American Physical Therapy Association, bone density, Connie Schultz, exercise, Health, heel lifts, leg fractures, leg length discrepancy, limb length discrepancy, lower back pain, Marlo Thomas, orthopedics, osteopenia, osteoporosis, Pelvic floor, pelvic obliquity, Physical therapy, Pilates, postural anomaly, Virginia Commonwealth University, Women's Health
Welcome to the “The Midlife Second Wife’s” debut feature—Monday Morning Q & A. In the months to come you can expect to read interviews with experts on a wide range of topics. Among those with whom I’ll be speaking are financial planners, authors, fashionistas, relationship and dating experts, life coaches, artists and artisans, lawyers, therapists, doctors, cooks, butchers, bakers, and even a real honest-to-goodness candlestick maker. Who knows? I might even snag an interview with my hero (and, some have said, doppelgänger), Marlo Thomas. At least, I’ll try! And although these interviews won’t appear every Monday, at least not at the start, I do want you to know that on select Mondays, we’ll be learning from others.
Incidentally, that’s one of the things I’ve come to love about writing this blog. I’m not an expert on anything, really. Well, maybe on life. Because, like you, I am living it. And as Pulitzer Prize-winning columnist Connie Schultz wrote, Life Happens. It happens to me, to my loved ones, to you, to all of us. I want to understand it, learn from it, and move forward—with as much grace and grit as I can muster. Do you know what I think is really cool? As followers of this blog, you get to join me on the journey.
Why does this matter to me? Well, for one thing, I don’t like pain and I don’t like trouble; yet I’ve had plenty of both. And so have you. No one among us gets a free pass. But if even one sentence that I write in this blog helps you avoid either, I’ll be able to consider mine a life well-lived.
So, on to today’s inaugural interview. A suggestion before you start: You might want to take another look at “There Was a Crooked Woman…,” parts one and two, for some context. To recap, Dr. Miller treated me (quite successfully) for severe lower back pain, and I am eager to share with you what I have learned—and continue to learn—from her.
I came to see you for treatment of lower back pain, and you determined that I have limb-length discrepancy—my left leg is slightly longer than my right. Do you see many such cases? Would you say that it’s a common occurrence in the general population?
Leg-length discrepancy is a controversial topic, especially when it comes to treatment. There is a difference between true leg-length discrepancy and apparent leg-length discrepancy that results from other postural anomalies. I think the estimation in the literature is anywhere from a 40-percent to 70-percent prevalence in the population.
That’s around half of the population! To be clear, we’re speaking only about the United States, correct?
What makes it controversial? What treatments are considered “controversial?”
The effects of LLD on function and the magnitude of LLD that warrants treatment are controversial. There is disagreement regarding the role that LLD plays in musculoskeletal disorders. There is also not a “gold standard” or most preferred way of accurately measuring discrepancy.
As you know, I broke my left leg several years ago—that’s the leg that’s out of whack. In my case, did the fracture lead to true, rather than apparent, leg-length discrepancy? I guess I want to know the meaning behind the terms “true” and “apparent.” And when you say “postural anomalies,” what do you mean? Can you give me some examples?
True—or structural—LLD can be caused “traumatically” by fractures and repairs, fractures affecting the growth plates in children before they have finished growing, and total hip replacements. They can also be congenital, such as congenital dislocation of the hip, or other skeletal disorders. Postural anomalies include impairments such as scoliosis, and muscle imbalances causing changes in standing/sitting posture. For instance, if you are a swimmer and breathe only to one side during freestyle, you may develop shortening of your oblique muscles—the the trunk muscles that do rotation and side-bending—on one side. That shortening can lead to a slight sidebend/rotation at rest in standing or sitting.
Do fractures always lead to LLD? Would the fact that my orthopedic surgeon had to install a plate in my leg (at the knee joint) have contributed to the problem I’ve been having?
Fractures and other surgeries don’t always cause leg-length discrepancies, but it’s something to be aware of, certainly. And again, leg-length discrepancies don’t always cause pain or dysfunction.
Might either osteopenia or osteoporosis cause LLD?
Changes in bone density can be a factor; muscular asymmetries that change the way the spine, pelvis, and hips move are also factors. For instance, if someone is prone to standing on their left leg with hip cocked, they can cause asymmetric muscle shortening that can appear as a pelvic obliquity or leg-length discrepancy.
Pelvic obliquity. You referenced that when you were treating me; that’s when I discovered you are a pelvic-floor specialist. Could you please talk a moment about what you mean by “pelvic obliquity”?
Pelvic obliquity refers to an apparent change in the bony alignment of your pelvis, often caused by muscle imbalances. The contributing muscles may be of your pelvic floor, or back/hips/trunk.
If LLD can lead to lumbago, or lower back pain, to what other medical issues can it contribute?
Anything from ankle, knee, and hip-dysfunction, all the way up to neck and shoulder pain. Leg-length discrepancy, or any postural dysfunction, can change the way you move and carry out normal activities of daily living, as well as recreational or athletic activities.
How does one even know to check for LLD? If a person is suffering from chronic lower back pain, is LLD something for which a doctor should check?
Your basic primary care doctor—and even most orthopedic doctors—will look for postural dysfunction, and, hopefully, refer you to a musculoskeletal specialist for further work-up. If you are having any dysfunction, and a possible leg-length discrepancy may contribute, make an appointment with a physical therapist
Let’s talk about appearances. You initially thought I would need to wear a heel lift, but determined that my discrepancy was subtle enough that I could do without one. If a person does need to wear a heel lift, does that mean he or she can no longer wear certain styles of shoes? It gets awfully hot in Virginia in the summertime; must a person forgo flip-flops and sandals? And what about high heels?
If a patient needs a heel lift for a true discrepancy, as opposed to an apparent discrepancy, then they will need to wear comfortable shoes that they can put the heel lift in whenever they are doing a significant amount of standing or walking. Flip-flops are inadvisable for anyone who has back pain, unless they provide a lot of support. Some sandals have removable inserts that heel lifts can go under. High heels are dependent on the height of the heel and the width of the back of the shoe. Of course, if all you do in your shoes is walk from your car to your office, and then you sit all day, shoe choice is not as big of a concern.
A friend of mine has a name for the high heels you just described. She calls them “curb shoes”—as in: “I’m wearing high heels, so please pick me up/drop me off at the curb.” But what about a situation where your job has you sitting all day; that’s not good, is it?
The sitting or the shoes??? Neither are great. If you can’t walk comfortably in your shoes, you should probably not be wearing them. If you have to wear them, keep your flats in your purse, and use those for walking.
Other than heel lifts, are there other things a person can do to alleviate not only the leg discrepancy, but also its symptoms? Short of stretching with a medieval torture rack?
Exercise!! If your muscles are stronger, they are better able to control motion and transfer load across your lumbo-pelvis, which means improved stability and decreased pain and irritation across the joint. Appropriate shoe wear and good body mechanics are also essential.
Let’s talk about exercise, then. The first thing you had me doing were exercises to strengthen my core; in fact, I shared your exercise for “setting” one’s TA, or transverse abdominis, in part two of “There Was a Crooked Woman…” Why are these exercises important? And can you talk a moment about what it means, exactly, to strengthen one’s core?
Sure. The core is made up of four muscle groups: the transverse abdominis that you mention, which is the deepest abdominal muscle; the pelvic floor muscles; the multifidus, or the deepest back muscle, and the respiratory diaphragm. These muscles work to optimize intra-abdominal (inner abdominal) pressure in order to help stabilize the spine during load transfer or movement. We often see core dysfunction in people with back, pelvic, or abdominal pain. I believe that the first step in treating this kind of back pain is to improve the function and use of core muscles, along with pain management techniques and lifestyle modifications such as body mechanics—for example, how you transition from a sitting to a standing position.
Yes! Another thing you had me think about was how I’ve been getting up from a chair. I must first “engage my core” in the manner of the exercise I published last week, right?
That’s right. This is something that should happen automatically but often doesn’t in people who have pain.
As I recall, when I was in pain it really wasn’t all that easy to “engage my core,” but I see how important it is. What other exercises are helpful in alleviating lower back pain? And isn’t that something of an oxymoron? If one is in pain, won’t exercise lead to more pain?
Actually, oftentimes movement helps decrease back pain, especially once you are out of the acute phase. A gentle walking program, strengthening and stretching exercises, core work, are all helpful. Avoid a lot of high-impact stuff at first, and make sure motions and activities that you are doing are comfortable and controlled. Never ever hold your breath with exercise, remember to exhale on exertion, and don’t forget to engage your pelvic floor!
I’ve started walking three mornings a week with a friend; I’m up to two miles a morning now.
That’s good! Keep it up.
What about core work? You have Pilates reformers in your exercise studio, and I really enjoyed trying them out. Pilates is all about core work, isn’t it?
That’s right. Pilates does a great job of incorporating all components of your core, including your diaphragm and pelvic floor.
You mentioned pain-management techniques earlier. There’s always some confusion about this when I speak with my friends. Does one apply heat at the immediate onset of pain, or ice? At the end of each session at Progress Physical Therapy, either you or one of your assistants would apply ice to my back, and you told me to ice my back after doing my home exercises. Is there ever a good time for heat-therapy?
Ice is better for inflammation; heat is better for muscle tightness. Always try ice first if you are unsure which category you fall into. Heat can, at times, make inflammation worse.
Hmmmm. “Fall into.” Not the best choice of words when speaking with someone like me! Is there anything I didn’t ask you that you wish I had?
Nothing that I can think of! The moral to the story is keep active. And if you have any specific questions about your core, or specific limitations, please see your physical therapist.
I will, Dr. Miller. Thanks so much for being my first guest on the blog.
Dr. Amanda Miller is a member of the clinical staff at Progress Physical Therapy in Glen Allen, Virginia. She earned a Doctor of Physical Therapy degree at Virginia Commonwealth University’s School of Physical Therapy in 2009, and, in 2006, a Bachelor of Science degree at Virginia Tech, where she majored in human nutrition, foods, and exercise and minored in psychology. Dr. Miller is a member of the Women’s Health and Orthopedic sections of the American Physical Therapy Association, and serves as Central District chair of the Virginia Physical Therapy Association. She is also a member of the National Vulvodynia Association and is a clinical instructor at Virginia Commonwealth University.