The evaluation and treatment of back pain is often interesting because there are so many reasons for this condition. I will briefly highlight the back pain and sacroiliac pain associated with bilateral lower extremity inequality and explain how I use a combination of orthopedic and other treatments to treat this condition. First, bilateral lower extremity inequality can be divided into two different categories: 1. Structural a difference in the long bone measurements of the lower extremities. It may be hereditary or traumatic. 2. Functional – The biomechanics of the body is affected for various reasons, such as physical compensation and trauma, including: (1) Muscle imbalance due to activity, such as poor training techniques. (2) Habitual: for example, always sleeping unilaterally. (3) Trauma: trauma to soft tissue, not bone. In my experience, common symptoms associated with bilateral lower extremity inequality may include (1) Headaches (including migraines) (2) Blurred vision (3) Misalignment of jaws (4) Neck and shoulder pain (5) Back pain (including slipped discs) (6) Foot pain (7) Ankle pain (8) Knee pain (9) Hip pain (anterior or posterior pelvic distortion) Muscles, blood vessels, and the nervous system may also be affected. Osteoarthritis at the joints, mainly on one side of the body and scoliosis (including idiopathic) are also typical features of bilateral lower extremity inequality and pelvic distortion. In patients presenting with back pain, I always start with the basics and complete the full biomechanical evaluation, including long bone measurements as well as more basic anterior and posterior rotational volumes. The patient is first examined for the presence of unilateral or bilateral anterior rotation. If the patient has unilateral anterior rotation, we need to determine if the patient has: 1. suffered a trauma where the ligaments in one foot may have ruptured or elongated more than the other foot. This results in more anterior rotation of one foot, producing a functional short lower extremity. 2. exhibits a lateral tibial torsion with hip pronation: the psoas major and adductor muscles tighten to correct the foot position. This will either twist the pelvis forward or, in the case of medial tibial torsion, the pearls, iliotibial bundle and gluteus muscles may tighten as a surrogate for torsion to try to correct the inward eight position. All of these compensations can twist the pelvis forward or backward, causing functional bilateral lower extremity inequality ask 3. Exhibit long lower extremity compensations, with structural long lower extremity rotation coming forward to balance the pelvis. For this substitution, the patient may present with unilateral knee valgus or a bent knee position. Next, we need to determine if there is a true structural inequality, starting with a lower extremity length measurement using the N A S technique. This can then be verified using either a CT scan image of the lower extremity length computed tomography or plain x-ray film (the latter, in my opinion, is less accurate than the CT scan image and has a higher radiation intensity). Whenever treating back pain and sacral joint pain, I always recommend evaluating and treating structural bilateral lower extremity inequalities. In cases of functional and structural bilateral lower extremity inequality, the longer lower extremity is more likely to suffer from hip country joint wear, which, if left untreated, may result in the patient needing a hip replacement later. Therefore, it is important to inform patients of the consequences of not treating lower extremity asymmetries if they are present. Some doctors will say that the body can naturally compensate for this discrepancy, so what is the need for orthotic insoles and heel raises to balance the pelvis? My answer is, if you were sitting at a table that was rocking from side to side, would you use a wooden wedge to level the table and stop the rocking? Most people would say yes! Well, if the wobbly years are bothering you, imagine the impact of a 3-4mm bilateral lower extremity inequality on the patient’s biologic eclipse structure. Treatment If the patient’s condition is due to hip compensation, then they will need adjustments or exercises to “square up” the pelvis, stretching and strengthening exercises to correct the abnormality. Orthopedic insoles are also used to realign and correct the associated biomechanical abnormalities. In my experience, a combination of orthopedic therapy, adjusting dental exercises, and muscle stretching and strengthening will yield the best treatment results. If the patient has a structural deformity that is not due to a recent trauma-related imbalance, then the use of heel pads for structural short lower extremities is required. I recommend either starting with a nephrologically measured unequal volume of both lower extremities in half, or starting with a heel pad of approximately 4rnm and adding that amount to the orthotic insole only. After this is done, the amount of heel pad height can be gradually increased. This is because it will alleviate the initial discomfort and allow the soldier to adapt more quickly. Contraindications to this condition are fusion or osteoarthritis of the spine, as the treatment may cause more pain for the patient. If you use an ICB orthotic insole on a patient without measuring the length of the lower extremities and the patient does have structural bilateral lower extremity inequality, the orthotic insole will eventually remove the normal compensation of the body’s “long legged front”, resulting in restriction and interference with the hip joint. This interfering effect will cause problems with the sacral joint (STJ) and the long lower extremities may also cause scoliosis to occur, as described by Blake & Ferguson in 1992. It is not recommended that no orthopedic insoles be used, only that heel pads be placed in the shoes of the short lower extremity. This may cause lower extremity length problems on the short lower extremity side because the more one structural lower extremity will continue to rotate forward due to ligamentous laxity that has developed over the years. However, with the use of a heel pad alone, the interference that initially occurs in the long lower extremity hip may transfer to the short lower extremity side as the short lower extremity now acts as a functional long lower extremity, thus never eliminating hip and low back pain. The use of an orthotic insole is never recommended because the foundation needs to be balanced and the necessary biomechanical corrective attachments need to be added to the orthotic insole. In summary, follow these simple steps to treat back pain and associated bilateral lower extremity inequalities: 1. Measure and confirm the presence of structural or functional bilateral lower extremity inequalities. Use the NAS technique to measure the length of the lower extremities – then confirm using CT scan images. 2. Treat “long lower extremity rotation anteriorly” with an ICB orthotic insole shaped to the patient’s neutral heel in stance, and add a heel pad to the orthotic insole for the short lower extremity. It is recommended to gradually raise the short lower extremity. If the amount of inequality is large, start with half of the measured amount. If the patient has suffered a trauma in the last 6 months, the full amount can be added to the orthotic insole after the rehabilitation period, when the patient’s body has not yet begun to compensate.