Letters to the Editor  |   February 2014
Author Affiliations
  • Donald R. Noll, DO
    Professor of Medicine, New Jersey Institute for Successful Aging, Rowan University School of Osteopathic Medicine, Stratford
Article Information
Imaging / Neuromusculoskeletal Disorders / Osteopathic Manipulative Treatment / OMT in the Laboratory
Letters to the Editor   |   February 2014
The Journal of the American Osteopathic Association, February 2014, Vol. 114, 81-82. doi:
The Journal of the American Osteopathic Association, February 2014, Vol. 114, 81-82. doi:
I thank Dr Juhl for his thoughtful letter to the editor1 regarding my study published in the September 2013 issue of The Journal of the American Osteopathic Association (JAOA).2 It was a pleasure to read Dr Juhl's literature review and discussion of pelvic functional mechanics. I will only offer a few additional thoughts for discussion. 
Although the standing lumbosacral (SLS) radiograph may be our reference standard, sadly it is not the method of choice for the larger biomedical research community. In 2002, Gurney3 reviewed the literature on LLD, and in 2008, Sabharwal and Kumar4 published a systemic review of 42 articles describing methods for measuring leg length discrepancy (LLD). Neither of these reviews mentioned the SLS radiographic method of assessing LLD. These researchers do not seem to know about measuring LLD by comparing the relative positions of the heads of the femurs on a standing radiograph. Typically, the rest of the world assesses LLD by measuring the length of each limb by various ways and then comparing the difference between the 2 limbs. Some of these methods are supine and some are standing. There is an indirect method to assess LLD by putting blocks of known height under the apparent short limb until both iliac crests appear level by palpation.5 
We may forgive these allopathic authors for not knowing about the SLS radiographic method or even Dr Juhl's work for several reasons. First, the literature cited by Dr Juhl in his letter1 is rather old, and few researchers do literature searches as far back as the 1950s. Second, the few relatively recent articles describing the SLS radiographic technique6,7 do not use the terms limb or leg length in the title, so they are easy to miss. But I think the main reason the SLS radiographic technique was overlooked is that the osteopathic medical profession publishes too few scholarly papers. Collectively, we are failing to make the impact we should have on the larger biomedical research community. The osteopathic medical profession has a wealth of pragmatic knowledge, but it is failing to translate that knowledge into evidence-based, peer-reviewed literature, which is the driver of modern clinical practice. In this sense, Dr Juhl is a hero because he has already done far more than most to counter this problem. 
The genesis for my research was a simple clinical observation: when my patients present with unilateral knee pain, more times than not it is on the side of the apparent short leg as measured by the supine medial malleolus physical examination technique. Any osteopathic physician has the skill to check this observation. When I read a study showing that LLD by whole limb length radiographic assessment was associated with progressive and symptomatic knee osteoarthritis in the short limb,8 I decided to collect data to see if my observation was so. Assessment by physical examination is far less expensive and easier than radiographic testing and should correlate reasonably well. I opted for an observational study design, one that would allow me to collect the data during my busy office practice. Whereas randomized controlled trials are always better, these projects take considerable time and money to conduct. Confirmatory clinical trials can come later; it is better to start somewhere than nowhere. 
I agree completely with Dr Juhl1 that this physical examination technique is not the reference standard and should be termed “apparent” LLD. Measuring the supine medial malleolus bony landmarks for leg length is like measuring the length of 2 poles by comparing their relative positions at 1 end without being sure that the other ends are lined up evenly. The beauty of the SLS radiography method is knowing that 1 end is level (the floor). The examiner only needs to measure the relative difference between the femoral head heights to find the anatomic LLD. 
I agree that we should not dismiss the role of sacral base unleveling in LLD, especially in the standing position. Nevertheless, I am not sure the sacrum influences apparent LLD when the patient is supine and the iliac crests are approximately equal. Because the femoral bones attach directly to the innominate bones (of which the iliac crests are a part), it seems to me the positions of the innominate bones would govern supine apparent LLD, regardless of sacral base unleveling. I do believe the position of the sacral base is very important, especially for things such as gait, back pain, and scoliosis. 
I hope Dr Juhl persists in his efforts to publish the rest of his work in a peer-reviewed journal. His work is very important. Reviewers can be overly restrictive, demanding, and even unreasonable, but they have the responsibility of ensuring scientific quality. My study2 was rejected by 2 journals and had to be revised multiple times before the JAOA would publish it. One journal loved the concept but rejected the manuscript because it was not a randomized controlled clinical trial. The other journal was reluctant to publish it because the data collection was not fully blinded. These are legitimate concerns, but we should be realistic and acknowledge that it takes substantial financial resources to overcome these limitations. 
As a profession, we do not invest much money into osteopathic medical research, even though it is the single most important thing we could do to secure our collective future. While the profession is exploding in size, practically doubling since 2000, the spending by the American Osteopathic Association (AOA) on osteopathic research has remained flat. Degenhardt and Standley9 recently pointed out that the AOA, through its Council on Research, spends approximately $250,000 per year on research from funds originally donated by members of the profession in the 1990s. As of May 31, 2012, there were an estimated 69,429 osteopathic physicians in active practice,10 making this amount equivalent to spending approximately $3.60 per practicing osteopathic physician per year on research. Or, if the money was divided equally among all of the 29 colleges of osteopathic medicine (not counting branch campuses or additional locations),11 each would receive $8620 per year to conduct research. This amount is not much money. 
It is sad that we encourage osteopathic medical students and residents to conduct small research projects and present posters at research conferences when the profession is failing to invest sufficient funds to support them if they want to go further. Of course, student and resident research projects are of great educational value. Those who complete an original research project from conception to publication have a much deeper understanding of evidence-based medicine. But at current funding levels, virtually none of these students or residents will have an opportunity to develop a career in osteopathic research. 
To reach a critical mass, we need to provide sufficient funds to support both developing and established full-time career osteopathic researchers. It is a mistake to depend on funding external to the profession because osteopathic research is not a priority outside the profession. It is our responsibility to first make a sufficient investment and then perhaps we can realistically expect greater funding to come from the National Institutes of Health and other external sources. 
The current AOA strategic plan for research calls on every member and college to financially support osteopathic research.9 The AOA can show leadership by restoring the full $50 per membership fee investment into the Osteopathic Research and Development Fund. Anything less will be inadequate for the task. 
Juhl JH. Leg length discrepancy and osteoarthritic knee pain in the elderly [letter]. J Am Osteopath Assoc. 2014;114(2):79-80. doi:10.7556/jaoa.2014.018. [CrossRef] [PubMed]
Noll DR. Leg length discrepancy and osteoarthritic knee pain in the elderly: an observational study. J Am Osteopath Assoc. 2013;113(9):670-678. doi:10.7556/jaoa.2013.033. [CrossRef] [PubMed]
Gurney B. Leg length discrepancy [review]. Gait Posture. 2002;15(2):195-206. [CrossRef] [PubMed]
Sabharwal S, Kumar A. Methods for assessing leg length discrepancy [review]. Clin Orthop Relat Res. 2008;466(12):2910-2922. doi:10.1007/s11999-008-0524-9. [CrossRef] [PubMed]
Hanada E, Kirby RL, Mitchell M, Swuste JM. Measuring leg-length discrepancy by the “iliac crest palpation and book correction” method: reliability and validity. Arch Phys Med Rehabil. 2001;82(7):938-942. [CrossRef] [PubMed]
Juhl JH, Ippolito Cremin TM, Russell G. Prevalence of frontal plane pelvic postural asymmetry—part 1. J Am Osteopath Assoc. 2004;104(10):411-421. [PubMed]
Willman MK. Radiographic technical aspects of the postural study. J Am Osteopath Assoc. 1977;76(10):739-744. [PubMed]
Harvey WF, Yang M, Cooke TDet al. Association of leg-length inequality with knee osteoarthritis: a cohort study. Ann Intern Med. 2010;152(5):287-295. doi:10.7326/0003-4819-152-5-201003020-00006. [CrossRef] [PubMed]
Degenhardt BF, Standley PR. 2013-2022 strategic plan for research: a role for everyone in promoting research in the osteopathic medical profession. J Am Osteopath Assoc. 2013;113(9):654-659. [CrossRef] [PubMed]
2012 Osteopathic Medical Profession Report. Chicago, IL: American Osteopathic Association; 2013. Accessed December 30, 2013.
Commission on Osteopathic College Accreditation. Colleges of osteopathic medicine. American Osteopathic Association website. Updated November 18 , 2013. Accessed December 30, 2013.