Thread by @BadgleyLaurence

UNEQUAL LEGS IN EDS: this is a subject that has titillated my clinical curiosity for many years. I have parked the idea here; so that I can pontificate on the subject over the next several days; as a threadreader chapter for my book.

https://twitter.com/pig_witch/status/1315694827661557761

SHORT LEG & CHRONIC PAIN
In 1972, I was building my first medical practice (San Francisco Bay Area) & heard about a seminar being put on by a famous British Orthopedic Medicine expert, Dr. James Cyriax. I went to his seminar & learned fundamentals of bio-mechanical diagnosis.

Over the years, Physical Therapists & Chiropractors have been reporting a phenomenon called the “Short Leg Sign”, which has been touted as a sign of lower body bio-mechanical disorder & pain generation.

After studying Cyriax, I tried to evoke the Short Leg Sign. Indeed, it could be demonstrated in people who had low back pain & who went from supine to seated on the exam table; noted as asymmetry of medial malleoli of ankles. During this maneuver one leg became shorter.

I used a rubber glove box, placed sideways between patient ankles, as a template with ruler markings, to note malleolar changes as people changed position. I wanted to be able to measure this phenomenon.

I was interested to find out what happened to leg length on the side of the low back that hurt, and wherein several Provocation Maneuvers (see below) suggested a unilateral sacroiliac joint disorder.

After countless measurements, I became assured that leg measurements changed, but that the changes seen as the patient went from lying to seated were random and unpredictable.

I regarded that as the patients performed sitting up on a firm exam table, their pelvic bones encountered the exam table in various directional vectors; sometimes these bones shifted; at other times they did not.

The theory I began to ponder was that there was NOT an absolute difference in leg lengths, but illusionary ones. I suspected that observed leg length differences were due to pelvic girdle sacroiliac joint rotations.

The problem became more solvable once I taught myself that most people with sacroiliac joint injuries experience a unilateral injury.

Bilateral sacroiliac joint injuries are rare. As the pelvis is injured by a damaging impact, the injury force dissipates when one pelvic ring joint is first sprung (my idea).

One day I was frustrated with the non-reproducible short leg findings and intuited that I needed to tip the patient’s pelvis from side to side with a bolster. The idea was to use the patient’s own upper body weight to deform the pelvis.

I looked for an item for patient to sit on. I chose a Guideon Bible; I had one in each exam room for patients to read while they waited for me. I judged that the size of the bolster I wanted would be about 1 inch & fit under the Ischial bone, the seat bone.

Once I had chosen the Guideon Bible (about one inch thick), I tried the following: first I had patients sit up on the exam table with legs horizontal & next placed the Bible under each buttock in turn; noting their medial malleoli for asymmetry at each placement.

By this time, I had also become aware that pelvic girdle injury usually occurs within just one sacroiliac joint, & that patients were commonly able to report which side (right or left) of their low back & pelvis hurt. These were major insights that simplified my analyses.

By this time, I also became aware of 16 Provocation Maneuvers of sacroiliac joint subluxation able to be performed in the clinic: Forward Flexion Test, Fortin Sign, Gillette Sign, Gaeslen’s Sign, Sacral Shear, P-4, etc.; all reported in the Work Comp clinical literature.

Most of these Provocation Maneuver Signs relied on pain as an end point, but pain is subjective. Subjective pain was what patients reported. Next, the clinician made subjective estimates of the patient’s self-given pain intensity report.

The medical literature reports that when 3 Provocation Maneuver Signs (out of 16 possible) are positive, this becomes criteria to advance to a fluoroscopic guided diagnostic block of the sacroiliac joint. The operant word here is “diagnostic”.

In the field of chronic low back pain diagnosis, image-guided diagnostic blocks are the highest means of proof (“gold standard”). When anesthetic is injected into a joint causing immediate pain relief, this is definitive proof of the joint being a pain generator.

Back to the new observations I was making with the Guideon Bible & while the patient was seated on the exam table with legs horizontal. Again, my method was to place a Gideon Bible under one buttock, and as an ischial bolster. Each buttock was tested in turn.

I noted that Bible placement evoked a measurable leg length change on the side of low back pain & whereat Provocation Maneuvers were positive; thereby suggesting that the ligaments of this joint were damaged, lacked tethering integrity, and enabled joint subluxation.

Amazingly, the phenomenon was reproducible from one clinic visit to the next. The phenomenon was measurable, reproducible, and teachable, i.e., scientific. I named the sign the Badgley Book Sign (BBS).

With greater use, I discovered that the Badgley Book Sign was even predictable & could be predicted to occur in patients who had several Provocation Maneuvers positive. Predictability of scientific phenomena is pretty good assurance the mechanism causing the phenomena is real.

But the Sign (BBS) I discovered was not only scientific, it did not rely on pain as an endpoint; taking subjective noise out of decision making. Subjective pain is not a reliable endpoint for a clinical test. Most SIJ Provocation Maneuvers rely on report of pain. BBS did not.

An additional benefit of the Badgley Book Sign (BBS) is that it is able to be evoked by a standard instrument (Guideon Bible); they are everywhere, free for the asking, & help to standardize the test. I call (tongue in cheek) this Bible a “divine medical instrument”.

Later, I regarded another quality of the Badgley Book Sign. Mechanical force used to deform pelvis was proportional to the patient’s own size: their own body weight above the waist was the force used to impress the bony pelvic ring. This quality rendered greater test consistency.

Explanation for the book/leg shift phenomenon, which I named the Badgley Book Sign or BBS, is that the Bible evokes sacroiliac joint rotation, either Nutation or Counter-Nutation, within a lax (ligament damaged) & injured sacroiliac joint.

The sacroiliac joint (SIJ) is known to rotate about a transverse virtual axis that runs through the mid-region of the joint. The SIJ is known to have a normal range of motion: 0.5 cm shift as a person goes from lying to standing.

When a sacroiliac joint is loose from ligament tethering deficits, due to injury, the joint rotates about a transverse virtual axis & carries the femur acetabulum along with it. This is what functionally shortens or lengthens the leg.

A Principle of clinical medicine is that if a joint moves with a normal range of motion, bio-mechanical injury can deform ligaments that tether the joint and cause abnormal ranges of motion (ROM). Abnormal joint ROM hurts - greatly.

Abnormal joint ROM arouses generous pain. Pain elicited by ligament stretch has been well known to the Priest Class. During the Spanish Inquisition, torture on “The Rack” was an effective instrument to extract confessions of heresy.

A question to be asked is, “why has sacroiliac joint (SIJ) abnormal motion measurement been so elusive?” Because it does not manifest in imaging studies, which are static 2-D images. Secondly, abnormal SIJ ROM related to pain and dysfunction is a small measurement.

Along this line of inquiry about range of motion (ROM) of the sacroiliac joint (SIJ) it is instructive to realize that the small ROM normal to the SIJ is what enables human upright ambulation. Gorillas do not have sacroiliac joints.

I did a geometric calculation & showed that a mere 2-3 degrees of sacroiliac joint rotation translates to 1-3 inches of functional leg length asymmetry; via unique and varied bio-mechanical shifts of the ilium, acetabulum, & femur.

I published that study of geometric analysis of sacroiliac joint rotation and leg length differential at an international symposium (Barcelona, 2007). But that is another story.

At the same symposia (Interdisciplinary World Congress on Low Back & Pelvic Pain), I published (Dubai, 2013) a cross table lateral X-ray study of pelvises of 20 people wherein the Badgley Book Sign (BBS) was radiologically demonstrated. Before & after films showed the movements.

Several of my SIJ-injured patients had sacroiliac joint fusion, & both BBS & Short Leg Sign (SLS) disappeared (unpublished); evidence that Psoas muscle spasm was not cause for SLS; a time-worn Chiropractic explanation for SLS.

Over course of my sacroiliac joint investigations, I studied & learned meaning of Nutation & Counter-Nutation, as applied to sacroiliac joint. This understanding is critical to understanding leg length changes, inequalities, & true bio-mechanical dynamic of the Short Leg Sign.

During Nutation the sacral verge shifts anterior relative to iliac crest. At same time, as the 2 bones rotate about the sacroiliac joint virtual axis, the acetabulum shifts anterior. During Counter-Nutation these bony elements move in directions opposite to those of Nutation.

A student must keep in mind that these terms describe a relative relationship between ilium & sacrum. It is improper to say that one of these bones “nutated”. They move as a unit that shifts into a mutually abnormal posture.

When a sacroiliac joint is loose from ligament tethering deficits, due to injury, the joint rotates about a transverse virtual axis & carries the femur acetabulum along with it. This is what functionally shortens or lengthens the leg.

Nutation lengthens the leg & is due to injury of the Sacrotuberous ligament system. Counter-Nutation shortens the leg & is due to Iliolumbar ligament system injury. This knowledge relies on another body of observations (unpublished), but that is another story.

The medical literature reports that it is impossible to use a tape measure on the external body to measure for a short leg. The only way to measure for a true short leg is with a radiologic imaging study, called a Scannogram.

The reason for this is that the leg length differential is caused by sacroiliac joint rotation & this bio-mechanical shift occurs within the body & at a place inaccessible to the tape measure.

While studying countless patients with the Short Leg Sign, I had many with this sign undergo a Scannogram. Outside of an iatrogenic short leg via fractured leg or knee replacement, a true short leg is exceedingly rare; so I discontinued doing Scannograms.

My own regard is that nature conserves equal leg length as a fixed characteristic. An inherited short leg would lead to an animal not well suited to survive; the genes would dissipate from the herd.

The Short Leg Sign (SLS) is one of the many observations that attends & suggests sacroiliac joint disorder/subluxation. The Badgley Book Sign (BBS) is the most dependable way to monitor for a short leg reflective of sacroiliac joint disorder/subluxation.

The importance of the observations and bio-mechanical analyses described herein is that sacroiliac joint subluxation evokes SIJ Subluxation Chronic Pain Disorder Syndrome (my own nomenclature), which is severely incapacitating.

It is important for doctors to learn how to discover Sacroiliac Joint Subluxation Chronic Pain Disorder Syndrome because the condition is treatable (see below).

The medical literature reports that 13-30% of persons with chronic low back pain experience pain generation from a disordered sacroiliac joint. Unfortunately, the condition is commonly overlooked by medical practitioners.

It is important to realize that clinical studies intended to show that patient-described regions of pain due to vertebrae or sacroiliac joint or hip joint are distinctive have failed. Due to the physiologic dynamic of referred pain, these regions of subjective pain overlap.

My own regard is that many patients undergo major back operations for Degenerative Disk Disease (DDD) & incur operations that fail, because surgeons operate on the wrong spinal part.

At 17 cm square, the sacroiliac joint is by far the largest joint in the axial spine. It is a joint held together by numerous ligament systems. DDD is reported, in the medical literature, not to be a cause of chronic low back pain.

It is my view that clinical practitioners commonly choose “DDD” as a diagnosis & reason for patient low back pain due to ignorance how to diagnose & because radiologists commonly put this specific nomenclature, “Degenerative Disk Disease”, in their reports.

Degenerative Disk Disease (DDD) is a natural concomitant of the aging process that begins in the third decade of life. DDD is common in the imaging studies of people who do not suffer low back pain.

One reason for the oft overlooked diagnosis of sacroiliac joint disorder is that ligaments are radiolucent; even though seen on MRI, these tissues are not routinely commented upon by Radiologists, who seem unable to discern signs of injury.

At the Interdisciplinary World Congress on Low Back & Pelvic Pain (Singapore, 2016), I presented a novel method of analysis of Sacrotuberous ligament injury at site of insertion on the Ischial prominence; correlate with diagnosed ipsilateral sacroiliac joint dysfunction and pain.

A typical sequence of examinations & treatments for sacroiliac joint disorder should be: History, Provocation Maneuvers, Badgley Book Sign (BBS), an image-guided diagnostic block, dorsal medial sacral nerve block & ablation, & Prolotherapy.

Surgical fusion of the sacroiliac joint should be a last resort. The incision is about 2-3 inches long and the procedure requires overnight stay in the hospital.

Knowledge of the Badgley Book Sign enables the practitioner to discover the exact ligament system with chronic injury & laxity, and which might be corrected by Prolotherapy. This is my present research interest & about which I am gathering data.

A satisfying and instructive aspect of encountering sacroiliac joint disorders is the history, once deftly taken, can elucidate the mechanism of injury that has led to chronic low back pain syndrome. History is so important & can help to suggest which body part has been injured.

Permanent injury to the sacroiliac joint is a common cause of chronic low back pain & can be debilitating. Unfortunately, women with Hypermobility Syndrome and Ehlers-Danlos Syndrome (EDS) are prone to develop this disorder.

Unlike men, women have delicate pelvises that are exposed to hormones, (Relaxin) that loosen sacroiliac ligaments & joints each month at menses. Childbirth can be particularly injurious to pelvic joints. Women do lots of lifting.

The medical literature reports that even menial slip & fall & seemingly harmless lifting events can permanently injure sacroiliac joint ligaments & generate constant pain. Nurses are particularly exposed to injurious lifting events.

It is my regard that the prevalence of so many failed back operations is because sacroiliac joint injury is overlooked and under-reported. People get operated on for the wrong reasons.

Another long-term study I have made is of Fibromyalgia. This Syndrome begins as sacroiliac joint injury. A sedentary lifestyle & functional scoliosis leads to shoulder girdle asymmetry and crossed muscles in the neck and shoulders.

In the tilted bodies of those with Fibromyalgia (many who have bendy bodies of Hypermobility Syndrome to begin with) autonomic nervous system dysfunctions, dysautonomias, express due to spinal subluxations & neural impingements. At least this is my theory.

Fibromyalgia causation is another story and one I do not have time for here, but it is one I have discussed many times in other of my threadreaders of the last 2 years. THE END.

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