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ADMIN NOTE: The messages below have been split off from the thread on Foot pronation and knee pain

That's the best way to do it.

Bruce, do you notice if AJE is always on the functionally short side?-The leg with a shorter stance phase.



When I say functional shortage, I mean the side that functions short (shorter stance time). The measurement of umbilicus to MM doesn't do much for me either.


Your opinion is based on what you see. To get permanent changes it takes a lot of effort. If A causes B which causes C which causes D...etc., to correct the condition so it doesn't revert back, then you have to go back way back. I am getting better at this.
For instance, let's say you have a low ASIS with equinus (this is the one that you put in neutral and the pelvis levels out). If you were just to manipulate the lateral cuneiform you would get correction that would last a short time. (In your case, you would manipulate the mortise to correct the equinus, and then support the foot-do you find you get long lasting results in this case?) If you were to perform soft tissue work on the ligaments and fascia that support the joint, then you would get a longer lasting effect. But that is only 2 steps back. So this is where the AK comes in. You want to find what is effecting the tone of the soft tissues that allow the joint to "sublux". Using AK techniques, you can challenge the soft tissue and using the neurologic protocol you can find where in the body the problem is. Let's say it takes you to the cervical area. Most chiropractors would jump to manipulate the appropriate cervical level, but at this point you can look deeper. I check the muscle strength of the SCM and the scalenes, as these muscle seem to be key. If one of these muscle is affected, then you can go back to the neurologic protocol, and find out what is causing this. Let's say the protocol takes you to the skull. Now you check out the skull and find it is a UICF, a lambdoidal suture, a sagital suture on the left side of the skull. You can go deeper, and say what is common to all this, and you will see the Superficial back line covers all this. So you challenge it to see if this is where the therapy is required. To double check you see if the challenge of the SBL weakens a previously intact muscle. This type of pattern is not that uncommon. You can also see why several chiropractors will fall short of the cause. In this scenario, this goes back 6 steps. Lateral cuneiform, ligament/fascia, cervical, scalene, cranium, supericial back line. Following this, I seem to get more long lasting results.


In the theoretical case I gave, your orthoses will push the cuneiform back in. In time the fascia tightens up, and the patient is able to go for a certain time withour orthoses. In time, without the orthoses, the patient will revert back, which is probably good enough to make the patient happy. Makes a lot of sense.

Regards,

Stanley

Stanley;

Answered in order:
Usually the AJE is on the shorter side. That does not rule out AJE due to MTJ collapse on the long limb side as well. I will also usually see more inhibited Peroneals on the shorter limb side.

Functional shortness due to shorter stance time works for me. I see that in-shoe.

Finally I almost completely agree with the last statement. Depending on the extent of the patients dysfunction before orthosis therapy and gait analysis, after we get the prescription correct they can go for brief periods of time w/o their devices. The more focused the problem, ie plantar fasciosis / fascitis or state 1 PTTD, the more time they can go without. Some even claim complete resolution, but I'd say less than 10% if that. The more difficult patients tend to become "orthotic junkies" ie they cant function for more than a few minutes w/o their devices or they will get pain back immediately.


Bruce

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Bruce E. Williams, D.P.M.
Breakthrough Podiatry

Bruce,

Now that we have some definitions in place, when you say AJE is on the shorter side, does this mean the side with 1. the shorter stance phase, 2. the lower ASIS, or 3. the lower PSIS.

The reason I ask, is that they are not always the same.

Also if it is not the side with the shorter stance phase (which is the side that is functioning short), what is your correlation of the side functioning short and AJE?

Regards,

Stanley

Stanley;
I usually see more AJE on 1) the shorter stance phase side, 2) the lower ASIS side, 3) the lower PSIS side, 4) the side with the more stable MTJ in most instances

I don't understand your last question.
Bruce

__________________
Bruce E. Williams, D.P.M.
Breakthrough Podiatry

Bruce,

Since the shorter stance phase side, the lower ASIS side, and the lower PSIS side do not occur together all the time(except with a lateral cuneiform problem); which of these above three do you find to have the highest correlation with AJE?

Regards,

Stanley

Stanley;

I honestly have not really looked at it that closesly. When I do my manipulations, I do the AJ, the STJ and the lateral Cuneiform successfully.

I also do not regularly check the PSIS, but the ASIS and shoulder height and foot position.

Do you feel there is no Lateral cuneiform problem on the long sided limb? If not, what is going on over there and how is it different from the short side?

Bruce

__________________
Bruce E. Williams, D.P.M.
Breakthrough Podiatry

Bruce,

I find that a “dropped” lateral cuneiform will cause weakness of the posterior tibial muscle on that side. Remember the posterior tibial inserts plantarly on all the cuneiforms. If there is a subluxation and additional tension of a tendon will result in additional subluxation, then that muscle gets inhibited. In the case of the lateral cuneiform, the posterior tibial gets inhibited with subsequent pronation. I also find that this results in an equinus and an anterior ilium (Supinate both feet and the ASIS becomes level). Correct the lateral cuneiform and you correct the anterior ilium and the equinus.
I see pathology mostly on this functionally short side. I do see pathology on the long side, which gets better with correcting the cuneiform on the opposite leg and orthoses. I am not sure of the specifics, so I will look for it and let you know.
Here’s my question to you. Do you ever see an equinus on the side with the high ASIS? If so, what side is functionally longer, and what do you do for it?

Regards,

Stanley

Stanlye;
I actually see things differently from you. In the patient with the short limb, AJE and displaced lateral cuneiform I will usually see weakness in the Peroneus Longus and not the PT.

I think that the displacement of the cuneiform keeps the lateral and medial columns from acquiring their positional stability in late midstance that helps both the PT and PL to function correctly.

I find more PT weakness with lateral Cuneiform displacement on the long limb side.

What I would like to understand is why the short limb side w/ lateral cun displacement still tends to maintain integrity at the MTJ more so than the long limb side which tends to lose the structural integrity of the MTJ. thoughts?
Bruce

__________________
Bruce E. Williams, D.P.M.
Breakthrough Podiatry

Bruce,
Thanks for making me expound on what I said. You’re right in what you see. When I talked about the weak posterior tibial, I meant weight bearing. I know the mechanism of lateral cuneiform and its effect on the posterior tibial (for that matter any of the insertions of the posterior tibial), that I use that muscle to test. If the Posterior tibial is weak, I can just press up on the lateral cuneiform to see if it strengthens, but I usually skip this and just go to the AK neurologic protocol. If the posterior tibial is not weak in the clear(which I do find more commonly) then I press the lateral cuneiform plantarly and if this is related, the posterior tibial gets weak. I do see the Peroneus Longus weak, but I only use this to check to see if my correction(s) get(s) this muscle also (by retesting after the corrections).
Bruce, so try this next time you see a patient with the Short leg, AJE, lateral cuneiform. 1. Press up on the lateral cuneiform and retest the peroneus longus strength. 2. Have the patient turn their head to the left, and retest the peroneus longus strength. 3. Have the patient turn their head to the right, and retest the peroneus longus strength. 4. Snap your fingers close the the left ear and retest the peroneus longus strength and 5. Snap your fingers close the the right ear and retest the peroneus longus strength. (2-5 is a good part of the AK neurologic protocol)



Could be, I’ll look for it.

Short sides tend to pronate less than the long side at the early part of stance. What do you think?

Regards,

Stanley

I agree, and have the in-shoe data to support it. It is all about timing and limitation of joint ROM's.

Bruce

__________________
Bruce E. Williams, D.P.M.
Breakthrough Podiatry

Hello there, interesting discussion. I am only about to finish my degree and I was wondering if you could explain further about the importance of the lateral cuneiform displacement and how to assess for it.

Regards,
Dean

Dean,

The ways to assess this is either by palpation of the joint range of motion, plantar palpation, or by muscle testing.

Regards,

Stanley

Dean,

The ways to assess this is either by palpation of the joint range of motion, plantar palpation, or by muscle testing.

Regards,

Stanley

So similar to having a subluxed cuboid? And the importance of the displaced lateral cuneiform clinically and biomechanically? This leads to tibialis posterior impairment?
I hope my questions are not too simple.

Dean

Dean,

Your question is not too simple. In fact as a student, you show great understanding to even ask the question. But since you asked here is the answer.

Structurally I find the following with a displaced lateral cuneiform: equinus on the ipsilateral side, and a lower ASIS which levels when putting both feet in neutral position.

The multitude of possible problems is listed below. This does not mean that they will get any of these problems, but they will improve when you treat the imbalance with orthoses, or mobilize the lateral cuneiform and treat the remaining imbalances. It is easier to diagnose a problem and think of the biomechanical cause, than to remember what follows.

An interesting clinical gem to this is the patient that has pain in the back when he walks. This is the patient that typically will respond to orthoses. It is also the patient that has seen a chiropractor for the last months to years with no long term effect. The pain is related to an anterior innominate (the side with the low ASIS) or a functionally short leg secondary to pronation. Pain related to a short leg in the back is lumbar pain on that side or a posterior innominate on the opposite side (pain just medial to the PSIS at the SI joint, groin, or lateral leg). An anterior innominate will cause pain at the insertion of the Rectus femoris.
At the hip level, the patient is prone to trochanteric bursitis on the functionally low side. At the knee level, the patient is prone to IT band syndrome, and/or chondromalacia (excuse the old term, I still like it. It describes the knee that has pain at the distal medial patella +/- proximal lateral patella). The contra lateral side is prone to chondromalacia.

In the lower extremity, there will be symptoms related to equinus on the side with it (Achilles tendonitis and central plantar faciitis), and in long standing cases pronation related pathology (medial plantar fasciitis). The weak peroneals will make a patient prone to ankle sprains. The short functioning leg with equinus will make a patient more prone to Morton’s neuroma (but also check for a displaced 4th metatarsal cuboid joint. This is the patient that will show some supination pathology with pronation pathology.

The opposite side is prone to medial plantar fasciitis.

This is what I see.

I am sure I left out something, so Bruce, if you want to jump in, please do.


Regards,

Stanley

Leg Length Related threads:
Limb length discrepency
Treatment of a functional limb length discrepancy
Leg Length differences
Hip replacement causing leg length difference
Shoe inserts for LLD and chronic low back pain
Leg Length Differences and Quality of Life
Measuring LLD
Functional propulsive phase limb length discrepancy
Hip replacement causing leg length difference
Achilles tendonitis and LLD

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Thankyou for your informed reply Stanley. Just have some other queries.

You state on the functionally shorter side this is where the displaced lateral cuneiform is mostly found. Is there a reason for this? Is it due to the tibialis posterior insertion? And is this due to the foot being more pronated than the contralateral side?

Is it normally the pronated foot, either due to equinus, functional hallux limitus, tib post dysfunction etc which cause the functional leg length difference and the anterior innominate pathology, with the low ASIS? Or is it the other way around with the lower ASIS and anterior innominate causing the functional LLD and resultant mechanical problems in the foot? A bit of the case, 'which came first, the chicken or the egg?'

Regards,
Dean

Dean,

I was first alerted to this area of the foot by Kevin Miller. I promised him I wouldn't tell the results of his research. He did say that things would be OK to discuss it around now. I will do my best to work around what I can't say.
The displaced cuneiform results in a low ASIS with equinus. I used to look primarily at the PSIS and think that we had to treat the sacroiliac joint as podiatrists. 20 years later, I feel that if we level the ASIS, eliminate equinus, and then check the foot (lateral talus, posterior calcaneus, 3rd met-cuneiform joint [and a bunch of other things that have specific pathology]) then we do what we need to do for the foot. If at this point there is a primary iliosacral lesion, then the patient will have back problems.
Dean you will be a leader in the profession one day, because you ask the right question which is "why?"
This is something that I came across:
http://www.anatomytrains.com/uploads...e_manner.p df
Then you ask yourself what controls the fascia? and you have to answer the same thing that controls all muscles- the nervous system. The next question is what is messed up in the nervous system, how can we find it, and how can we treat it? The answer to this is why I do AK.
I don't mean to brush off the answer, but it took over 300 hours of seminars to learn this, and I don't know if I can summarize it quickly. Therefore, it might be best to manipulate the joint and make an orthosis for now.

Regards,

Stanley

That article is actually quite an interesting read. Sheds a different light on how you possibly look at the lumbar fascia during gait and of course the plantar fascia.

One last question. You say you used to look predominantly at the PSIS but now you look at the ASIS and touch on the importance of leveling this structure. How does this differ from the PSIS, I would suspect the ASIS and PSIS move as one structure as they are both apart of the illium? (I dare say there is a little bit for me to learn in this area and the relationship between the lower extremity and the sacroilliac joint). That question may be a little broad.

Thankyou for you swift replies and insights Stanley, much appreciated. Will have to pick your brain again soon. I must stop getting side tracked and start looking at more relevant material for my final clinical exam tomorrow, which I should be studying for!

Regards,
Dean

Hi Dean,

I am sure you did well on your clinical exam.

Regarding, the pelvis, there are two halves, and they can move independently. The way to determine this is to check the ASIS and the PSIS.
Try to visualize this: The PSIS is in the back and the ASIS is in the front, so that if one hemi pelvis (let’s say the left for this example) rotates anteriorly (anterior innominate), the anterior part goes down and the posterior part goes up. So the left ASIS is now rotated down and backwards so that the ASIS and PSIS are more directly under each other making it functionally longer. The sacrum will now be higher on the left side. It will also be rotated on the transverse plane with the left side anterior to the right. This asymmetry in the pelvis can be caused by muscle imbalances around the pelvis, or as a compensation for a leg length, or by pronation.
To check the effect of the foot on the pelvis, put the foot in neutral and see if there is a change. The foot can cause an anterior innominate. This is the type of patient that has been to the chiropractor and only has short term relief. If the foot is a causative factor, then it should be corrected with orthoses. When I used to make Schuster style devices, I would change the subtalar joint position, and I was able to correct an anterior innominate, which was related to pronation. Currently, I find that the anterior innominate can be caused by subluxed lateral cuneiform. When this occurs, there will be an anterior innominate, and also an equinus will develop on that side. So all I have to do is look at the anterior innominate and the ankle dorsiflexion to make this diagnosis. This works out better, as I used to use forefoot posts which can cause problems at the first MPJ.

There are other conformations, and as you go through the clinics and see them, I’ll give you my experience on them. Just measure dorsiflexion and tell me which ASIS is low.

Regards,

Stanley

It went very well thanks!

Understood. So you then compare PSISs on both sides. The one with the functionally longer leg will be higher.? Similarily you could check for ASIS position and would see the ASIS lower on the functionally longer leg?
I always find it difficult to find the ASISs on the, how do I say, endomorphic body type? Is it easier to assess for the PSISs and do you simply visualise the hip, or palpate?

Could you just quickly explain this term, I don't fully understand this term.

Sorry for all the questions.

Kindest regards,
Dean

Hi Dean

I don’t like the term functionally long leg, as this may confuse you. One of the first things you need to do is to watch the patient walk. Look at his head, the PSIS and the ASIS. The pelvis drops when the patient is on the opposite leg at midstance. Look for the amount of drop, and compare it with the other side. You expect to see the PSIS drop on the short side more than the long side. Now see what the head is doing. If the head elevates when the hip is dropping, then you have a shortage due to an imbalance in the upper body (scoliosis). If you put a lift on the side where the hip drops, you will have some major problems. I did this once on a runner, and he developed a tibial stress fracture shortly thereafter.
This being said, the side with the low PSIS usually functions as a short leg.


The PSIS is much more difficult to assess. One way to make it easier when you first start out is to look at the spine, and see how it is lining up with the pelvis. It should be perpendicular.


An anterior innominate is when the innominate bone is rotated anteriorly, so the ASIS is lower and the PSIS is higher.

Regards,

Stanley