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Compensating for leg length difference

Discussion in 'General Issues and Discussion Forum' started by jdbs3, Dec 7, 2006.

  1. Leah Claydon

    Leah Claydon Active Member

    Ref: Chiropracters approach, I recently was on a course that included chiropracters, physios, osteopaths and Pods and a chiropracter demonstrated as follows: patient supine, knees flexed and malleoli together he asked the patient to raise his pelvis 3 times from the couch to 'ensure spine was straight' then he extended the legs along the couch and visually assessed LLD - let's say left was 5 mm shorter at medial malleolus, he then asked the patient lie prone, flexed the knees so that the plantar aspect pointed to ceiling and manually dorsiflexed at the ankle. The patient's LLD had then swapped to the right leg. He said that if this was the case this represented a functional discrepancy and that it arose from the spine but if the LLD had remained on the left side this would represent a structural discrepancy that would need some kind of heel raise. Has anyone else come across this kind of technique? Your thoughts please.
     
  2. David Wedemeyer

    David Wedemeyer Well-Known Member

    There is a technique in chiropractic Leah where they rely on this type of check but not specifically the one that you describe. While it may be a rudimentary and simple screening tool for LLD, the subject is far too complex to rely on this type of "test" in my opinion. Measurements and radiographs should always be obtained for a suspected structural LLD as the treatment will depend on accurate measurement of the actual difference to afford appropriate treatment.

    It is called a Derefield Leg Check commonly used in the Thompson (table assisted) and Activator (instrument) Techniques.
     
  3. David I wrote a reply last night but did not post it.

    Can you help with this point .

    A LLD must be structural

    Functional LLD is bad terminology - really is should all be about the hips or back.

    if the leg are the same length then there is no discrepancy, so really functional LLD is a misnomer, right ?

    ps these are all questions loaded but questions.
     
  4. David Wedemeyer

    David Wedemeyer Well-Known Member

    Must it? I do feel that a Functional short leg is still a leg length difference or (leg length inequality as we learned it LLI) but it is not a true and anatomical difference, correct. I used the term LLD to respond to Leah and it was imprecise of me because what she described was a Functional (apparent) assessment. Rather than murk up the waters I responded to Leah using the same terminology. Never one to argue with a lady anyway!

    This is a loaded question alright! Let's just say for arguments sake that a Functional LLD (FnLLD) can be caused by myriad factors and that there is little agreement among varying professions approaches to assessing and managing FnLLD. Agreed?

    There is a discrepancy but it is functional not structural Michael and it is NOT the length of the legs causing it. To answer your question, there is no "true" difference I agree. The fact remains that there is a 'difference, discrepancy, inequality' what have you that is not structural but is causing the patient symptoms.

    Are you going to pounce now and tell me that FnLLD does not exist? :craig:

    I would like to see the terminology revised because I feel that you are correct Michael, FnLLD is a misnomer but it is a misnomer in wide and common usage in many professions. The actual cause of FnLLD (sic) is actually a confluence of complex functional changes in in the lumbopelvic complex.

    Are you just picking on me sir, or trying to make more precise ? ;)
     
  5. Boots n all

    Boots n all Well-Known Member

    Leah, we use the same method, more than happy with the results and its very visual so that the career/partner can see what you are talking about, a point worth its weight in gold.

    As to how much we would correct first time, that would depend on how long(no pun intended) the client has had the LLD.

    .
     
  6. Can someone explain to me how a health practitioner can "correct a limb length discrepancy" by doing "adjustments" to the pelvis and/or lower extremities? In other words, how does a health practitioner lengthen the femur and/or tibia by pushing and/or pulling on the pelvis, hips and/or legs?

    My eyes roll every time I hear a patient state that their chiropractor or physical therapist has been equalizing out their leg length discrepancy by doing "adjustments".

    Please explain to me how this femoral/tibial lengthening surgery by manipulation works.
     
  7. Was a serious set of loaded questions. Not picking wanting see if my thinking was correct from a man whos option I value.

    Have a nice weekend David.
     
  8. David Wedemeyer

    David Wedemeyer Well-Known Member

    Kevin are we discussing an actual anatomic LLD or a functional one? This goes to Michael's question regarding terminology and I feel the podiatry profession views "discrepancy" as a true, anatomic difference. I often hear colleagues describe them interchangeably, which to me they are not.

    You cannot change an anatomic LLD with manipulation (verified by imaging difference in the length of the tibia, femur or congenital deformity). I roll my eyes at that concept as well Kevin, are they really saying that?

    I value yours as well Michael, thank you. I am teasing you a bit, I'm prone to brevity despite some of what you have seen here on PA (Kevin would hopefully agree that I have a sense of humor). I think your questions were good ones. The terminology between professions gets murky, being precise is important and distinguishing between an LLD and a FnLLD is of paramount importance.
     
  9. If the superior surface of the femoral heads are at the same height from the supporting surface in standing, then there is no limb length discrepancy. Agreed?

    Now, how accurate is it to call someone with level femoral heads, but has a pelvis which is tilted, to have a "limb-length discrepancy"??
     
  10. David Wedemeyer

    David Wedemeyer Well-Known Member

    I agree that if the femoral heads are aligned and no difference in the length of the limbs, that there is no LLD.
     
  11. Then, what is a "functional leg length discrepancy" and how is that measured?

    Why do so many of my patients say that they are routinely adjusted by their chiropractor to bring their legs to being equal? How is that accomplished?

    I don't understand....:confused:
     
  12. David Wedemeyer

    David Wedemeyer Well-Known Member

    Kevin,

    I "get" your point and in all honesty I have no defense. I can only speak for myself and I practice honestly and ethically.

    The functional or unloaded leg length discrepancy (sic) is discussed ad nauseum here:

    http://chiromt.com/content/13/1/12

    The visual check as is not adequate to assess for a functional difference in my opinion. I use a combination of visual, hands-on and functional measurements just as I am sure do you, whether it is an apparent or a functional difference. The leg length visual check has been beat to death in other threads. I had a good row with one of your colleagues over the subject and lifts that I don't wish to revisit (think FFT :rolleyes:).

    In the case of vertebral body rotation and compensatory changes in the pelvis, manual adjusting often helps. The problem remains accurately assessing all causes of the dysfunction as many professions view it differently. No one profession has all of the answers, sometimes "adjustments" have a profound and lasting effect. Other times there is no result and no long-term change, they will come back with the same FnLLD. I have no answer for you there, just an honest observation from my experience over the years.

    If you want a more in-depth explanation of the myriad functional changes that can produce a FnLLD, we can discuss that when I visit. I promise that I am more than willing to demonstrate on you Kevin ;)

    I tend to think that we all exhibit some degree of FnLLD and that it is normal up to a degree and so long as the patient is asymptomatic. I attribute this to the same reasoning that causes the dominant hand shoulder to be lower visually than the contralateral side. Is this normal? I say yes as dominance affects muscular and neurologic development (Apley's Scratch Test is a good example of this for shoulder function; the dominant side will exhibit less abduction and external rotation of one shoulder and adduction and internal rotation of the other shoulder. Normal is considered being able to reach your thumbs up to around T7 or T8 of the thoracic vertebra from the lower back and T4 or T5 of the thoracic spine from above but they will not typically be the same or symmetric . Why? Dominance and development I presume. Try it for yourself if you've never assessed a shoulder complaint before.)

    I won't defend what my entire profession does (no more than will you I am sure), I can only speak for myself and like-minded DC's. I'm sure after some of the epic debates here on PA you will agree that we all have practitioners in our ranks with financial ambitions that don't necessarily reflect best practices. I digress.

    My approach would be never to promise any patient miracles such as "leveling their legs". I do assess low back and lower extremity patients for LLD and FnLLD when it is plausible that it is causing their complaint. I would never use this approach to keep a patient coming back for care. I am aware that others do just as you point out and it is one of the issues that I have with a segment of my profession. It does not make me popular, I can say that with all honesty.

    The need to establish a complete clinical picture is paramount. If a patient comes in with a complaint in their neck for example, that would be the focus of their exam in my office. If they have a low back complaint, I typically do perform a standing, seated, supine and prone examination of their leg length. If they have a history or exam findings that suggests an anatomical LLD or I suspect one of the myriad congenital or acquired pathologies that can cause a true, anatomic LLD they are referred out for films (measurements) to complete the clinical picture and arrive at an appropriate diagnosis and treatment plan.

    If the films are negative and they have lumbar and/or pelvic or sacral pain then the etiology must be bony, muscular or both. The options are lengthy. I treat both bony and muscular causes, I don't believe that you can just "adjust" every complaint away. I also don't believe that it is appropriate to make patients dependant on care using illusory findings of normal phenomenon.
     
  13. Isn't it possible to have someone with their superior femoral heads at the same height from the supporting surface yet having marked difference in the lengths of their femurs and or tibias? What if the leg with the longer boney segments displays marked "bowing" either varum or valgum at the knee? Functionally the limbs may be the same length, yet structurally the limbs are different lengths....?
     
  14. David:

    Thanks for your response. Is there a true belief among some chiropractors and other like-minded health professionals that manipulations/adjustments actually do "correct for unequal leg length" or is this just marketing-talk to get patients to come back for more manipulations and adjustments?

    Also, how would you define a functional LLD?
     
  15. David Wedemeyer

    David Wedemeyer Well-Known Member

    Kevin,

    Again I believe that the terminology is imprecise. While there may an observable difference at the heels lying (as in the Derefield leg check that Leah describes), there is no true difference in the actual length of the lower extremities. This is a functional problem and not a structural one.

    At the same time although the correlation between low back pain for example and this finding is poor in the literature, I often find an asymmetric lower extremity on visual check in mechanical low back pain (LBP) patients clinically. A functional asymmetry may be due to nutation of the pelvis as a compensation for lumbar vertebral body malposition with rotation. In this case specific manipulation will produce an observable difference in the asymmetry, yes, but you’re actually correcting more proximal structures. Changing the relative position of the lumbar vertebral bodies has a profound effect on the function and position of the pelvis, I see it everyday Kevin and the result is what patients pay me for. As I stated it is not a panacea but often the effect is immediate and observable visually and subjectively (VAS) as reported by the patient.

    Why this is so difficult for you to conceptualize I am having difficulty with? Manual manipulation of the vertebra is completely different than the extremities for one very obvious reason; the spinal disc, which is also why LBP is such an endemic health problem due to its structure. I think that may be where you are having trouble with the potential effect of manual manipulation in general? At times the measurable changes in the alignment of the vertebral bodies are profound and an observable change is visible and measurable on plain film over time. You will not find the same effect (radiographic evidence, but I could be wrong) in say a cuboid bone do to the absence of the disc, architecture of the joint and limitations of free movement.

    In other cases there is dramatic muscular influence such as tight quadratus lumborum (QL) and/or iliopsoas muscles, or a combination of the above. As the psoas major and iliacus cross the hip joint they exhibit a strong flexion moment at the hip. A spastic psoas complex or QL can not only mimic LBP and sciatica, they can be the primary cause of an apparent asymmetry of the lower extremity via their location and strong influence on the hemipelvis. We see this syndrome in sedentary patients and especially those who sit for prolonged hours at work as the QL and psoas are highly active during seated postures. Add abdominal wall weakness and general deconditioning to the equation you have a rx for low back pain the next time they walk for a longer than normal periods or lift a heavy object due to the contraction of these muscles and their inability to cope with the new demands of their activities of daily living.

    There are various methods to treat a spastic QL and psoas but they are not relevant to the thread. What is relevant though is that when a LBP patient comes in bowed over and in a high level of pain and you note an apparent limb asymmetry. If we treat the cause of their problem proximally and they obtain relief and resolve, often so does their apparent asymmetry in their “legs”. The asymmetry is not the cause of their problem but a finding and an adaptation. It is a complex interaction and requires more professional diligence than just saying “you have a short right leg Mr. Smith, we’re going to fix that today (or over six months!)

    The above examples are functional asymmetries Kevin and they are real clinical entities.

    In another thread I advocated a full orthopedic exam of the lumbar spine and pelvis to localize the etiology which would include the Thomas and Ely’s test among others. Their treatment may include chiropractic manipulation, physical medicine or both. I never use a lift for this subset of patients, tried that early on with poor results.

    I quote Stanley here because at the beginning of the thread I feel that his comments were very relevant and interesting:

    It would be interesting to hear Stanley’s comments on potential causes because I feel that all health professions encounter apparent or FnLLD and all treat them differently according to their scope and focus. I feel that here a cooperative effort is crucial and of benefit.

    To answer your question more directly yes, it is a commonly held belief in the chiropractic profession that a functional asymmetry can be corrected (at least in the short-term) via manipulation, manual therapies, functional exercise etc. Why? Because we see it every day. In my opinion the terminology “Leg Length Difference” is imprecise and incorrect, I agree with you (and Michael) here. They are correcting an asymmetry of more proximal structures. Is it often used as “marketing-talk to get patients to come back for more manipulations and adjustments?”? Yes I believe that that is true. Do these issues recur and is there a long-standing asymmetry in some patients who are now asymptomatic? Yes, not all asymmetries are resolved via manipulative treatment and yet the patient is asymptomatic. I like to think of them as normal variants that require no further treatment unless symptomatic.

    I covered creating patient dependence on chiropractic care previously. In a perfect world there would be a whole lot more Chiefs and fewer Indians.
     
  16. Happens a lot to me just before I'm about to start some measurements.

    Pt -one leg is slightly longer

    Me- which one and have you had it measured?

    Pt -can't remember, but I go the (insert physio,chiro,osteo) and they make the shorter leg longer by pulling on the shorter leg and working on my hips

    Me- really then I pass them my pen and ask them to make it longer by pulling one end of the pen, which

    Pt- I can't do that

    Me- without very large amounts of surgery no one can make you leg longer either

    Happens every week, I sugar coat it a bit more does drive you nuts
     
  17. David:

    You don't need to duck your head David, I'm not hunting chiropractors this weekend.;)

    However, as the one chiropractor whose opinion that I trust on Podiatry Arena, I am relying on you, David, to be somewhat of a spokeperson for your profession on this podiatric forum. I'm sure I'm not the only podiatrist who is often confused or skeptical about certain terminology used by other health professionals which, many times, become most evident to us when our patients tell us stories of what happens at the offices of their chiropractors or other "manipulative specialists". In other words, I want to understand more about chiropractic medicine and how it can help my patients, but also am somewhat skeptical of much of what some of your colleagues do and say on a regular basis to our patients.

    As far as the podiatric world is concerned, a structural limb length discrepancy is defined as a difference in length of the lower extremities when measured from the ankle joint to the hip joint. A functional limb length discrepancy is defined as a difference in the height of the hip joints due to asymmetrical height of the ankle joint from the ground which, in turn, is due to asymmetrical rotational position of the subtalar joint and/or midtarsal joints during relaxed bipedal stance. By the way, these definitions above are ones you are unlikely to find in any podiatric reference (i.e. since they are educated guesses on my part), but these definitions probably represent what most podiatrists mean when they use the terms "structural leg length discrepancy" and "functional leg length discrepancy".

    If there is an asymmetry in the rotational position of each hemi-pelvis above the hip joints, and the hip joints are otherwise level during relaxed bipedal stance, then this should not be considered either a structural or functional limb length discrepancy. Rather, this should be considered an asymmetrical rotational positon of the pelvis or a pseudo-limb length discrepancy since the pelvis, above the hip joint, should not be considered as a structural component of the lower extremity any more than the scapula or clavicle should be considered to be structural components of the upper extremity.

    It is my opinion that the various pelvic and lumbar vertebral manipulations you have outlined do not change limb length but, instead, may result in an apparent change in the three dimensional spatial location of each hemi-pelvis to the other hemi-pelvis while the patient is standing in relaxed bipedal stance. In addition, these manipulations, even though they may appear to alter the limb length [since limb length is most often measured with pelvic reference landmarks], in fact, these manipulations do not actually affect the heights of the hip joints from the ground in relaxed bipedal stance.

    These differences in terminology have been bothering me for the past 20+ years and it is about time someone spoke up in their respective medical professions to clear the confusion and bring out the biomechanical truths about what "limb length discrepancies" are and are not. In this way, a better understanding of the human locomotor apparatus and its pathologies may be appreciated by the many health professionals that have an interest in the subject.
     
  18. David Wedemeyer

    David Wedemeyer Well-Known Member

    Good illustration Michael.

    Whether you believe in manual therapy or not what we are discussing is the complex interaction between the axial and appendicular elements as measurable at the heel; the apparent leg length is a common term. IF there is an appreciable change (no matter how dramatic or ephemeral) it is not a change in the physical properties of the bone or length of the bones.

    Have we satisfied the question of the notion that the actual measurable length of the lower limbs is being miraculously changed by these interventions and that the terminology is very inappropriate?

    Are we in agreement that a clinical entity termed a functional short leg is acknowledged and addressed by our professions?

    PS I posted this just after you did and did not see your response. Thank you kevin
     
    Last edited: Feb 19, 2011
  19. David Wedemeyer

    David Wedemeyer Well-Known Member

    Just this weekend Kevin? Kidding, good to hear!

    Thank you Kevin. By now you know that I try to be as unequivocal and honest as I can. I highly doubt that I am the one to speak for my profession but I do not mind at all answering these questions. I wish for my profession to advance and abandon certain long-held beliefs and practices, to communicate openly with other professions and to back our claims with science and research where possible. This begins at the didactic level and trickles down and it is evolving albeit slowly.

    This is possibly where the difference and confusion in lexicon lies. We would of course look at the spine and pelvis first and from your response I now better understand how a podiatrist would view it. I believe that both are valid approaches and are a result of our focal training.

    Perhaps you should speak for my profession, well done! I have no argument with your explanation Kevin with one caveat. Systems such as Gonstead are very precise in using radiography and standard mensuration lines to assess the lumbopelvic complex and document changes in the course of treatment. I can say without any doubt that changing the lumbar/innominate/sacral relationship can effect a dramatic change in Ulman's Line, the Lumbar Gavity Line and resultantly the height of the femoral heads via the spatial relationship of the hip joint.

    I commiserate with your frustration. I am working from both sides being a DC and spend nearly all of my free time communicating with DPM's. I hope this thread is helpful to anyone else who has shaken their heads at the confusing difference in terminology and approaches. On the approach to treatment I feel our professions have much to learn from one another.

    The interesting thing that came to mind today was seeing a colleague post enthusiastically about what a great resource this forum is and that it is sorely lacking in chiropractic (which is giving me ideas...). You responded that the contributors make it what it is and ultimately Craig and all that contribute alongside him must be congratulated on a job well done! This forum has opened the lines of communication for any professional interested in podiatric biomechanics and for me has been a career changing course of learning. Thank you.

    Best Regards,
     
  20. Stanley

    Stanley Well-Known Member

    Hi Dave,

    Only because you asked, I am answering this question.

    30 years ago, almost every patient I had received a heel lift, as I thought everything was structural. In 1981, I took a post graduate physical therapy course at Cleveland State which had to do with muscle energy techniques for treating sacroiliac and ilio-sacral joint dysfunctions. So at that time I thought everything was either structural or sacroiliac in function. The sacroiliac dysfunction was caused by a muscle imbalance either a tight or weak muscle. For example a tight hamstring would cause a posterior innominate on that side if the patient was a runner who was doing speed work. This would result in a functional shortage on the side of the posterior innominate.
    Fast forward to the present. Depending on findings in my exam which is ASIS to the ground, PSIS to the ground and ankle dorsiflexion, I will find the cause to be either a lateral talus, a lateral cuneiform dysfunction or a TMJ dysfunction. These can be primary or caused by a cranial sacral dysfunction or emotional issues. Occasionally I will find a weak tensor fascia lata (which shows when you derotate the pelvis on the transverse plane the pelvis rises on one side) or a weak quadriceps of hamstring which causes an ilio-sacral dysfunction.
    As far as a structural leg length, it is extremely rare.
    To give an example of what I am talking about. If a patient has level ASIS's, the PSIS's are unleveled, and no equinus. I find that one of the talus has a lateral dysfunction. I correct it by treating the cervicis ligament usually on the side of the low posterior innominate.

    Regards,

    Stanley
     
  21. Griff

    Griff Moderator

    Don't worry everyone - it's finally all been worked out by some bright spark. How do we overcome leg length discrepancies??? Run barefoot of course! (we should've worked that one out!)

    http://fb.me/IcbCU3Et

    Warning: Do not click this link if you have had a bad day...
     
  22. hylander

    hylander Member

    Hi Kevin, Here in the UK it's called 'rounders' and is generally a kid's game! :D
     
  23. In working with many runners' it is very clear that the individual with the LLD has already had many compensatory mechanisms and the art of lifts for correcting short and long legs is a transition..i.e. slowly making the changes based on continued mechanics. The body is a unit...it certainly works that way
     
  24. Here's my theory: the body compensates for limb length discrepancies by making the shorter limb stiffer and the longer limb more compliant.
     
  25. Bruce Williams

    Bruce Williams Well-Known Member

    Simon;
    i know it is splitting hairs, but I think it depends on what segment of the foot and leg you are referring to.

    What about a short limb that externally rotates at the hip in compensation and ends up with a bunion? Where is the stiffness of that medial column?

    I think you need to talk about stiffness in a more segmental aspect, but that's just my opinion.

    Overall I tend to agree with the stiffness definition, but we still all need to define when stiffness is a good thing and when it is not. My opinion.

    Cheers,
    Bruce
     
  26. Stanley

    Stanley Well-Known Member

    Hi Bruce,

    I like your point. The short leg that develops an equinus in a better class runner is what you are talking about. This leg compensates for the equinus, and hence the toe out and the pronatory changes which shorten the leg more. The end stage compensation of this is an anterior innominate on that side (if not, there is a severe hip drop). I also like the compliance/stiffness concept, but it does not seem to explain all that goes on, but I am open to hearing an explanation from Simon.

    Regards,

    Stanley
     
  27. Bruce, I don't have a lot of time right now as I'm preparing for my lectures in Belgium next week. Ultimately it is the net stiffness of the leg which I am referring to. So if we have a segment with decreased stiffness, another segment will demonstrate increased stiffness, but overall the shorter leg has to have a higher dynamic stiffness than the longer leg.

    What influence does the externally rotated limb position have on hip / knee stiffness?

    What influence does hallux valgus have on foot stiffness?

    Stanley,

    It is interesting to note that forefoot strike running results in greater leg stiffness. Does the equinus ankle position increase leg stiffness? It seems that way. In which case your example reinforces my hypothesis.

    How much change in leg length occurs with foot pronation, Stanley? Why do some people have feet that pronate more on the shorter limb and some people have a foot that pronates more on the longer limb?
     
  28. Stanley

    Stanley Well-Known Member

    I don’t know if the equinus increases stiffness. I do know that an equinus position allows for more shock absorbtion.

    I am not sure how much pronation shortens a leg, but I think it would be approximately 1/4".

    First we have to ask “Does the body want to shorten a long limb or lengthen a short limb?” The answer is whether we want a high gear or a low gear. For low gear we see shortening compensations on the long side, for high gear we see lengthening compensations on the short side. If the individual functions at a slow speed then we will see shortening compensations. Initially, knee flexion, but that is an inefficient way to compensate and that gives way to hip rise and pronation.
    If the individual functions at high speed or has functioned at high speed earlier in life, we will see an equinus on the short side. As time goes on, the equinus decompensates, and we end up with a toe out and pronation on the short side along with either a severe hip drop or an anterior innominate.
    When I was a student, Dick Schuster used to say that the long side pronated, and Steve Subotnik used to say it was the short side that pronated. Dick took care of weekend athletes in New York City, and there was never a shortage of them.
    Subotnik took care of the better class runners.
    So some of this goes along with your theory. Stiffer springs are required for race cars, and according to your theory, the shorter leg stiffens (lengthens in faster runners).

    Regards,

    Stanley
     
  29. healthyfeet

    healthyfeet Active Member

    It was interesting reading all the posts. i know alot of podiatrists are 'afraid' to adjust a LLD. Probably as from experience it often appears that when we add raises or posts, the opposite affect appears to happen to the posture or gait from what we would expect!
    I generally start with a raise 50% of what i assess to be the LLD. When its difficult to tell if you've actually added the raise to the 'short' leg shoe, sometimes you can confirm your diagnosis by temporarily adding the raise in the 'wrong' shoe first! This will usually show up the mistake more obviously, and usually the patient will also tell you that its wrong too! Usually i add raises in combination with asymmetrical posts. We shouldn't always try to 'fix' a LLD problem in one visit!

    When i worked in the NHS gait lab around 15 years ago, we used as little as 3mm raises for children and often saw a marked change to gait and symmetry even with 3mm!
     
  30. Leah Claydon

    Leah Claydon Active Member

    Would you correct a functional LLD in a patient with scoliosis? This has always been a quandry for me. I'm a pod with an 18 yr old daughter with a moderate scoliosis (22 degree Cobb angle) which creates a lifted and anteriorly tilted pelvis on one side. Her limbs are anatomically equal but the lifted pelvis makes her have an functional LLD resulting in marked supination in one foot and pronation in the other. In this situation would you:

    1. Only treat the excessive pronation and supination and no raise?

    2. Add a whole foot raise to level the pelvis and hope that prevents the need to compensate by pronating and supinating?

    3. Do both of the above?

    4. Do nothing (probabaly not an option as she has discomfort L5/S1, hip pain in functionally short limb that is helped by daily exercises).

    I work in a multidisciplinary clinic with physios and osteopaths, we all have different ideas on this but having read the threads above I am curious what other pods would do.
     
  31. Stanley

    Stanley Well-Known Member

    Hi Leah,

    From a foot orthosis only treatment protocol (that is not treating the pelvis or spine via neurologic, muscular or manipulative means), I would first evaluate the patient statically and then walking. I would check the ASIS and PSIS in NCSP and RCSP. (standing is the proper way to evaluate leg length). I would also check the dorsiflexion. In walking I would look at the head. I would look for the height of the head at midstance of the left limb and the right limb. If there is a difference, then the leg at midstance with the head elevated maximally is the functional long limb. One of your goals is to balance out the asymmetrical elevation of the head. Another goal is to eliminate any pelvic effects from the foot. To do this is to look at the difference from NCSP to RCSP of the ASIS and PSIS to determine if being in NCSP reduces the pelvic torsion. If this helps, then you need to make an orthosis that mimics this position. If there are no pronatory symptoms and pronation does not affect the pelvis, then the only reason to make orthoses is FnHL.
    The lack of dorsiflexion ideally determines the amount of heel lift required. The heel and sole lift ideally would then be added for the amount of lift required.
    Any of the above is not set in stone, as a pelvic manipulation or changing a muscle in the spine can change the postural pattern.

    Regards,
    Stanley
     
  32. Peter1234

    Peter1234 Active Member

    Great postings, thanks everyone for sharing their opinions. I quite honestly think that as podiatrists we need to understand the pelvic and low back muscles more before we treat leg length discrepancies with heel lifts.

    Having said that, when I undertake an examination I check the patients medial maleoli supine after 'bridging', then i do the lying to sitting test- that will show me any changes that occur when there is flexion of the pelvis- if there are changes at the medial maleoli- the test will tell me how much pelvic rotation is involved in the leg leg difference.
    I then check internal and external rotation of the femurs with the patient prone and knee flexed - this can confirm asymmetry of the hip ab and adductors - hamstring, quad and iliopsoas, and maybe most importantly ankle equinus of one side.

    I then assess them standing and normally check the PSIS and iliac crests, in RCSP and NCSP and check for differences in height.

    I finally get them walking and look at the lower limb alignment, and any asymmetry at the head from one step to the other, and other signs such as early heel lift etc etc.
    If i am still convinced they have a longer leg, I will suggest half of their leg length difference as a heel lift if I think their complaint is related to their LLD.

    Any feedback or comments???
     
  33. Peter1234

    Peter1234 Active Member

    Hah, I just saw your posting Stanley, snap -
     
  34. Peter1234

    Peter1234 Active Member

    I would probaly try out changing her amount of supination and pronation first, and see how the pelvis aligns - PSIS, ASIS. If she is level at the pelvis, great - if not, try adding a heel lift to the 'functionally' shorter limb and see what it does. If you take David's advice from above where he says not to add a heel lift if a shorter leg is on the concave side of the spine, I dont think you can go far wrong.
     
  35. Rob Kidd

    Rob Kidd Well-Known Member

    At the risk of being shot down for "being in the twylight of my years" (misquote - comment about Churchill in the Wilderness), in the years I taught biomechanics at schools of podiatry in four countries, I found measurement to be essentially a waste of time. This was 1) because a hopeless lack of reproducibillity, and 2) a probable irrelevance to the actual issue - all being compounded by structural/functional issues. In collaboration with others we introduced "the telephone book treatment"; a 'phone book was turned by as many pages as deemed clinically sensible, the patient stook on, tested, adjusted by some pages, and so on. This level of raise was then made, and tried out. In terms of health care outcomes - I mean - who cares about numbers? this was found to be highly successful. I await to be shot down.
     
  36. why´s that makes sense

    I do something similar with EVA sheets
     
  37. Stanley

    Stanley Well-Known Member

    Hi Rob,

    I used to use a prescription pad.

    Regards,
    Stanley
     
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