Vertebrae out of alignment? Leg length differences? A back that is too hollow or too convex?

Within physiotherapy we often see that the cause of lower back pain is often explained by wear and tear and aging on the one hand and on the other hand our posture or the position of the spine.

Leg length difference?

One of the most well-known examples is a "leg length" difference. We hear very often that a previous therapist has indicated that the complaints of the lower back are caused by a difference in leg length. When we take a critical look at the observation of leg length differences in practice, there are many snags and catches.

Changes in attitude are often something that a therapist or practitioner has taught himself. Compare it with this example when you are looking for a red car, you will see them more often! In this we cannot blame them, because you are looking for something to treat. But in most cases a leg length difference is not very noticeable or less than 1 cm. And when your leg length difference is less than 1 cm, it is probably not relevant for the development of complaints.

leg length

(Maybe it's also just really hard to do?) In 2016, a study was published where two experienced chiropractors were unable to get agreement on a group of people they were supposed to assess for leg length difference. Comparison of Supine and Prone Methods of Leg Length Inequality Assessment

And not only the previous study shows that pointing out a leg length difference as THE reason for your low back pain is very slippery ice. Back in 1984, a study appeared in the Lancet which clearly indicates that a leg length difference has little to no influence on the development of low back pain. Does unequal leg length cause back pain? A case-control study

Extremes are often very interesting and often tell us a lot. An example of this is people who have undergone a leg amputation. When we look at this group of people we see that the factor leg length difference does not influence whether or not they have lower back problems. By this I mean that people with a leg length difference do not have more or less back problems than the group without leg length difference.

Interesting? Read on here. Low-back pain in transfemoral amputees: is there a correlation with static or dynamic leg-length discrepancy?

Do you want to know when a leg length discrepancy could possibly affect your lower back? Then read here continue on another page. (blog leg length).

Pelvic tilt

Another well-known example is the tilting of your pelvis. This of course goes nicely together with a leg length difference because one may cause the other. I do not mean that a different position of your lower back and also your pelvis is not made up. But the influence it has on the development of lower back pain often is. It often comes down to this: a tilt or rotation of your pelvis is often not noticeable. The idea that a small variation in position is the cause of your symptoms is very unlikely. Your back is simply not that vulnerable.

Another example is a back that is too hollow. As with our pelvis, there is an awful lot of variation in the curve of our lower back between people. We simply do not know how much hollowing is bad. When is it too much? When we start looking at the evidence again we often see that it is not there!

Lumbar lordosis: study of patients with and without low back pain

The biomechanics of the lumbosacral region in acute and chronic low back pain patients

Relationship between mechanical factors and incidence of low back pain

So you have to ask yourself if treating, or wanting to change a back that is too hollow is really useful? People who are so frantic about a hollow back are often the same people who say that sitting for a long time or office work is bad for your back. While this is just the opposite of this posture? Do you still understand?


A small grain of truth

As human beings we walk on two legs. This is probably the reason why there is a lot of pressure on our lower back. If we compare this with people who often sit in a deep squat position (the hollow back is now convex) as people often do in Asia, we see that in this group the spine is less subject to wear. Even in animals that walk and move on four legs, we see wear in the places in the spine where the curvature is sharpest. But even if it is true that in the western world we develop more wear and tear because of our way of sitting and moving, this does not mean that we also experience more pain in the lower back. The degree of wear and tear is not a measure for the degree of pain experienced.

This brings on to us the other often stated cause for your back pain. Wear and tear! A good example is the twin spine study:

Twins from the United States, Canada and Finland have been followed over a period of time. This research looked at several factors that may play a role in the development of osteoarthritis symptoms or wear. This research specifically deals with osteoarthritis of the spinal column. The conclusion of the study is that wear of the spine is largely determined by heredity. This hereditary factor weighs many times heavier than, for example, a heavy profession or a sport where you can expect a lot of strain on the spine. Now you probably think: great! But it also appears that more physical activity and muscle mass have a positive effect on not developing more arthritis in the spine. In twins of which one smokes and the other does not, we see that there is more osteoarthritis.

The belief that our spinal column is a fragile cube that needs to be straightened or can just get skewed has led to people having less confidence in their own bodies. They are really convinced that something is wrong while in 99% of all cases we speak of a normal anatomical variation. The danger is that people become their "diagnosis". What you can do about your symptoms we will discuss in our next blog!


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