Articles

Implications of Thoracic Stiffness and Prolonged Slumping and Slouching

Leg Length Discrepancy (LLD) and Pilates

“I've only just discovered that I've got one leg longer than the other.....”

It really is worth knowing that the vast majority of leg length discrepancies are apparent rather than actual: one leg appears longer through muscle tightness and joint misalignment rather than actual bone length variation. As few as 1:1000 LLDs is as a result of bone length discrepancy. This means the Pilates Method of Exercise and a good Pilates teacher have an important role to play in countering any musculoskeletal problems that may occur as a result of this asymmetry.

If you believe, or have been advised by your medical practitioner, that you have a leg length discrepancy, take the time to read through the following review summary – partly to be assured that there are many things that can be done to minimise any impact.

Take a look through the section on possible musculoskeletal disorders associated with LLD and be assured that Pilates Exercise can help to prevent onset or alleviate symptoms of many in the list.

Although the review summary is written for colleague Pilates teachers, I have minimised or softened the use of medical terms to aid lay-understanding.

I hope you find it useful!

Mark Thistlewood

Leg Length Discrepancy (LLD)

A Non-Medical Summary by Mark Thistlewood BCPA of a Review Article by Burke Gurney P.T., Ph.D (2001) published in Gait and Posture 15 (2002)

For the full review follow:

http://www.thiagovilelalemos.com.br/downloads/musculo/Discrepancia%20de%20Membros.pdf

Gurney reviews a large number of recent studies of LLD:

Limb (or here, Leg) Length Discrepancy (LLD) also known as Anisomelia.

2 types of LLD:

Structural LLD (SLLD) – shortened bony structures. As few as 1 per 1000 population.
Functional LLD (FLLD) – caused by altered mechanics of the lower limb – muscle and joint tightness. 40 – 70% of population can experience this

SLLD Aetiology (cause):

Congenital dislocation of the hip (CDH)
Congenital hemiatrophy (one-sided wasting)
or ACQUIRED: tumour, infection, paralysis, hip operation complication etc.

FLLD Aetiology:

muscle / joint tightness in lower extremity or spine

It appears the body can better compensate and adapt to LLD acquired in infancy or early life than when onset comes later on.

Possible Bio-Mechanical Alterations in the Body as a Result of LLD:

pronation (longer leg side) / supination (shorter leg) of feet
hip abduction / adduction
lumbar scoliosis (side bend of the lower back)
knee hyper-extension
changes in standing balance
changes in gait
Pelvic tilt on frontal plane (hip hike)
Greater pressure through hip of long leg (LL)
Gait asymmetries (e.g. shorter stance phase on short leg, shorter stride, toe walking, increased knee flexion)
increased Ground Reaction Forces (GRF) through LL side
Less energy-efficient gait (VO2 measurement studies, disputed)

Measuring LLD:

Medical imaging – X-Ray, CT, MRI etc
Observation / Measurement – ASIS to Lateral Maleolus found to be more reliable.

Severity:

Many measurement scales have been put forward. One suggests:

0 – 30mm MILD
30 – 60mm – MODERATE
>60mm SEVERE

Treatments:

Non-surgical: shoe inserts
Surgical interruption of growth plates on lower leg (Epiphysiodesis) – can have many complications (a possibility with 20 – 50mm LLD)
Limb lengthening – traction cages (>40 – 50mm LLD)

There is much controversy about surgical treatment – when to treat (LLD severity), age of patient (young cope better than old at adapting) etc.

Warning for LLD Runners:

LLD bio-mechanical abnormalities magnified by up to 3 times running v walking
Though some studies show that LLD needs to be >19mm before running parameters are affected.

Possible Musculoskeletal Disorders Associated with LLD:

Lower back pain (LBP)
Lumbar scoliosis
pelvic / sacral misalignment
arthritis of spine
hip pain
osteoarthritis (OA)
lower limb stress fracture
Aseptic loosening of prosthetic hip
trochanteric bursitis
myofascial pain syndrome (MPS)

LBP:

LLD can lead to saggital pelvic obliquity (hip hike) causing a compensatory , non-progressive lumbar scoliosis.

Friberg reports possible:

lumbar convexity towards the short leg (SL)
wedging of lumbar intravertebral discs (IVDs) and axial rotation
possible wedging at L5
concavities of lumbar vertebral end plates which can lead to
traction bone spurs
osteophytes of vertebral bodies
possible early degeneration of IVD space
arthosis of facet joints (FJs)

Sacroiliac Malalignment:

Those LLD patients with a sacral tilt are more than 2 times likely to complain of LBP
asymmetric loading of SI ligaments can cause chronic strain
possible degeneration of SIJ

4 of 5 studies reported that 13 – 22% of LPB patients had LLD.
Incidences of radiating leg pain in short leg were significantly reduced with a shoe lift.

Hip Pain (HP):

Brunet studied 1493 runners: HP 2 times more likely in LLD subjects

greater pressure / GRF through LL hip joint
greater muscle activity in quads of LL (EMG tests)

Stress Fractures:

Higher incidence for LLD subjects. 2 times more likely for LLD runners (LL stress fracture in 73% v 27% SL)

Other Pathology:

Swezey reported trochanteric bursitis with >25mm LLD (disputed)
patellofemeral problems

Conclusions:

The range of studies draw no consistent conclusions – therefore, at present, any cause / effect relationships are not proven.

Better to treat on a case-by-case basis:

<20mm LLD often regarded as non-problematic, though a guide only
long-standing LLD generally more easily adapted to
young, inactive LLD subjects less likely to suffer complications
older, active, late onset LLD more likely to create musculoskeletal problems.

Implications of Thoracic Stiffness and Prolonged Slumping and Slouching

The thoracic spine or mid-back consists of 12 vertebrae with pairs of ribs attached. It is the spine's most stable area for good reason – to protect our vital organs – and therefore relatively immobile. However, limited movement in the thoracic spine can have significant bio-mechanical implications throughout the body.

Thoracic and Ribcage Structure and Movement.

The vertebrae of the thoracic spine are cleverly designed to limited extension (backward bending) with the spinous processes (the 'dinosaur' bones that we can sometimes see at the back of the spine) being very close together.

Movement in the thoracic spine can occur in all directions, but with the attachment of the ribs, is of small magnitude. Therefore each joint in the spinal column must contribute its bit!
We have:

7 'True' ribs (ribs 1 – 7 from the top attaching directly to the sternum (breastbone)
3 'False' ribs (ribs 8 – 10 attaching to costal cartilage)
2 'Floating' ribs (ribs 11 – 12 with no sternal attachment) * A general guide as there can be some variation amongst individuals.

Flexion and extension are more limited in the upper thoracic; rotation and lateral flexion (side bend) more limited in the lower thoracic.

Movement limitations increase with age as ligaments and joint capsules stiffen but an important aim of Pilates exercise is to maintain optimal levels of movement in all planes throughout our lives!

Prolonged Slumping and Slouching

This can cause an increased convexity of the thoracic spine (hyper-kyphosis) which can have the following bio-mechanical implications:

with an increased 'hunch back' the neck (cervical spine) may have to extend, causing disc stress throughout the neck and joint stress at the base of the neck – headaches and neck pain.
A permanent lengthening of ligaments and muscles in the spine – a vicious cycle where the supporting structures become increasingly less able to do their job.
Upper limb (shoulder and arm) bio-mechanical alterations – the scapulae (shoulder blades) can become pulled around the back of the ribcage (protracted and rotated) which can cause scapula-humeral impingement (a squeezing of the all-important space between the ball of the arm bone and the ridge of the shoulder blade (the acromion process (the sub-acromial space)) leading to possible inflammation of muscles and tendons that occupy this space. This can result in shoulder movement impairment, injury and pathology (frozen shoulder, supraspinatus impingement etc.)
Altered movement and position of vertebrae throughout the spine – the lumbar (low back) may have to alter its shape as a consequence of the hyper-kyphosis above, becoming less able to shock absorb and more prone to lower back pain (LBP)
Inhibited respiration as a result of poor posture.

Pilate offers a wealth of exercises that promote optimal movement throughout the spine. With patience and practice, a rounded mid-back can gradually improve and then you may well find - no more headaches, neck pain, shoulder limitations and discomfort!

Inguinal Hernia

(information supplied by: http://www.intelihealth.com)

What Is It?

When part of an organ protrudes through an abnormal opening or in an abnormal way, this is called a hernia. A groin (inguinal) hernia occurs when part of the intestine bulges through a weak spot in the abdominal wall at the inguinal canal. The inguinal canal is a passageway through the abdominal wall near the groin. Inguinal hernias are up to 10 times more common in men than in women. About one in four men develop a hernia at some point in life.
There are two types of inguinal hernias:

Indirect inguinal hernia. This occurs when the internal opening of the inguinal canal, which usually closes around the time of birth, remains open. This allows a portion of the intestine to slip through the inguinal canal. These hernias often are diagnosed within the first year of life, but may not show up until adulthood. This condition affects between 1% and 5% of normal newborns and up to 10% of premature infants.
Direct inguinal hernia. This occurs when a portion of the intestine protrudes through a weakness in the abdominal muscles along the wall of the inguinal canal. These are common in adults, but rarely occur in children.

In adults, direct and indirect inguinal hernias look and feel about the same. They can occur on one or both sides of the groin. Your doctor may not know which type of hernia you have until surgery is performed. However, both types of hernias are treated in a similar manner.

A type of hernia called a femoral hernia can appear similar to an inguinal hernia. Femoral hernias are much more common in women than in men. They may cause a lump that appears just below the groin and extends into the upper portion of the thigh. In a femoral hernia, a portion of the intestine protrudes through the passage that is normally used by large blood vessels (the femoral artery and vein) when they pass between the abdomen and the leg. Femoral hernias are most common in older, overweight women.

Symptoms

At first, an inguinal hernia either may not cause any symptoms or may cause only a feeling of heaviness or pressure in the groin. Symptoms are most likely to appear after standing for long periods, or when you engage in activities that increase pressure inside the abdomen, such as heavy lifting, persistent coughing or straining while urinating or moving the bowels.
As the hernia grows, it eventually causes an abnormal bulge under the skin near the groin. This bulge may become increasingly more uncomfortable or tender to the touch. As the hernia increases in size, a portion of herniated intestine may become trapped and unable to slide back into the abdomen. If this happens, there is a danger that the trapped intestine may twist and die because its blood supply is cut off. This causes severe pain and requires immediate treatment.

Diagnosis

Your doctor will review your symptoms and medical history. He or she will ask you when you first noticed the lump in your groin, whether it has become larger, and whether it hurts.

Doctors can diagnose most inguinal hernias by examining the area. Your doctor will look for an abnormal protrusion near your groin and will feel the area to check for a mass. Often, the protruding hernia can be pushed back temporarily into the abdomen with careful pressure. Your doctor may ask you to cough or strain, which may make the hernia easier to feel or see.

In some cases, your doctor may need to confirm the diagnosis with an ultrasound orcomputed tomography (CT) scan. In these procedures, painless sound waves or X-rays can distinguish a hernia from other causes of a mass in the groin area, such as an enlarged lymph node (swollen gland).

Expected Duration

An inguinal hernia will not heal on its own. It is likely to become larger and cause increased discomfort until it is repaired. Hernias that are not repaired can cause bowel obstruction or strangulation, which is when part of the intestine dies because its blood supply is cut off.

Prevention

Indirect hernias in children cannot be prevented. To reduce the risk of inguinal hernia as an adult, you can:

Maintain a normal body weight.
Exercise regularly to strengthen abdominal muscles.
Avoid straining while defecating or urinating.
Avoid lifting heavy objects.

Treatment

Not all hernias need to be treated. However, most hernias that cause symptoms or that become larger should be repaired by a surgeon. While awaiting surgery, some people wear a device called a truss, which puts pressure on the hernia and keeps it under control. In people who are poor candidates for surgery because of poor health or advanced age, a truss may be used permanently.

There are two basic types of hernia repair: open surgery or laparoscopic surgery. Both usually are done on an outpatient basis and take about one hour to complete.

Open surgery. Most inguinal hernias are repaired by open surgery with the patient under general or local anesthesia. After the surgeon makes an incision in the groin, he or she pushes the herniated tissue back into place and repairs the hernia opening with stitches. In many cases, a small piece of synthetic mesh material is used to reinforce the area to prevent another hernia.
Laparoscopic surgery. In laparoscopic hernia repair, a surgeon makes three small incisions in the abdominal wall and then inflates the abdomen with a harmless gas. The surgeon then inserts a laparoscope through the incisions. A laparoscope is a tubelike instrument with a small video camera and surgical instruments. While viewing the internal scene on a monitor, the surgeon pushes the herniated intestine back into place and repairs the hernia opening with surgical staples. Although this surgery seems attractive to many people, the long-term success rate is lower compared to open surgery. Laparoscopic surgery often causes less discomfort, and lets the person return to activities more quickly. If you are interested in laparoscopic surgery, discuss the advantages and disadvantages with your doctor.

When To Call a Professional

Contact your doctor if you develop a lump, tenderness or a persistent feeling of heaviness in your groin area. In babies and young children, call your doctor promptly if you notice a lump in the child's groin or scrotum.

Prognosis

Hernia surgery is very safe and usually quite effective. Depending on the location and size of the hernia and what technique is used, up to 10% of hernias may develop again at some point in the future.
After open surgery, the person can usually resume normal activities within one to two weeks. For laparoscopic surgery, full recovery generally takes one week or less. After any hernia surgery, the person should avoid heavy lifting for six to eight weeks (or as long as the doctor directs) to allow muscle and tissues to heal completely.