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Is leg length discrepancy really causing your back or hip pain?

Downers Grove Chiropractor Talks Leg Length

Traditional biomechanical view of the human body

As long as Downers Grove chiropractors, bone setters, massage therapists, physios, and other forms of manual therapists who deal with the musculoskeletal system have been around they have often found structural issues to be a root cause of a patients pain or injury.  These issues range from bones being out of place (the infamous subluxation), to muscles that are “turned off”, to a hyperdominant random muscle (that darn quadratus lumborum). 

This post is about a common “problem” that is often labeled as the reason humans suffer from problems ranging anywhere from low back pain, headaches, to pain in the big toe...leg length inequalities (LLI).

Without any context and a tunnel vision geared towards the biomechanical view of the body, LLI might sound like a logical reason you might be experiencing pain.  If one leg is longer than the other, it could throw your body off balance, cause you to walk in circles, putting more forces in one area eventually leading to pain.  It turns out this is an overly simplistic view of the body and completely disregards the human bodies ability to adapt, something which it has been doing for, you know, millions and millions of years.  

If we are going to have any long term success in treating pain in humans we must have a deeper understanding of what pain is.  I have written in a bit more detail HERE, but in short, the current best understanding of pain is viewed under the lens of the biopsychosocial model, which states there are many confounding factors that contribute to a human’s pain and blaming it on one source, be it a structural, social, or psychological issue is incredibly short-sighted.  Many factors contribute to the genesis of pain and only addressing one aspect of it does a disservice to our patients, especially when we are blaming something as nuanced as pain on something as ubiquitous as a leg length discrepancy.

LLIs can be divided into two separate categories, structural & functional, and it’s important to differentiate the two because one potentially matters and one likely doesn’t.

Structural LLIs are when there is a legitimate difference in length somewhere along the structure of the leg.  This can commonly be in bones such as the femur or tibia, the two bones which contribute to the majority of leg length.  This difference can happen from injuries, surgical alterations, birth anomalies, etc.  These differences in structural LLI tend to be the larger of the two categories and are more commonly clinically significant once they reach a certain difference, which tends to be around a 20mm difference in leg length, but in truth, this is a minority of cases.  

In comparison, functional LLI are inequalities due to postural compensations in the body.  These functional LLIs are commonly blamed on over-pronation of the foot, hip rotations, tight muscles or inhibited muscles, not enough qi, or not properly bracing your core 100% of the time during all activities.  Clinicians will tell you that once these issues are fixed, then your legs will be back to equal, your pain will disappear, and maybe even your performance will increase in whatever sporting activity you partake in.  I find myself saying this over and over again, if only it were that simple our jobs as clinicians would be much easier. 

If we are going to blame pain and injury on a structural factor, we need to observe it’s prevalence in asymptomatic populations, as in how common is said structural “abnormality” in people who have zero complaints.  As far as structural variations go, LLI is by far one of the most common in the human body.  Multiple studies have estimated that LLI are prevalent in ~90% of the human population with an average of 5.2mm difference in leg length and the right leg being the more common of the two.  When I was in grad school I was always amazed at the professors and clinicians who “predicted” a patient or a student had a LLI.  Turns out if you throw a stone in the ocean you are going to hit water.  Let’s think about that for a second, if LLI is a cause of low back, hip, knee, ankle, or foot pain like so many clinicians claim, 1) why doesn’t 90% of the worlds population live in chronic pain and 2) why doesn’t 90% of the population have injuries stemming from their LLI? 

The answer is because the vast majority of people have a LLI that is clinically insignificant, an average of around 5.2mm.  This discrepancy is likely an adaptation to the gravitational forces humans experience every single day and nothing more than that.  It doesn’t mean the someone is pronating too much.  It doesn’t mean people’s hips are off balance and needed to be fixed.  It’s not from a tight QL yanking up the pelvis.  It’s definitely no reason to sign up for 3 visits a week for 12 weeks to avoid future arthritis and joint degeneration (which is going to happen anyway).  In the vast majority of cases blaming pain on LLI is a made up problem that doesn’t exist and is a way to convince patients who don’t know any better they need x or y treatment to be fixed.  

As for those of you who have been told you have a LLI (which you probably do and it probably doesn’t mean much), had an adjustment and BOOM you feel better there are a few answers that could explain your reduction in symptoms.  The first and foremost is the hallowed placebo effect, something which has been playing a role in the reduction of symptoms since the beginning of time.  If someone is given a problem and the problem is perceived to be fixed, symptom reduction is likely to happen.  Consider the scenario when we fell and bumped our knee as a child.  Mommy comes and kisses the boo-boo and the knee feels better.  Does mommy’s kiss have magical healing powers that restored the tissue and healed the injury? No.  That is a prime example of the placebo effect working at its finest. 

Translate to the scenario when a patient is told their legs are different lengths and the only cure to their problem is a form of manual therapy to restore balance. Patients may feel better after treatment, but how are we sure that it is that specific treatment itself that causes the reduction in symptoms? This brings up the idea of the post-hoc fallacy, which describes a scenario where event y follows event x, therefore x causes y.  Consider this, the mailman comes to your door every day.  Your coonhound also barks at the mailman when he approaches your door every day.  After the mailman drops off the mail he leaves and goes to the next home to drop off the mail.  Does he leave because the dog was barking at him or for another reason? 

In the context of treating a LLI, does the reduction in symptoms occur due to the specific clinical intervention, a regression to the mean, or the unknown?  Was it the “balancing of structures” or the “releasing of tissues” or was it the placebo effect?  If the initial “problem” was likely not even a concern to begin with (in the case of an average LLI), the unknown is by far the more likely answer.  

Now, this is not to say that ALL LLI are clinically insignificant, just the majority of cases.  As stated earlier, the estimated average LLI is 5.2mm with a standard deviation of 4.1, so at any given time a human could be walking around with a LLI of between 1 and 9mm.  This range likely does not matter and will also not be fixed over the long term.  But, the higher the number, the greater the chances that the inequality will pose a risk for injury and the genesis of pain.  Studies show that once the difference reaches near 20mm (around 3/4 of an inch) the difference becomes clinically significant.  In these cases, clinical interventions such as orthotics become relevant and could potentially be a solution to issues the patient is dealing with.  But until the difference becomes clinically significant, your LLI is likely normal and NOT the sole cause of your pain.  

If you are interested in further reading on this topic here are a few sources that can get you started

  1. Prevalence of LLI: Knutson GA. Anatomic and functional leg-length inequality: a review and recommendation for clinical decision-making. Part I, anatomic leg-length inequality: prevalence, magnitude, effects and clinical significance. Chiropr Osteopat. 2005;13:11. Published 2005 Jul 20. doi:10.1186/1746-1340-13-11
  2. Biopsychosocial approach to LBP: Kikuchi S. New concept for backache: biopsychosocial pain syndrome. Eur Spine J. 2008;17 Suppl 4(Suppl 4):421-7.
  3. Use of manual therapy as a treatment protocol: Bishop MD, Torres-Cueco R, Gay CW, Lluch-Girbés E, Beneciuk JM, Bialosky JE. What effect can manual therapy have on a patient’s pain experience?. Pain Manag. 2015;5(6):455-64.
  4. Cook C. Immediate effects from manual therapy: much ado about nothing?. J Man Manip Ther. 2011;19(1):3-4.

 

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The application of strength in endurance events and how to program strength-training into running programs

Dr. Andy Boyce – Your Downers Grove Chiropractor

Strength is often a misinterpreted quality when considering its relation to different sports. 

When people hear strength, they think of big and strong power lifters, strongmen, linebackers, or the jacked Crossfitters who seem to be good at everything that involves picking up a barbell. 

While it’s true that ALL of these sports do require significant amounts of strength, the function of strength is often overlooked when looking at endurance sports such as running and cycling. 

This to the detriment of many runners and cyclists performance. 

Let’s take a deeper look.

Definition of Strength

First, we need to look at what the actual definition of strength is before we go any further. 

Strength can be defined as the ability to apply force against an external load.  Going a little deeper, we can define force by Newton’s 2nd law, Force= Mass x Acceleration. 

Simple algebra tells us that in order to increase the amount of force generated, we need to do one of two things, increase the mass we are moving (adding more weight on the bar), or increase the rate of speed of the object we are moving, this can be a barbell or our bodies against gravity.

Utilizing Newtons 2nd law throughout training programs is a way to consistently generate high amounts of force without constantly being under a high load.

This can help moderate the amount of stress that is placed on the body, ensuring it is a beneficial type of stress (eustress) to stimulate an adaptation, and not a distress, which can lead to overtraining and injury. 

This is one of the basic principles of the conjugate style of training, something that will be covered in a different post. 

Physics aside, we need to go into further depth at the application of strength in the context of endurance events.  

Downers Grove Runners Pay Attention

Lets look at runners as our example. 

We can define endurance events as repeated submaximal contractions of a muscle over an extended period of time. 

In the case of running, this means all the muscles involved in the stride are generating submaximal amounts of force every single stride. 

So, over the course of a marathon the muscles responsible for moving the legs might be contracting at 20% of their maximal force output. 

The muscles will contract submaximally over the course of the race, increasing the force of contraction during surges or during the final kick of the race.

Improvements in strength don’t change the fact that endurance challenges are repeated submaximal contractions over an extended period of time, but it does make that 20% of maximal contraction more forceful each and every stride. 

This improvement in strength leads to improved speed, conservation of much needed energy, and an increase in mechanical efficiency. 

Improvements in strength also play a role in decreasing injury risk on two different levels. 

Firstly, stronger people are more hardy and resilient, it takes more for them to get hurt. 

Two important things to consider while programming strength training for runners is that it improves tendon strength and bone density, two things that are often hurt during the course of a running program in the case of runners knee and stress fractures. 

Adding strength training to a running program also helps decrease injury risk by decreasing the amount of total mileage runners have in their program, which is quite often the reason for pain, injuries, and stagnation.

Contemporary training plans tend to overemphasize specificity part of the the SAID principle, or the specific adaptation to imposed demands. 

This means the body will adapt in a way to best handle the stress that was imposed on it in the future. 

For example, if someone practices benching heavy weight, odds are they will improve in their ability to bench heavy weight. 

Likewise, if we practice piano, we would like see an increase in our ability to play the piano. 

Running programs tend to overemphasize the specificity part in that they have their athletes run far too much during programs, leaving no time for alternative training to improve other areas of weakness. 

Not only does the excessive miles commonly lead to overtraining, injury, and eventual stagnation, but it completely ignores the fact that getting stronger (to a point) is bound to help performance.  

Replacing the junk miles, or the days when runners just go for a run to meet their quota for the week, is a great place to substitute days where we lift weights.   

Downers Grove Runners – Let’s Talk About Junk Miles

Anyone who has trained for a race knows what the junk miles are. 

They are the miles that we plod through just because they were written into our plan we “need to get a run in”. 

These are some of the silliest miles people run, they don’t provide any real benefit and all they really do is add to the accumulated fatigue, increasing the risk for injury. 

A better idea would be to replace those days with strength training, providing a novel stimulus to the body, improving strength, reducing injury risk, and improving overall performance. 

Downers Grove 

Excellent exercises to add into programs would be those that do the best job at improving overall strength. 

Downers Grove Chiropractor Uses Strength Training for Runners

These would be the squat, and the deadlift. 

Proper application of these exercises into running programs do an excellent job of increasing strength in the muscles that are utilized during running, such as the glutes and hamstrings. 

Not forgetting the SAID principle, adding single leg work is also important to improve the bodies ability to perform on one leg. 

Running is a coordinated bound from single leg to single leg with a period of floating inbetween. 

If two feet are on the ground at one time, by definition it is not a run. 

This definition highlights the importance of single leg work, such as the lunging motion, box-step ups, single leg RDLs, etc. 

My personal favorite single leg exercise is Russian step-ups. 

The extra hip flexion at the top of the lift adds an extra challenge that makes the exercise that much more fun.  

downers grove chiropractor russian step up

Starting position for the Russian step-up

downers grove chiropractor finishing russian step up

Ending position of the Russian Step-up

Downers Grove Chiropractor Says “It’s all about Programing.”

Lastly, one common error coaches who do program lifting for their runners make is the amount of load they prescribe. 

Often, runners will perform these exercises in an unloaded fashion, or just against the force of gravity on their body. 

This can help athletes who have never performed these motions before, but the body will quickly adapt to this stimulus and its utility will eventually expire. 

Progressive increases in load, whether by weight or volume, is a tried and true way to improve upon strength, much more effectively than doing incredibly high reps of body weight squats and lunges. 

The gains in strength can be achieved in a quicker and much more efficient manner under a heavier load compared to body weight exercises until failure.

If you are a runner or an athlete who is looking to improve your performance in any race distance your Downers Grove Chiropractor is here to help. 

Click on the link above to schedule a free consultation. 

Core1 offers chiropractic care, physical therapy, and sports performance training.  

 

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The acute and chronic effects of stress and how they relate to your pain

Pain is most frequently the reason people visit their chiropractor.  

“Doc my back hurts.” 

“Doc when my shoulder moves like this it hurts.”

“I woke up and my neck was killing me!”

These are some of the complaints I have heard from my patients when they present to the clinic.  I have yet to have a patient walk in telling me they have strained their quadratus lumborum or transversospinalis which is the source of their low back pain.  I tend to see a lot of athletes, Crossfitters in particular, and the more common verbiage is “the morning after my WOD my back started speaking to me.” Or something along those lines.

If you’ve talked to me before you probably have heard the phrase “pain science” thrown around along with “pain is pretty dang tricky.”  That’s because pain is rarely as straightforward as the biomechanical model would have you think.  Let’s take the low back as an example.  There are literally dozens of structures located in and around the lumbar spine that are innervated by nociceptive, or pain sensing, fibers.  This means that they can all contribute to the experience we call pain.  Many clinicians will do a physical exam, testing this and that structure, and maybe even take some imaging then come back with the conclusion that one structure is the source of their back pain and if we fix that structure you will be pain-free.  According to the evidence, this is becoming harder and harder to say with absolute certainty.  

If only it were that straightforward.   Blaming pain on one single structure is like blaming the course of world history on one single event.  It MAY have played a part in the genesis of pain, but there is always a context and other confounding factors that contribute to the current state of.  If you follow the biopsychosocial approach to healthcare, this probably makes sense to you, but if not I wrote about it HERE.  In short, pain is something that is highly nebulous in nature and can be affected by biological (physiologic processes going on inside the body), psychological (how the person interprets and feels about their pain), and social factors (factors such as work and family stress).  These factors all play a role in the pain milieu and taking a microscopic view on one single factor could potentially be more harmful than helpful.  

These different factors can all be looked at as “stressors” to the body, which are very important when considering someone in pain.  Stress can be psychological, for example, when someone is waiting for the results of a blood test.  It can be social, like trying to meet a deadline at work.  This post will focus on the physical effects of stress, such as the stress of exercise and the benefits and potential risks it brings.  

First, we need to agree that exercise in and of itself is a stress, and that is not necessarily a bad thing.  Stress can divided into two different categories.  The good stress, eustress, is a stress that you can adapt to and you are better off for it.  Think of the stress a final exam brings.  If we are adequately prepared for the test we are equipped with the knowledge required to pass the test.  We have newfound knowledge to apply and are able to continue on in our education.  This is generally a good thing.  On the other hand, distress, or bad stress, is something we are not able to adapt to and can leave us worse off.  Think about a final that you are not prepared for, you didn’t go to class and you end up failing.  This means you have to pay for the class again and you aren’t able to continue on to the next class.  This is obviously not a good thing. 

Exercise can be viewed similarly.  In the right dose, exercise provides eustress that allows the body to adapt and become more robust and resilient.  For example, when someone who is trying to get stronger utilizes the principles of progressive overload the body is able to adapt to each successive increase in weight, becoming stronger after each stimulus.  If the increase in weight is too much, or excessive volume is performed, the body cannot complete the task and will not make the necessary adaptation to become stronger and more resilient, also running the risk of overtraining and injury.  

This concept is important for athletes to understand, and I look at runners and Crossfitters in particular, due to the vast amount of volume stress they put their bodies through any given day.  For those who have adapted to the high volume snatches or the 20 mile runs on the weekend it probably isn’t an issue, but for the majority of people who in the more novice category, this high amount of volume can be a huge contributor to your pain state.  

When we exercise we are breaking tissue down…that’s the goal.  We break tissue down in order to build it back up and become stronger than before.  In any given workout the goal is to accumulate enough stress to stimulate a response, but not so much to where we cannot recover.  With too much weight or too much volume, the eustress is bound to turn to distress which can eventually lead to the experience of pain. 

Think about the pain experienced after the first long run of a marathon program, or how bad your triceps may feel after doing a high amount of skull crushers for the first time in a while.  Hopefully, this is transient and you are able to recover in a relatively short time so you can train again.  If you do too much too soon, for example increasing your long run by a significant distance above the 10% increment rule or trying a 50lb PR in the deadlift you are putting yourself at risk of accumulating too much stress.

The effect of too much acute stress is highlighted, unfortunately, by what is deemed a crowning achievement of many gyms, rhabdomyolysis, which is a result of the breakdown of muscle tissue and the release of their contents into the bloodstream and can potentially lead to kidney failure.  A less serious scenario would be shin splints in runners who run too much, shoulder pain when one gets above 30 reps in the clean & jerk, or low back pain after too many deadlifts.  There is a good chance there are readers out there who have had complaints like this and there is also a very good chance that complaint is a result of too much stress and its associated fatigue rather than “imperfect form”.  The simple solution would be to pay attention to what point your pain starts to come on and tone the volume/weight back to a point where the pain isn’t present.

Chronic stress/fatigue is very similar but needs to be observed over a longer period as opposed to a single workout.  This can be viewed over the course of weeks to months.  With the accumulation of stress from any given workout, the body needs adequate time and supplies (nutrition) in order to recover enough to perform again.  If there is inadequate time or supplies, the stress and fatigue will accumulate over a program and can lead to the genesis of pain and a significant drop in performance.  Examples here can be people who tend to burn out several weeks into a training plan, someone whose worst running performance happened to be on race day, the development of an injury such as plantar fasciitis, runners knee, or shoulder impingement.  

An effective solution to both acute and chronic stress is working with someone who has knowledge and experience in programming and is adept at noticing the signs and symptoms of acute/chronic fatigue and stress.   They can help create a program to control the amounts of stress and fatigue to a desirable amount, avoiding overtraining.  

Core1Chiro, your Downers Grove chiropractor,  specializes in working with people who are dealing with aches and pains during training and can help design a program to improve fitness while decreasing pain and minimizing injury risk.  Click on the link to schedule a FREE CONSULT to get pain free and STRONG. 

 

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Exercise and Low Back Pain

Low back pain (LBP) is one of the most common complaints Americans face each year and is one of the most prevalent reasons people will go to healthcare providers such as their doctor, chiropractor, physical therapist, massage therapist, or others in the allied health community. 

Being one of the most frequent complaints, LBP has a significant economic burden on our community at large and contributes a to large portion of our medical GDP. 

Estimates have been made that the cost is north of $100 billion annually when considering cost of health care, lost wages during time off of work, decreased production from LBP sufferers taking time off of work, as well as the decrease in production of those who struggle through the work day with LBP.   

Common treatments that contribute to the cost are prescription medications, chiropractic and osteopathic manipulation, phyiscal therapy, and eventually surgery. 

These differing treatment options all have varying levels of success, yet the amount of people complaining of LBP is still increasing and our costs are still on the rise, indicating a different look needs to be taken at how to effectively treat LBP. 

In order to treat LBP, we need a better understanding of what pain is and how it presents. 

If we were to look in a neuroscience textbook we would find a definition somewhere along the lines of “A negative emotional and physical experience that is associated with tissue or potential tissue damage.” 

Potential is the key word here because it means that not all pain means damage has been done. 

Pain is a warning signal sent from the brain indicating a looming threat, alerting the organism that action needs to be taken to ensure safety. 

This idea that pain is sent from the brain is a relatively novel idea that has recently gained traction in the clinical world. 

This signal can also be amplified or dampened depending on the physical state of organisms system, psychological, and social factors.

These factors and how the interact with pain is referred to as the biopsychosocial (BPS) approach.  

The BPS approach is a way of looking at all the contributing factors to pain; mechanical factors, social stress, chronicity of the pain, fatigue, feelings about pain, behaviors, etc. 

These all play an important role in the perception of pain and should be addressed by the clinician in order for the patient to have the best chance of combating their LBP. 

If one of these factors is the dominant pain mechanism and it is not being addressed by the clinician the odds of the patient recovering will undoubtedly decrease and their risk of going to acute pain to chronic pain increases. 

The combination of these factors and their contribution to pain should highlight something that many clinicians seem to forget, that there is no catch-all, quick fix. 

What works for one person may not work for another. 

Treatment inside the clinic should be multifaceted and equip the patient with the tools he or she needs to help themselves outside the clinic to effectively reduce the pain response.  

Effective treatment of LBP should always start with education on pain, what it is, what it means, how it presents, and where to go. 

This starts with reassuring the patient that they are not broken.  I can’t tell you how many people I have come across who have given up hope on any sort of activity because their MRI reports showed a few bulging discs and maybe a herniation here or there in their lumbar spine. 

It needs to be screamed from a mountain top that just because the MRI shows disc bulges or herniations it does not mean that they are the pain generator. 

A recent study out of the Journal of Spine took MRIs on asymptomatic Air Force cadets aged 18-22 and found that 77% had signs of disc bulge, herniation, disc extrusion, or other signs of degeneration. 

Lets say that again…77% of people with absolutely no pain or other symptoms had signs of disc disease. 

Does this mean they should have surgery?

Should they stop moving and exercising to avoid a pain response? 

Odds are they were better off not knowing about the state of their spine due to how it can cause them to manifest on the image, lead to fear avoidance behaviors, and stop doing otherwise healthy activity. 

This study isn’t the only one to show a minimal association with imaging findings and pain.H


How do we treat low back pain? The current best evidence for patients dealing with LBP is to stay as active as possible. This means clinicians need to find an activity that the patient CAN do without pain, and encourage that motion. It needs to be understood that a mobile spine is a healthy spine, and the more prolonged the rest, the higher the chances is the pain becomes chronic. These activities may start with gentle, restricted range of motion exercises such as the hip-hinge or cat-camel (I have found success in these two motions but the list is literally limitless because each and every patient responds differently). These small movements can cause small increases in patient confidence as well as provide a therapeutic effect on the spine. Once the small motions are tolerated the range of motion needs to be increased until it is full and pain free.

After the ROM is full and pain-free strengthening the patient is generally a good place to start. A large “chicken or the egg” debate is prominent in the rehab community on if weakness of the posterior chain causes back pain, or if the atrophy seen in the lumbar extensor muscles is due to the inactivity of the patient from the back pain. Regardless of the answer to that debate the end result is still the same…there are some weak muscles that need be strengthened.

When considering strengthening the posterior chain, there are few better ways this is done than by utilizing the movements of the deadlift and/or the squat. Not only do these two exercises recruit an incredibly large amount of muscles they are two of the most functional movements the human can perform as they translate to activities people do (or at least should do) every day. Think about how many times you bend down to pick something up, or how frequently you stand up from a seated position. Training these two movements not only do an excellent job at strengthening the posterior chain and the muscles that make up the core, but they also prep the patient for movements that they will be doing every day of their life.

Now, this does not mean anyone suffering from LBP should just go get under a barbell and try to set a PR. That is a recipe for disaster and would likely lead to more low back pain. The concept of progressive overload that is known in the world of strength training needs to be applied in the world of rehab. Loading the deadlift or the squat to a tolerable weight is the key focus here in order to make sure the patient does not do too much too soon. This is where working with a professional who 1) knows how to properly teach these movements and 2) understands the concepts of progressive overload can help turn someone who is scared to put their socks on for fear of “throwing their back out” (whatever that means) to picking up 200+ lbs.

Core1Chiro specializes in treating low back pain by getting our patients pain free and STRONG.  If you have Low Back Pain and would like to see if I can help click this (FREE Low Back Pain Exam) and schedule today!

 

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