DEVELOPING A SHORT LEG AS AN ADULT: HOW AND WHY ?

A few years back I wrote a series on short leg presentation in chiropractic. When it comes to a true anatomical short leg, it is usually acquired during growth with a mild unrecalled injury to the growth plates (very common at the knee). That particular bone stops growing at the same rate as the contralateral leg, leading to a leg differential over time. The severity of the discrepancy depends upon how early the injury happens to the child.

In the past few years I have come to appreciate the development of acquired short legs in adults, especially senior adults, in a way that I did not appreciate before. It is entirely possible, in fact probable, that I missed many of them over time, as the possibility of short leg coming on later in adulthood was not on my radar.

The mechanism by which adults develop short leg is different than youth, since our endplates have fully closed by the age of 20. Some examples are:

• Loosing cartilage in one knee (less commonly in the hip. This can happen over time gradually with a deteriorating knee joint, but sometime can be very abrupt as in the case of knee meniscal removal. The combination of the knee cartilage and meniscus is well over a half inch.

• Having a joint replacement. Depending upon your anatomy and the extent of the damage, the prosthesis can add or substract a half an inch to your operated leg. I have had two cases in the last year alone where the post surgical leg differential was a full inch, because the underlying bone required a large prosthetic peg.

• Ankle/foot fracture and surgeries, which change the height of the foot arch.

Adults with sudden onset of pain in the hip and low back, especially on the opposite side of their leg surgery, should especially be on the lookout for acquired leg difference. How much of a correction you will need needs to be assessed in the office.

Cat Cow Stretches

Cat Cow or Cat Camel stretches are routinely given or performed for lumbar stretching and mobility. I usually give these in the quadruped (hands and knees positions) for individuals that can maintain proper positioning. For those that are not able to be in this position or have a difficult time finding time to complete these, but are sitting for large amounts of their day (cough cough, I see you office workers) we can do a similar stretch or movement while sitting. The goal of the sitting movement is to keep the pelvic mobile in appropriate ways rather than allowing some stiffness to settle in which we all become very familiar with when maintaining one position for long periods of time.

Click the images below to be taken to each video.

Click the image to watch the YouTube video of the Cat/Cow Stretch

Click the image to watch the YouTube video of the modified Cat/Cow Stretch AKA Pelvic Tilts

PAIN IN THE "NETHER REGIONS" AND CHIROPRACTIC

I am trying to find a delicate way to describe a delicate subject, but have found that those patients affected by it have lost any false modesty in describing a problem for which they can be pretty desperately seeking relief. And so it goes.

Dr. Alvarez and I each had a patient presenting with genital/perineal pain in the same week (one was a female patient with acute onset of unilateral labia burning pain and the other a man with severe testicular pain). It reminded me of the very first patient I saw with such presentation, three months into clinical practice, and it made a lasting impression. He was an 18 year old young man with intractable testicle pain on his left side. Long before COVID nasal swabs made us shudder at the sight of a very long Qtip in a sterile pack, the young man’s age and interest in young ladies had earned him, not only one, but three swabs up a different orifice in search of an infection that never materialized. He failed to respond to a broad spectrum of antibiotics. A CAT scan later, he remained a medical mystery. He developed sacroiliac pain that landed him in our office, and to everyone’s delight resolved both his butt and groin pain in a few treatments.

Pain in the genital, perineal, and inguinal area, can have many sources and chiropractic will not fix all of them for certain. But once internal and infectious causes have been medically ruled out, I am amazed by how many folks are sent home without a good reason for their continued symptoms. And in those instances, you really need to look at the neurology of the area and investigate the possibility that this very pesky problem may be a “pinched nerve in your undercarriage”. (line stolen from one of my patients)

The attached image is a good summary of the sensory innervation of the pelvic floor front to back . Of those nerves, I want to circle in on the pudendal nerve because it is the most frequently missed source of pain in men and women. In men, testicular pain can be referred from the mid lumbar spine through the lumbar nerve roots at L2 and L3, and this will usually affect the anterior groin into the front of the testicle. The pudendal nerve will cause pain that is more directly in the groin area and in front of the rectum, slightly laterally. In men this will feel like pain shooting into the posterior aspect of the testicle and penis, and in women the pain will affect the area of the labia, lower vagina. The pain can feel deep and internal, or more superficial like a burning, prickly sensation.

The pudendal nerve has a path that makes it vulnerable to entrapment in several areas, most commonly as it exits the lateral lower sacrum and travels by the sacrotuberous ligament and around the ischial spine. The nerve can be easily injured by sacroiliac strains, falls on the buttocks, and chronic repetitive frictions sitting on the wrong chair. Patients with pudendal nerve entrapment of neuromusculoskeletal origin will frequently report associated pain in the upper gluteal and tailbone pain at some point.

The moral of the story is that pain in your private areas is worth bringing up to your chiropractor if you have no good medical explanation for it. A pinched nerve is a pinched nerve, no matter how “private” its location.

Flat Head, Baby Milestones and Chiropractic

http://jccponline.com/Marinus.html

I had a chance to hear the author of this article speak at an online conference recently and he had many insights that were not fully fleshed out in this research paper. He is a fellow chiropractor in the UK and specializing in pediatrics. While many published researchers no longer are actively in clinical practice, he still very much was. And thus his insights were invaluable.

Parents who present to our office for chiropractic care of their new baby will often be concerned about abnormal head shapes and “flat spots”. The traditional medical pediatric standard for what is a benign versus medically significant abnormal head shape is pretty generous. Unless there is concern over premature closing of the head sutures, or other gross distortion of the head shape and size that could compromise brain growth, the approach is to spend less time laying on the back and let the child “grow out of it” (or grow hair over it).

The chiropractic approach tends to lower the threshold of when we feel the need to intervene, and the reason is that we connect the deviation from optimal head shape to neurological function and development. Practicing chiropractors and craniosacral therapists have empirically observed the causal relationship for a long time, but it is always good to get reinforcement from a solid research paper. I wanted to note two particular observations:

• The neurological function most affected by the head flattening was motor development. Parent should keep this in mind if they have a child that seems to be behind siblings or peers in fine or gross motor skills, and has a history of misshaped head.

• Head flattening develops from a combination of too much time spent laying on the back (sleep on back but play time on tummy), as well as abnormal rotation, or flexion extension of the cervical spine. The latter being very common with even minor straining during birth, and responds well to chiropractic care.

Remember that a flat head is not primarily a cosmetic issue. You cannot cover up neurological delay with a good patch of hair.

THRIVING ENVIRONMENT PART I- CLEAN AIR

I had been searching for some research regarding clean air and came upon this piece on clean air and brain development. It's interesting that air pollution exposure was linked to preterm birth and low birth weight as well as risk factors for neurodevelopmental disorders in children. Are your kids at home more often with school being hybrid or from distance learning? Be sure they have the right environment to thrive in. We now have an air purifier in each of the treatment rooms and in the waiting area.

Article:

https://ajph.aphapublications.org/doi/full/10.2105/AJPH.2018.304902

YouTube Link for our “How to: Breathe” Video:

https://youtu.be/_WcVPcCxn8s

COLD AND NECK PAIN

I blogged about this more extensively a few years ago, but this polar vortex is worth at least a brief reminder of an overlooked fact: exposure to cold windy conditions can aggravate neck pain, especially for patients with underlying moderate degeneration and post traumatic scar tissue formation in the collagen of ligaments and muscle fascial layers.

Cold and wind exposure results in two phenomenons : vasoconstriction i.e. diminished blood flow to superficial tissues as the body tries to conserve energy for core organs, and protective posture of the neck and shoulders: hunched forward with trapezium muscles drawn up to your ears. Neither of which is helpful for chronic neck pain.

Remember to keep your cervical spine covered with an additional layer of warmth and insulation. A good neck gaiter, scarf, turtle neck or fully zipped up collar is all it takes.

Neck strain, Reading, & Periscope Glasses

https://www.amazon.com/Horizontal-Glasses-Definition-Periscope-Watch/dp/B00CY9RQ2K

I am not much of a gadget person but I have been paying closer attention to anything that can decrease the amount of flexion neck strain, since that is a gigantic problem of modern life that is hampering the progress of our patients dealing with neck pain. A couple patients reported using “periscope” glasses recently, to read books laying on their lap while on a recliner. It basically allows them to keep the neck upright and relaxed while reading the material on their lap at waist level. This is made possible by the reflecting mirror of the glasses angling the written text toward eye level. It apparently does take a little practice to correctly angle your head and keep it steady, but also well worth the rewards of not having to endlessly look down and loading up the junction between the neck and upper back.

New Year Resolutions and "Sugar Detox"

In the last installment of New Year resolutions to be healthy, I wanted to briefly address the concept of “sugar detox “.

Refined sugars are, for most people, almost as addictive as a drug. And while the idea of having a small, controlled amount of it sounds good in theory, many folks know full well that when you start, you really cannot stop. If it all or none.

Refined sugar consumption seems to escalate during the year end holiday splurging of endless treats and cookies, so many will start the new year feeling bloated, heavy, and on a blood sugar rollercoaster. And as such, wanting to get off the sugar wagon totally and cold turkey.

The unpleasant truth about “sugar detox “ (I prefer the term “ refined sugar fasting “), is that getting off the sugar train can be really hard and truly lead to initial sugar withdrawal symptoms.

A few years back I read Stephen Guyenet’s fantastic book “ The Hungry Brain”. As a prime researcher on brain based obesity pattern, he describes an interesting and unique feature of the brain’s response to fast acting refined sugar the sweet taste in general: unlike with other tastes, the brain has a very poor, practically non-existent negative feedback loop to the sweet taste the keeps you eating it ravenously long after your other brains feedback loops (such as those regulating energy balance and satiety), would have signaled you to stop. As such, the majority of humans are truly at a disadvantage when it comes to controlling sugar eating behaviors.

There is not miracle cure for the bad sweet tooth. Breaking the sugar addiction cycle requires some acceptance of that fact, and the reality that there will be unpleasant initial withdrawals and cravings, not much different than cutting out cigarettes, alcohol, drugs etc..

However, there are a few smart things you should do to make this a feasible endevour.

• Don’t keep it at home. If you have it at home, you brain knows where it is and will send you hunting for it sooner or later. Splurge on it outside of the home , but let it stay there

• The first 7 days will be the worst.

• You need to be sure you are adequately nourished with protein, good fats, and fiber. People who cut out too much fat will find it more difficult to limit sugar cravings

• There are a few supplements that can help mitigate the sugar cravings (they do NOT replace having a solid plan in place). These would include inositol, berberine, and gymnema. The latter can be used as lozenges you suck on , which arguably have a mild unpleasant herbal sweet taste and desensitize your taste bud for several hours to the pleasant sensation of sweets.