy….
(Anoop has a website: www.exercisebiology.com. He’s an exercise physiologist and fitness/personal trainer with a strong evidence based focus in the fitness field… He writes, blogs and flogs..check him out!!)
Just heard about your blog!! I have read your articles in peak performance online on treatment of chronic pain in athletes and a couple of book chapters. In there, you write about checking the patient for leg length discrepancy, asymmetry and hamstring length and ROM. My question is what do these measures tell us about the person’s pain or tissue condition? If a person has leg length inequality, what could it tell us?
Thank you so much, Anoop…
Anoop, Can you point me to where you read this.. so I can see context…Thanks,
Here is the article: http://www.pponline.co.uk/encyc/biopsychosocial-pain-1107#ref‘. I have a lot of questions usually.
Right, I had to re-read it.
That leg length mention was almost in there by reflex I feel…have to credit my colleague, good friend and co-author Steve Robson with it perhaps? No, we both did it…together…it was his fault…
You ask about the relevance of leg-length … well it’s absolutely no big deal, and what could be done about it anyway?… Tell the patient/sportsman and make them worry about it unnecessarily?…… Tell him it’s because of an SI joint upslip or something… Sorry, not my scene – it creates fear of structure, notions of weakness in the very people who want to feel invincible….. and it’s… well, bull-s**t?
A great many patients come in and say that the chiropractor /osteo/physio told them their leg length was out… so if they say this I always check it and 90% or more of the time it’s fine… So, patient lies flat, I ask them to wiggle the hips and back and get as straight as they possibly can … I bring their legs together at the ankles, both medial malleoli hit each other exactly, I get the patient to look and … they go ‘Ah it’s OK’…and I usually say… ‘They must have fixed it….!!’.. and laugh…(if appropriate)… Or if it is slightly different… I say – ‘If we took 50 people off the street with no problems at all we’d find a large number of them had small differences like yours…. Having a leg length difference is normal and very common and is of no consequence…. Anyway I can lengthen or shorten whichever leg you want… watch’….
I shift his hip slightly to one side… and hey presto… same length… or bring both legs marginally off to one side… or push one of the legs back through the heel…. all with the effect of slightly side flexing the back/pelvis and hence shortening/lengthening the leg.
‘Hey, I can make your longer leg even longer… and your shorter leg even shorter… party trick…. show your kids… get them to watch your feet and tell them one leg’s going to grow shorter….and just subtly and very slowly pull your hip up from the pelvis/back little by little…. do it sitting with your legs stretched out on a chair….do a bit of chanting at the same time…. even turn the lights down a bit to create atmosphere…
Chiropractors charge for this flim flam and faith healers make gullible worshippers think that a miracle has happened…Check out James Randi on faith healers..(http://www.youtube.com/watch?v=wsKBP1TOdYI) ….. he shows how they do it with the help of their Lord… Swing the legs to the side and pull the shoe off a little…. maybe even surreptitiously create a fearful trance like atmosphere… and while this is going on, push the leg so the knee bends a bit too….. they’re taking the piss, making a load of money and they don’t pay any taxes… Shocking in my opinion. Randi and his group of sceptics have been exposing them and showing the public the shams that they really are for many years now. It’s unbelievable frankly.
Do Chiropractors’ really think they’re lengthening/shortening the leg?? Anyone want to be a whistleblower and afterwards go hide in an embassy somewhere???
Now, do I ever use a heel raise to correct it? If it changes processing it may be worth it!! You try going round all day with a small heel cushion in your foot… Novel eh? Go for it… but don’t make the patient leg-length obsessed… they might just go see an orthopod for an osteotomy..
Louis… (scpetic/skeptic and non believer with life spirit and annoying healing powers).
This bit is where the sex comes in… I’ve just added this, so it’s ‘new’ to the blog….
Symmetry in nature is amazingly difficult to achieve. I’d like to quote Matt Ridley, author of ‘The Red Queen: Sex and the evolution of human nature’. …. ‘It’s a well known developmental accident that animal bodies are more symmetrical if they were in good condition when growing up, and they are less symmetrical if they were stressed while growing. For example, scorpionflies develop more symmetrically when fathered by well-fed fathers that could afford to feed their wives….. Making something symmetrical is not easy… If things go wrong, the chances are it will come out asymmetrical..
Consider that most biological molecules, large as they are, twist and contort into the most fantastic shapes that are usually far from symmetrical. That we are all made of asymmetrical protein molecules makes it quite fantastic that, at least for the most part, we do end up pretty much symmetrical; it has to be an incredible biological challenge.
I know this is rather politically incorrect, (please try to stay planted at the biological level) … but have you noted how attractive symmetry is? And how unattractive asymmetry is? Don’t have a short leg and look lopsided, or walk with a sway and a dip… and if you fly it’s not pretty to have asymmetry of your wings…. you really don’t look good, no one will want your genes… Sexual evolutionary selection has worked it’s wonders to produce a strong link between good genes and good looks – and a part of that might just be symmetry! Back to Matt Ridley again and his discussion of Møller’s study of swallows tail streamers (not the ones in the UK!). Møller noted that swallows with the longest tails were the most successful at securing mates. He also noted that the longer the tails the more symmetrical they were too. ‘So Møller cut or elongated the tail feathers of certain males and at the same time enhanced or reduced the symmetry of the tails. Those with longer tails got mates sooner and reared more offspring, but within each class of length, those with enhanced symmetry did better than those with reduced symmetry…
What girls make the boys do for a good time!! But biologically it all boils down to advertising your good genes…..plus your good upbringing (well fed, stress free, and as a result, well developed)…and ultimately your fitness to sire the young lady swallow and be a good provider for the offspring. Girls go for symmetrical boys and vice versa… plus, well, what about that human stallion driving a Rolls and controlling the Formula 1 Racing Empire, or that strangely symmetrical guy who won Wimbledon..? Oh, not for you…
So the moral of the story is to put that heel raise in, it might feel really weird but you’re much more likely to score!
It works, I’ve just tried it…
Thanks for listening and sincere apologies to any who may be offended.
some interesting thoughts from Lederman’s “The fall of the postural-structural-biomechanical
model in manual and physical therapies:
Exemplified by lower back pain: in his article about leg length and pain:
Leg length differences as a cause for back pain has been
debated for the last three decades. It is estimated that
about 90% of the population has a leg length inequality with
a mean of 5.2 mm. The evidence suggests that for most
people anatomic leg length inequality is not clinically
significant (Papaioannou et al., 1982; Grundy and
Roberts, 1984; Dieck, 1985; Fann, 2002; Knutson, 2005,
review), until the magnitude reaches approximately 20 mm
(Gurney, 2002 review; Knutson, 2005, review). Although
some earlier studies comparing people experiencing back
pain with asymptomatic controls suggest a correlation
(Giles and Taylor, 1981; Friberg, 1983 and 1992), more
relevant are prospective studies in which no correlation
was found between leg length inequality and LBP (Hellsing,
1988a; Soukka et al., 1991; Nadler, 1998).
Patients who have acquired their leg length differences
later in life as consequence of disease or surgery may also
help to shed light on the relationship between pathomechanics
and LBP. Individuals who developed a shorter leg
due to Perthe’s disease had a poor correlation between leg
length inequality, lumbar scoliosis and low-back disorders,
assessed several decades after the onset of the condition
(Yrjo¨nen et al., 1992). In studies of patients who had
marked changes in leg length due to hip fractures or
replacement, such changes were not associated with back
pain assessed several years after surgery (Gibson et al.,
1983; Edeen et al., 1995; Parvizi et al., 2003).
One of the arguments in favor of an association between
leg length differences and LBP is the supposed success of
heel lifts in reducing back pain (Giles and Taylor, 1981;
Gofton, 1985; Helliwell, 1985; Friberg, 1983 and 1992;
Brady et al., 2003 review). However, all these studies
failed to include controls or sham heel lift (such as inefficient
soft foam lift).
Its always gratifying to find no support for something stupid but it’s also necessary to balance this by trying to find support for the stupidity too (and weighing it up fairly like good scientists should) The task is then to analyse the quality of the the support for the stupid thing… whereupon you often find you get a double gratification-buzz-whammy because the quality of the stupid support is also stupid.
The big deal here is interpretation when a heel raise does indeed help the back pain; – which I’m sure it has done in a great many who’ve otherwise suffered for years, get quickly cured by this simple but surprisingly costly (therapist expert fees plus a bit of choice plastic when packing sponge works well in the right hands/feet)….and are now convertees. The assumption that it was their leg length all along is what should be called into question….The belief that it was ‘out’ – and is now fixed… plus the new sexy symmetrical feel and that amazingly good novelty feeling of the shoe slipping off all the time add to the charisma and well-being of the positive experience. That processing might have changed is rarely entertained and for me, should be the first port of call.
Lets take another example which seeks the truth at the end by actually interviewing the pain and getting its opinion! Wow!
The subject is a normally very healthy patient with back pain who on the first occasion seeks the help of a ‘cranio’ who holds their head very gently and makes immovable joints swagger back to their correct place of rest at the same time rebalancing some juice in the CNS that flows somehow incorrectly. it’s weird but very relaxing experience, that afterwards feels really like nothing much happened. Anyway, all corrected the happy patient, free of pain now goes bungee jumping and never feels better… Consideration for the careful work of the cranio and that fluid imbalance disregarded… hey ho.
Anyway, the unfortunate returns a year later with the exact same pain to find the therapist has been replaced by a reflexologist who now ignores the skull for some reason and makes a diagnosis via some thinkened skin in the foot… It soon becomes clear that its this guys pancreas and the back pain will be fixed once the pancreas is sorted. 10 easy and pleasant treatments later, (the same number as the cranio did by the way) and the said bungee jumper feels better and decides to follow up with another jump to positively reinforce the therapy like the last time…. they strangely seem to disregard all the careful work done on the foot reflex zones as the bungee cord gets strapped firmly to the feet and several times G force happily prevents our patient from almost smashing their face into the ravine below… Feeling pleased they then follow this up with a some wing-suit free-fall that finishes off with a parachute for some reason…. and even though they have quite a hard landing through their pancreatic foot zone, everything is completely tickety-boo for months afterwards. Said patient wonders if it’s his foot, his head, his fluid or his pancreas but totoally disregards his back.
What helped?… to the first therapist it was the displaced cranial suture and the cranio fluid and for the second it was the thick skin on the foot and therefore the pancreas. For the bloke it was the same back pain every time.
When the back pain was later interviewed it gave a shockingly honest appraisal of the real situation:- It was processing that changed and a whole bunch of novelty chemicals in all the various environments it had been exposed to. The quote was, ‘Yes, I’ve always been gullible’ The press listened and so did the original therapists but none of them believed the pain was telling the truth!
So, (I like morals), the moral of this story is that just because a pain improves with a technique to a particular structure does not mean that that structure was the cause of the pain or that what the therapist thinks they did to that structure cured it. I would particularly like to point this out to all those who get sucked into the sacro-iliac joint…. It’s yet another version of the leg-length joke.
Oh, and the pain said it was happy to be interviewed again if there was any trouble caused….or anyone didn’t quite get what it was trying to explain…
Thanks for revving me up again. I had to chuck the heels out they drove me mad… I’m now asymmetrical and lonely, but building up for a new theory of ‘pain centralisation’!
it is amazing you can take these complicated stuff and convey it though a nice simple story that it makes a lot of sense.
Paul Ingram –another good writer and sceptic has this to say….
Louis, I was thinking about your Mckenzie comments –maybe its an evolutionary adaptation and advantage to belong to a cult ? Seems like there is a desire to do this –stand behind a named ‘thing’ or personality ? I think at the time Mckenzie’s message/method of self management was good but times have moved on –I think all the methods and brands aren’t up to much to be honest – just means of desensitisation when they ‘work’ .
Eyal’s new book on ‘Stretching’ and mobility improvement is very good with regards to this — a great practical approach at simplifying the complex biology into empowering practical neurobehavioral inspired recovery …
Anoop’s last comments are interesting …so many ways of looking at the body and body language from biomechanics to embodied cognition –maybe you will think differently wearing vibram five fingers on rather than Hunter Welly boots … not sure what attire your are likely to score in though but no sheep jokes needed.
Excellent and insightful information, thanks Louis and thanks Ian for posting the link to that excellent article (love the John Sarno reference – the man who first made me see sense). Now how to get more people to read it……
Ian, maybe, Yes, your area of expertise… and don’t lets start talking about the hand that feeds you…and pays the mortgage…. See my thoughts after latest Anoop comment…
I’d like to suggest everyone reads Stuart Sutherland’s brilliant book: ‘Irrationality’ it basically tells you how stupid everyone else is… when you start realisiing that it includes you you’re getting somewhere….
I’m sticking to the hunter welly boots and I’ve found sheep jokes can work in the right context…
This is a comment an old colleague of mine put on my facebook page in response to me posting the ‘saveyourself……..’ link above:
“My head hurts. An incoherent, repetitive rant. I’m no advocate of structuralism, in fact I don’t know what I believe but I don’t write cynical blogs/books just to sell e-books to make a living. My advice, always ignore someone’s opinion if on the back of it they try and sell you something.”
“My advice, keep an open mind about everything, never denounce anything. This article is applying the same narrow minded view on structuralism, only in reverse. It raises a few interesting points but that’s about it and nothing that most rational people won’t of thought of before.”
An example of the problem we’re up against, not enough people willing to truly reflect on the theories they work by, let alone be prepared to change their practice 😦
peter, I think you might like this paper http://www.ncbi.nlm.nih.gov/pubmed/21277166
if you send me a message can send the full thing . Most people filter the ‘truth ‘ through the filter of early education . The limitations of structural thinking are endemic but because it seems like common sense in most people its hard to disagree with it .However when you have pt’s with bilat elbow fractures , ankylosed fused knees via juvenile Rh , spinal fractures following falls out of trees and no reported pain its hard not to think there is far more to pain than biomechanical anomalies !
In the book ‘Brainwashed: The seductive appeal of mindless neuroscience’ by Satel and Lilienfeld, I think I told you about… they refer to this ‘common sense’ view things usiing the philosophical term ‘naive realism’ and I rather like it…It’s defined as ‘…an intuition held by most people that the view of the world that we derive from our senses is to be taken at face value’….
Great, thanks Ian. Being a slight technophobe I can’t seem to find your e-mail address (is it on your profile somewhere??). But anyway, mine is email@example.com.
sent on a few papers to you pete …
Ian, sorry to be a pain, but nothing’s come through on my e-mail. Could you re-send? Or try firstname.lastname@example.org.
Thanks for the awesome post!! Glad i motivated you post another article. And thank you for the link to my website. You just made my day. 🙂
I was thinking how the evolutionary biology could be one reason how we tend to associate ( subconsciously) bad posture with bad health or pain or discomfort. And how some therapists cannot still discard the idea of posture when it comes to treating or preventing pain. Like we want to embrace the science, but something deep inside says it doesn’t sound right you know.
I always like it when I’m running and feel knackered and all hunched up feeling about 90 and staring at the ground looking for tree roots that might trip me up…and then I spy a couple of chicks ahead and suddenly find my head up, posture corrected, chest puffed out, speed up to running again and looking hot! Context is an interesting thing….Posture! well it may help to spread your genes around too… so hey, it must be evolved. Make a patient feel good and maybe their posture might improve…’Hey dude, you’re asymmetrical and your sagging….lets see what ya got…. sometimes works… ahem…