By Dr. Michael Cerami, DC

LLD or Leg Length Discrepancy leads to hip rotation and causes pain. How can you possibly move around with such a significant global imbalance and not have a problem? It is quite common, and I usually see an imbalance of anywhere from ½” to 1 ½” of discrepancy between the left and right leg on most new patients. In most cases it takes less than 6 visits to straighten the pelvis and legs out, see accompanying before and after photos) but sometimes the correction process takes a bit longer as in the case below.

During an initial examination, I check pelvic alignment front/back and side to side as well as foot position and knee alignment. I also will test the lower extremity muscle group to determine whether each muscle is firing.  These tests along with other functional movement screenings will paint a picture of where the source of the problem is located and that’s where we’ll go to work; unwinding the “focal loading” points of the body to create sustainable change.

The reason I mention this process is to describe how we assess and correct hip rotation. To the untrained eye/person/therapist/physician, it would seem much easier to just put a lift or shim in the shoe and level things out. The problem is that most times, this will not adequately correct the imbalance. In my 36 years of practice, I have prescribed a heel lift on less than 30 patients when I couldn’t correct the imbalance using chiropractic adjustments and muscle work. The imbalance in these cases were confirmed through x-ray imaging.

It’s difficult if not hard to tell if you have LLD; here’s how to check:  Look at your leg length while lying on your back. Lay on a flat surface with your shoes off and have a friend lift both of your feet off the floor (holding the back of the heel bone behind and under your ankles) about 18”.  Keeping the inner ankles together and the legs parallel and in alignment with the spine, see if the ankles touch each other or become misaligned. A misalignment at the ankles will usually indicate hip rotation. Under a ¼” difference is probably OK but anything more is significant and indicates imbalance. Pain is not a good gauge for this test as I’ve seen many patients whose ankles more than a 2” difference and were not experiencing any symptoms.

Challenging case report: This patient is a bike rider that had labrum (hip) surgery which caused a severe imbalance in his hip alignment and leg length. When this patient went for his bike fit, the only way the fitter could make him balanced was to provide an extreme amount of shimming to the bottom of his bike shoe (photo). This helped but caused other problems and the patient could not ride comfortably for any extended distance.

When I started making corrections on this patient, we would get a ¼ to ½” change each visit but some of the imbalance would return before the next session so we provided exercises he could perform at home to speed things up. The progress was slow but measurable and eventually got 90% of the rotation removed by summer’s end and the patient celebrated by riding his fastest ever Snowbird Hillclimb race and finished in the top 10 of his classification.

I think there are a few important take home points here for athletes and patients:

• Hip rotation and resulting muscle imbalances cause bio-mechanical distortions that affect the hip knee and feet.
• It you have lift in your shoe or a lot of shims in your bike shoe consider finding out if the “upstream’ cause is your hips.
• Once the problem is resolved, exercises can help maintain the correction.
• Get your hip rotation fixed BEFORE you get fit for that expensive or new bicycle.

This week from Dr. Cerami and Utah Sports and Wellness

From: Journal of Manipulative and Physiological Therapeutics, November/December 2010

Quick Summary:

With about 70% to 85% of Americans experiencing back pain at some point in their lives, chances are there will come a time when you will be looking for treatment options. This study was done to determine if there are differences in the cost of low back pain treatment courses between medical doctors vs doctors of chiropractic. The authors found “statistically significant lower costs in episodes of care initiated with a DC as compared to an MD.” While also showing that 61% of chiropractic patients reported their care as being “very helpful” with only 27% of medical patients reporting the same.

Abstract:

The primary aim of this study was to determine if there are differences in the cost of low back pain care when a patient is able to choose a course of treatment with a medical doctor (MD) versus a doctor of chiropractic (DC), given that his/her insurance provides equal access to both provider types. A retrospective claims analysis was performed on Blue Cross Blue Shield of Tennessee’s intermediate and large group fully insured population between October 1, 2004 and September 30, 2006. The insured study population had open access to MDs and DCs through self-referral without any limit to the number of visits or differences in co-pays to these 2 provider types. Our analysis was based on episodes of care for low back pain. An episode was defined as all reimbursed care delivered between the first and the last encounter with a health care provider for low back pain. A 60 day window without an encounter was treated as a new episode. We compared paid claims and risk adjusted costs between episodes of care initiated with an MD with those initiated with a DC. Paid costs for episodes of care initiated with a DC were almost 40% less than episodes initiated with an MD. Even after risk adjusting each patient’s costs, we found that episodes of care initiated with a DC were 20% less expensive than episodes initiated with an MD. Beneficiaries in our sampling frame had lower overall episode costs for treatment of low back pain if they initiated care with a DC, when compared to those who initiated care with an MD.

These authors also note:

• “About a quarter of the adult population reports LBP in any 3-month period.”
• Back problems are one of the top 10 most costly conditions treated in the US. 61% of chiropractic patients report their care as being very helpful
• Only 27% medical care patients report their care as being very helpful
• “Care initiated with a DC is still significantly, and sizably, less for patients seeking care for the 6 International Classification of Diseases, Ninth Edition, low back-related disorders investigated in this study.”
• These authors calculated that in the assessed local insurance, using chiropractors v. medical doctors could save “more than $2.3 million per year.”
• “Our results support a growing body of evidence that chiropractic treatment of low back pain is less expensive than traditional medical care.”
• “We found that episode cost of care for LBP initiated with a DC is less expensive than care initiated through an MD.”
• “Paid costs for episodes of care initiated with a DC were almost 40% less than episodes initiated with an MD.”
• “Our results suggest that insurance companies that restrict access to chiropractic care for LBP may, inadvertently, be paying more for care than they would if they removed these restrictions.”
• “Paid costs for episodes of care initiated with a DC were almost 40% less than episodes initiated with an MD.”
• “Beneficiaries in our sampling frame had lower overall episode costs for treatment of low back pain if they initiated care with a DC, when compared to those who initiated care with an MD.”

By: Dr. Michael Cerami, D.C.

Injuries can be a real problem for the beginner or advanced runner. Because there are many causes of injuries, you can save yourself some time and money if, before you self-treat, you accurately assess what you are experiencing.

The athlete should first observe the problem with a few things in mind. When did the symptom begin? Did the pain come on suddenly or gradual? How long does/did it last? Have you had it before? Is the pain in the same location? I find that if patients will focus on 3 things; Frequency, Intensity and Duration (FID) it will really help them determine if they are getting better or worse as they work their way through possible solutions. I strongly suggest people write these things down or log them in their phone. It’s too easy to forget or misinterpret problems 3 days after the situation began. Tracking the changes will help your thinking brain create an anchor for your emotional brain so you can make effective choices on whether to continue running, try something new or validate your improvement. Too often we humans go to one extreme or the other; “It stills hurts!” or “I’m all fixed!” We tend to think in absolutes not percentages of change. As difficult as it may be, try and rate the changes from day to day and see what direction you’re headed in.

Think positive but be realistic. If you start experiencing pain less than 4 weeks before your big race you have some options:

1. Take a few days off and see if the problem resolves itself.
2. Continue to run and hope you don’t injure yourself further. (My feeling is that if you are willing to take responsibility for the outcome, experiment if necessary). This approach is a little easier to employ if you don’t have any races after this event, so you can recover fully.
3. Self-treat with Epsom Salt soaks, ice, magnesium spray, StrengthTape, Trigger Point therapy.
4. Seek professional help from a sports medicine therapist or doctor.

I suggest you make your decisions based on the feeling you want AFTER the event is over. If you can’t get over being disappointed if you don’t run, then maybe run but don’t hold yourself to a specific outcome, just focus on completion. I did this a few years ago at the Salt Lake ½ Marathon. I missed most of my training but didn’t want to “bag” the race because emotionally and mentally I really wanted to set a new direction for the year. So, I decided to run it and not worry about my time and just tough it out. Even though I hurt like crazy afterward, I felt great inside. Another idea: Make a commitment to a new race so you can keep your fitness base.

The dialogue that we have with ourselves in these moments becomes a fine art of internal negotiation where we can learn a lot about what we’re made of. Life is never linear even though we so want it to be. As an athlete you can enjoy the ride more if you spend some time looking out the window and taking a few notes during your journey.