To truly evaluate for a static, structural, limb length discrepancy you need to do so via radiographic evaluation, not visual evaluation and tape measure.

There are inherent inaccuracies with the visual measurement methods and different practitioners get different values. Even the block method [sliding blocks of wood under one or the the other foot and then checking for equal malleoli/knee/and-or/hip] is not consistant across providers.

An erect leg view allows for proper measurement and comparison of bilateral leg length and allows for evaluation of the contribution due to growth arrest and/or prior attempts at correction to all segments: pelvic, hip, femoral, knee, tibial, and foot. Each segment is measured as well as total length and compared to the contra-lateral side. Pelvic tilt can be assessed.

Doctors in the limb deformity correction world rely on the Erect Leg view constantly. It's part of the new patient evaluation as well as for follow-up exams. Back in the day, I ordered it as 'orthographic limb length evaluation'. Why insist on subjective measures when accurate measures exist? 

I refer you to Methods for Assessing Leg Length Discrepency published by the US National Library of Medicine, National Institutes of Health [ http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2628227/ ] which, among other things, states this within their conclusion: "the standing full-length AP computed radiograph of both lower extremities with the pelvis level, along with use of a magnification marker, should be the primary imaging modality for the initial evaluation of LLD in the majority of the patients. A CR teleoroentgenogram is not only an accurate and reliable imaging tool, but the measurements can be obtained with limited radiation exposure in a cost-effective manner."

Don't agree? Don't argue with me, argue with NIH and the National Library of Medicine.

One can only approximate a limb length discrepancy by clinical exam, whether it's done sitting, standing, or whatever. If you want to know if there is a LLD then xray and measure. Be exact, be precise.

It's possible so why not do it?

Dave Gottlieb, DPM personal opinions only

  • Comments (31)
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  • Quote:

    Dennis,

    I call it practicing medicine.

    Until you publish your results in a peer reviewed journal it's considered your own personal experience. Once published it can be considered science.

    Dave Gottlieb, DPM personal opinion only

    So be it.

    Dennis

  • Dennis,

    I call it practicing medicine.

    Until you publish your results in a peer reviewed journal it's considered your own personal experience. Once published it can be considered science.

    Dave Gottlieb, DPM personal opinion only

  • Dave:

    I couldn't have stated it better myself.

    n=2.

    In stating "That doesn't make it science" when referring to Dieter, Eric, Daryl, you and I as we practice medicine, n=1, what does that make it?

    Dennis

    My teachers called it "The art and science of medicine.'

    Dr Bates:

    I would add creativity, intuition and experience.

    Then I would add utilizing the evidence that exists that is well conceived, valid and applicable to n=1 situations to guide my scientific side.

    Then I would call it evidence based practice and thank Dr Sackett.

    Then lets call it medical practice (oh wait, if we do, they'll come up with malpractice :-)

    As an n=1 doctor or an n=1 patient, it boils down to n=1 moments. The Art, Creativity, Intuition, Experience and Science of Medicine.

    Dennis



  • Quote:

    Quote:

    Dennis,

    Clinicians use n=1 [personal experience] every day. I do it, you do it, Dieter does it, Eric and Daryl do it too, I'm sure.

    Dave Gottlieb, personal opinions only (n=1)

    Dave:

    I couldn't have stated it better myself.

    n=2.

    In stating "That doesn't make it science" when referring to Dieter, Eric, Daryl, you and I as we practice medicine, n=1, what does that make it?

    Dennis

    My teachers called it "The art and science of medicine.'

  • Quote:

    Dennis,

    Clinicians use n=1 [personal experience] every day. I do it, you do it, Dieter does it, Eric and Daryl do it too, I'm sure.

    Dave Gottlieb, personal opinions only (n=1)

    Dave:

    I couldn't have stated it better myself.

    n=2.

    In stating "That doesn't make it science" when referring to Dieter, Eric, Daryl, you and I as we practice medicine, n=1, what does that make it?

    Dennis

  • Quote:

    Quote:

    Clincal assessment is all subjective and therefore not scientific.

    Dave Gottlieb, DPM personal opinions only

     

    I disagree if you are stating that the practice of medicine n=1 is not scientific. It is.

     

    Clinical assessment, intratester evidence and expert opinion, n=1 are Level V Evidence

    and

    Low level, n= 20 cohort evidence of which many of the 6000 articles published daily are wrong, poorly constructed and come to an incorrect conclusion very often are abundant. They are not very scientific.

    Science and EBM are not as black and white as you opine it.

    If all I do is improve the health and quality of life of tens of thousands of people and mentor those wishing to be mentored in Foot Typing and Centering, I will feel accomplished.

    When someone is available to help me publish, they will find me.

    Sorry if that is not enough for you.

    Dennis



    Dennis,

    Clinicians use n=1 [personal experience] every day. I do it, you do it, Dieter does it, Eric and Daryl do it too, I'm sure. That doesn't make it science.

    Statistically we need more than a n=1 report to feel confident in following something on a scientific basis. That's because there is no way of knowing if that single person was an anomoly or not, or even how much of an anomaly they are. That's the reason for wanting and asking for more.

    Science is as black and white as the statistical evidence behind it is. Give me n=100 and I'll pay attention. Give me n=1 and I'll trust my own n=1. 

    Dave Gottlieb, personal opinions only 

  • Quote:

    Clincal assessment is all subjective and therefore not scientific.

    Dave Gottlieb, DPM personal opinions only

     

    I disagree if you are stating that the practice of medicine n=1 is not scientific. It is.

     

    Clinical assessment, intratester evidence and expert opinion, n=1 are Level V Evidence

    and

    Low level, n= 20 cohort evidence of which many of the 6000 articles published daily are wrong, poorly constructed and come to an incorrect conclusion very often are abundant. They are not very scientific.

    Science and EBM are not as black and white as you opine it.

    If all I do is improve the health and quality of life of tens of thousands of people and mentor those wishing to be mentored in Foot Typing and Centering, I will feel accomplished.

    When someone is available to help me publish, they will find me.

    Sorry if that is not enough for you.

    Dennis



  • Clincal assessment is all subjective and therefore not scientific.

    Objective measurements are what NIH/NLM reccomend. If one does not have the radiographic ability to perform this in their office they can order it out.

    Personal opinion is one thing, and that is all it is. Statistical analysis and scientific measurements have a long and substantiated history. I will not repeat it here. N=1 is an accepted indicator that the information being provided is purely opinion or of limited value [since one does not know where on the bell curve that 1 specimen came from].

    Dennis, if you want your theories to be taken seriously by scientifically guided people then you need to provide much more than n=1 accounts. The posts about my knee are purely my own experience and ahould carry no real weight for someone seeking scientific validation. It's my knee, my pain, and quite possibly my placebo response to a product used n=1. At best these posts show that I am confident enough about the safety of these products to have an orthopedic surgeon inject it in my knee.

    You may very well have thousands or hundreds or even tens of patients who have responded well to your interventions. If indeed this is the case it behooves you to write them up [or get some student or resident to help, it might even be a physical therapy student who wants to get their name published] and get them published in a biomechanical journal, or a podiatry journal if you still care about keeping these 'trade secrets' secret.

    But please, stop trying to make it seem that n=1 implies any validity. It doesnt', it just doesn't.

    And, if you don't like my opinion then please don't respond. I try very hard to stay out of your posts.

    Dave Gottlieb, DPM personal opinions only

  • Quote:
    A point Dennis consistently likes to sidestep is the fact that we are NOT simply presenting n=1, on discussion points, but the body of evidence and standard of care depicted in learned articles and textbooks, comprised of a general consensus of expert opinion i.e. a very many n=1. It may, in some cases still simply represent 'opinion', but it is also the aggregate of many experts in agreement with this opinion. That lends credibility to the argument, when a TRUE n=1, carries little to no credibility.  Dieter


    Dieter:

    You are not accuarate in your statements in that there is no general consenus of expert opinion as you contend:

    The facts surrounding the evidence suggests no aggregate, no general consensus in agreement with you.

    Interrater agreement between two readers was 0.68 and 0.72, and between readers and authors, 0.32.

    The largest categories assigned by methodologists were "positive effect" (22.5%), "insufficient evidence" (21.3%), and "evidence of no effect" (20.0%).

    The largest categories assigned by authors were "insufficient evidence" (32.4%), "possibly positive" (28.6%), and "positive effect" (26.7%).

    The number of reviews indicating that the modern biomedical interventions show either no effect or insufficient evidence is surprisingly high.

    Interrater disagreements suggest a surprising degree of subjective interpretation involved in systematic reviews

     http://www.podiatry.com/etalk/EBM-Reviewing-the-reviews-t18669.html#-1 

    Dennis

  • A scientist knows that n=1 is at best personal opinion and at worst the experience of the single outlier.The scientist uses the phrase n=1 to denote to other scientists that there are likely to be problems in a larger scientific study of that subject. The phrase n=1 is used to denote caution in applying the results outside of that one, single, individual, instance. No scientist uses n=1 to denote authority of the subject. Many a n=1 conclusion gets retracted and apologized for down the line.

    Scientists deal with repeatable facts, standardization, and experimentation.

    Clinicians, serious ones as well as scientifically guided ones, tend to value personal experience [n=1] over scientific facts. We often feel that our experiences as so strong that they override scientific facts even when they don't. Good clinicians are able to adjust to the reality in front of them and come up with a workable plan that may not be acceptable to the scientist.

    As I tell many patients the perfect device does no good if it's sitting on the dresser top and not in the shoe.

    Dave Gottlieb, DPM personal opinions only

    Dave,

    Well said. A point Dennis consistently likes to sidestep is the fact that we are NOT simply presenting n=1, on discussion points, but the body of evidence and standard of care depicted in learned articles and textbooks, comprised of a general consensus of expert opinion i.e. a very many n=1. It may, in some cases still simply represent 'opinion', but it is also the aggregate of many experts in agreement with this opinion. That lends credibility to the argument, when a TRUE n=1, carries little to no credibility. 

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