Leg length discrepency how do you measure clincally?

C'mon dennis. You're not even trying now. What about the questions concerning the inconsistencies?

 

Lets debate this:
Possibly on its own thread if the Administrator approves as I answer Roberts questions.


The thing that prevents me from answering or causes you to ask questions is that it is impossible to debate or research feet because of their huge variations as one package because there are too many exceptions to any rule that is developed.

Root, Kirby and Dananberg have spent their careers focused on one aspect of some feet (rearfoot or forefoot) and have built a valuable body of evidence on how to diagnose, treat and monitor those feet.

The Rigid, Neurological Cavus Foot cannot pronate against momentary forces in the rearfoot, it cannot resist a dorsiflectory moment of the first metatarsal and has no element of FHL in the forefoot and if this type of foot is used for clinical or level 1 EBM research, the results would be devastatingly bad when applied to all feet.

So, some feet pronate and others supinate, some develop bunions and others not, some have posterior tendon dysfunction and some do not.

Examination of all feet, no matter what, without profiling them into groups having similar characteristics leads to the kind of debates that red herring all of us away from our common goal:
Biomechanical Patient Care for Humanity

These debates lead to anger from opposing camps :boxing:.

In order to have fruitful debate you must argue isolated subjects that adher to one biomechanical rule (isoloate on Kirby or Dananberg for a moment and forget all other feet when debating). They are research models that offer answers for to some feet and debate and harm to others.

Because when you debate that a foot that compensates LLD on the sagital plane with arguments over what it is doing on the frontal plane (i. e. the pronation-supination argument) it leads to what Dr. Payne lectures about and that is when it comes to biomechanics we have proven very little.

What we need is a system that separates feet into groups having common characteristics so that we can build a central body of valuable research when combined.

Examples would be the flexible rearfoot of Root and Kirby or the flexible forefoot of Dananberg.


Holy Moly Caped Crusader. What about a foot typing system?

:drinks :drinks :drinks

Dennis

 

Dennis as far as this thread the subject is LLD so why the reference to Root, Kirby and Dananberg I don't know, do you? I am also struggling with how a foot typing system addresses LLD when the foot is not the cause but may be affected by LLD.

We probably all agree that there are several methods to evaluate a structural LLD but that the real proof lies in radiographic measurement. When a true LLD exists often lifts perform very well in addressing the issue, sometimes the difference needs to be addressed in the sole of the shoe for obvious reasons.

Likewise different professions have very different methods for evaluating and treating functional leg inequalities and many of those have been explored here. I encounter FnLLD every day in my practice and the treatment is never a lift, but much more complex. We are not symmetric and a great number of us are walking around with some measure of FnLLD, the body will compensate though through a very complex system of adaptation more proximal. The most effective treatment is more proximal as well so how you weave foot typing into this escapes me.

Are you suggesting that LLD is mainly due to factors found in in the foot?

 

close the boards and board up the university craig. It's impossible to debate or research feet.

After 5 pages of debate you now won't answer my questions because it's impossible to debate feet.

Thank goodness. I thought you were going to be evasive and dodge the questions again.

"Can't pronate against a momentary force.". Classic! What's a momentary force dennis?

Actually, never mind. We're discussing your model. Stop trying to dodge or divert. Nobody is buying and it's painfully obvious. Answer the questions.

 

Our international friends may not have seen this one. This is National treasure Jeremy Paxman demonstrating the correct approach with someone who won't answer the question.

http://www.youtube.com/watch?v=BklT7Qy07Is

Remind you of anyone?

 

You mean like the one in Valmassey Chapter 3?

Its great. It has a grid with forefoot on one side and rearfoot on the other and it looks at whether the forefoot / rearfoot is inverted / supunated or everted / pronated. So you end up with a foot in one of the boxes depending on rearfoot or forefoot positions / ranges. Each "functional foot type" is then catagorised and observations are made for each type in terms of the sorts of problems that type suffers from.

It goes on to talk about rigid and flexible feet and such.

Dr Scherer and Dr Morris have every right to be proud of THAT piece of intellectual property! :drinks It's so hard to come up with a truely original idea isn't it.

Hope they patented it. Otherwise ANYONE could just tweak it slightly (say by changing inverted to rigid, perpendicular to stable and everted to flexible), trademark it and claim it as their own intellectual property.

But we digress.

 

Good to see you back in fighting form Dennis.

To some extent I think all practitioners start to build a mental resource similar to your FFT. Pattern recognition is what I believe it is called and I believe it is talked about at some length in a paper I studied in first year of University, looking at expert practitioners vs new grads and how they differ in how they go about diagnosing problems. I'll dig out the reference if anybody is really that interested...

As I've said before, FFT is all very well and good, but ultimately if you have only N number of foot types with which to categorise a foot you only have N number of options for treatment, diagnoses etc. I much prefer to look at each foot and understand what is going on to cause this.. some of them I can delve into my mental Pattern Recognition Locker and hey presto I have a veritable arsenal of previous knowledge on what to do in that situation, I can tailor my diagnostic tests and interventions a little more specifically..

On the other hand, some I need to take time with, look at, think about, break down the RoMs, timing in gait, look at all the factors, sometimes get a second opinion from another practitioner, because I'd need a FFT with more windows than the IFC tower on Hong Kong Island to have one big enough to include a foot that crazy.


Also, I had a patient today. 16 year old girl with a limb length inequality of approximately 1.5cm.

She compensated for it by hyper extending the knee of the shorter side which lead to the foot having a heavier heel contact and it appeared to me like the foot of the shorter leg was pronating more than that of the longer one. I must be seeing things.

As for inclined posture, I've just come back from the HK 7's.. (international 7-a-side rugby tournament in Hong Kong). My posture was inclined for a fair portion of the weekend, so i've been reliably informed.

Kindest Regards,

Sam

 

I am!

You crazy rocker you!

Cheers,
Bel

 

Hi Bel.. couldn't you tell by my phrasing I didn't have a clue where to find that blessed paper??!!

To reiterate my point above (with terminology from said paper); I believe FFT replaces the practitioners need for hypothetic-deductive reasoning and replaces it with only the ability to follow a formula. It may work very well as a teaching tool, while an inexperienced practitioner is improving their skills in a given field, but I do not believe it can or should be marketed as a total replacement to a clinicians ability to use their own reasoning.

But again.. we've wandered way off topic.

I found the paper it is:

LISA RIOLO: Skill Differences in Novice and Expert Clinicians in Neurological Physical Therapy, Neurology Report 20:1, 1996.

The PDF of the paper is attached and below is a relevant (IMHO - (in my humble opinion)) extract:

Other models of clinical reasoning from this same cognitive science
(empirico-analytical) perspective have focused less on the processes and more on the organization and accessibility of knowledge stored in the clinician's memory. Examples of knowledge organization used in clinical reasoning include "illness scripts" (11) and "pattern recognition." (12,13) In making use of illness scripts or pattern recognition, the clinician recognizes certain features of a case almost instantly, and this recognition leads to the use of other relevant information, including "if-then" rules of production, in the clinician's stored knowledge network. (14) This form of reasoning moves from a set of specific observations toward a generalization and is known as "forward reasoning." (12) Forward reasoning contrasts with hypothetico-deductive reasoning where a person moves from a generalization (multiple hypotheses) toward a specific conclusion. (14) Experts generally agree that both forms of this cognitively oriented reasoning are used at different times. (10,15) Pattern recognition is faster and more efficient and is used by expert and experienced practitioners in their domain. (14) Hypothetico-deductive reasoning is used by more inexperienced practitioners and by experts when faced with an unfamiliar problem or a more complex presentation. (10,15) These 2 cognitively oriented methods taken together are often referred to as "diagnostic reasoning."


Nuff respec'

Sam

 

Why is everyone so surprised that there are cases where the rules don;t hold in a clinical test?

The FEJA Test calls for a “relative” pronation compared to its short mate.

This means that if the rearfoot of a subject is rigid, or stable, it cannot evert beyond vertical and therefore would be pronated or vertical at PERM. Yet it would be seen in closed chain or when casted to be more everted than its mate.

I am no expert on the superstructure but when there is primary pathology in the back, for instance a scoliosis, there is a reactive secondary soft tissue tightening causing a SLLD on the opposite sided limb of the scoliosis. This could compensate by pronation in some cases. This may be the case in Sam’s 1.5 cm pronated short side, especially since it is compensated with knee hyperextension.

I have seen cases of torn tendo Achilles, p. tibial, etc. that cause of one side cause a presentation of a pronated short side.

The fact is that the planal compensation and location of the compensation presents such a myriad of possibilities and the ability of the body, whether treated or not, to overcome or even reverse FLLD makes your discussion mute in terms of invalidating my theory of TIP.

Finally, the paper states that TIP is diagnosed as existing until proven otherwise for a patient when there is a + FEJA Test and two or more confirmatories. This means that a patient with a + FEJA, a one sided bunion and a larger muscle mass of the calf and/or thigh on the longer side would have TIP even if pronating on the short side.

Inconsistencies exist as you claim but do not make TIP any less important until you consider scientifically, that the better the clinician taking the test, the more accurate the diagnosis and the more capable he/she will be in treatment (my claim that I am a better practitioner than many).

This is a very important statement that I would like debated:

I would have thought that the biomechanical guru’s of The Arena would have as a given that as a rule, we are not symmetrical people. That asymmetry can exist as an LLD (SLLD or FLLD) in many locations of the posture and would cause the need for compensatory reserves to balance that posture.
When those reserves are exhausted from fighting the terrain, ones weight, ones inherited biomechanical weaknesses and ones activity level, that imbalance causes stress upon the posture.
It makes sense to compensate for LLD externally when diagnosed whether it is causing symptoms so as to make that person a better performer with more compensatory reserves to fight other natural negative forces.

70% or more of you and your children have TIP that you are leaving untreated because you wish to argue its validity rather than test it in practice.

You will answer to your children’s biomechanical complaints in the future that you did not look at a valid but imperfect entity like TIP as their one sided calluses and bunions develop later in life that could have been prevented.

To SAM I say that a skilled practitioner utilizing testing to classify and diagnose biomechanical entities like foot type and TIP is a better practitioner than one utilizing their own random feelings. I actually think your comment is so unscientific and primitive.

I wonder what the reaction of The Arena would be in trying new work like FFT and TIP if it came from Payne, Kirby or Isaac instead of me?

Can any of you lopsided blokes understand this?

Dennis

 

Maybe psychic Bobs brother can ???

Guru Bob

 

Random feelings? That's not the first time you've directly insinuated something negative about my ability to practice dennis. Did you actually read my post?

Do you get up early in the morning to think up new and exciting ways to piss people off?

You would now have us believe our childrens future rests on your treatment and your treatment alone?

What happened with all the children that grew up outside your sphere of influence? Where is the epidemic of injured children? Do you dispute the waythat people like Angela Evans treats paediatric cases?

I've seen your website... One of the testimonials is from a guy who is happy because you are now helping him sell more insoles.

I'd like to repeat something I've heard Robert say on a few occasions. "make everything as simple as it can be, but not simpler."

FFT is too simplistic to be of use to anyone who professes to be a foot specialist and your goals appear financially driven.

 

I nicked it from albert Einstein. Damn good quote!

I'll ask him. He might need a few hours to reply. He's not on the forum yet.

 

My good friend Robert asked me for my transcendant wisdom. Its available here

Bit of a weirdo, Robert, but his heart is in the right place.

 

I did my thesis in clinical measurement, and my results were similar to those found in the literature. Clinical measurement is at best not accurate enough for podiatry. as the best technique still has a standard deviation of +/-5mm. Use clinical methods to look for a lld, but use x-ray scanography to confirm the quantum of the lld as well as to guide you to the management

 

Hi Charlotte, good to see someone else interested in the massive subject of LLI. I am currently studying for my PhD (PT) in LLI and have a few ideas for you. Firstly, there is no reliable method of measuring it on a couch prone or supine, only 'box tickers'. The best way to establish whether it is apparent, functional or bony is to look at the sagittal plane inclination between the PSIS and ASIS using a digital inclinometer and placing that patient in a functional pathway e.g. an ectomorphic body type with a longer left limb for example would probably develop what I call a 'Single femoral pathway' compensation mechanism. i.e. GRF under the longer limb would create a P.I (posterior inferior) ilium on the longer side, to lower the acetabulum (compensation mechanism). This would create a torsion between the inominates, which would present as an apparent different in LL and give you an exaggerated LL measurement on the couch on the left side. If you use a heel raise or whole foot platform of 50% of the difference, this would reduce the compensation mechanism to reveal the true difference after the patient has used it a few time. This process would be rather quick in a female patient on an oestrogen spike. There are loads of tips like this I can pass to you over the next few weeks. I am new to the arena also.

Chat soon

Clifton

 

I will relate my experience for what it is worth to the discussion. I was the chiropractic X-ray technician for our office. We has a radiologist, running enthusiast, come to us convinced that his running pain was caused by LLD. We had to do the radiology because only Chiropractors were still using 36 inch film. The radiologist was impressed with the care that I lined up his legs standing on a stool so that the projection would cover from the soles of the feet to the femur heads without a femur rotational compensation.
The outcome was that the femur heads were even, the femurs were equal, but one tibia was 6 mm shorter and the compensation was a raised arch on the short side and a lowered arch on the long side. Our orthotist made him a 6mm sole plate and he ran to his heart's content.
Hans Albert Quistorff, LMP
Antalgic Posture Pain Specialist

 

Hi

I have been giving an assignment at university which i am stuck on a bit the question is:
The aim of this assignment is for you to choose a measurement technique that you have used in your biomechanical assessment of patients:
• Review the evidence for its use.
• Design a methodology to test one aspect of the reliability of the measurement technique. Detail and justify the data analysis you would apply to your data.
• Conclude by discussing your experience of using the measurement technique you have chosen within the context of your literature review and the potential challenges you may encounter when undertaking your proposed method.

Now im thinking of doing it on lld or heel bisection but just unsure of which one theres more literature on? any help will be appreciated

 

Heel bisection every single time. Shed loads on that.

 

Hi All,

This is my first post so hope you find this useful.

We recently carried out a review of how everyone measures LLD in our acute hospital, (by everyone I mean, the GP, Orthopaedic consultant, Physiotherapist, Podiatrist and Orthotist), these were then compared to x-rays/scans of the legs. Scarily no-one was a 100% accurate, the most inaccurate were the GP’s, (when reviewed, one actually just looked at the patient and said you have a 2cm shortening!).
All the other groups’ measurements removed all symptoms and appeared to address the structural alignment issues.
The most accurate were the physiotherapists, (no I’m not a physio), we believe because, there assessment appointment was 1 hour and they spent the majority of the appointment manipulating the hips and legs and then measured. The methods of measurements i.e. landmarks were the same for everyone ASIS to medial malleoli, the only exceptions being the Orthotists, (yes that’s me), who also measured from the ASIS to base of foot as a secondary confirmation.

Lastly whenever shoes are raised by Orthotists there is this bizarre belief that the raise should be tapered, which is completely unrelated to the ankle range.
Even if the patient has normal ranges with no other issues the shoe will still be pitched as opposed to a through raise. Having asked lots of colleagues why the answer is always invariably because that is how I was taught!

Graham

 

Rabzash:

You have picked two topics that bespeak the problems with EBM when it comes to biomechanics.
It just doesn't exist at a high enough level to be relevant and applicable on a case to case basis for EBP.

Heel Bisection will produce more EBM of higher level.
The questions remain whether interrelationship values have a low enough % of error and possibly more importantly, the need for a heel bisection in biomechanics in the first place.

LLD will, I believe lead to a conclusion that measurement isn't accurate at all using any method and leads to failure in reproducability, accuracy and serving as a guidepost for treatment when reviewing the literature.
Summarily, we have not found a way to measure LLD with accuracy, consistency and reproducibility.

In addition, the % error produced by variances within study groups (weight, activity level, foot type, coincomittant bioemchanical pathology, etc) produces very low level results.

The same can be said for
How orthotics work
rearfoot to forefoot relationship measurement
subtalar joint axis measurement
calcaneal stance measurement
"Q" angle measurement

Your topic of "measurements in biomechanics" is an exercise in futility for the most part and produces little clinical relevance or substance from an EBM position.

My personal bias would be towards LLD so that you can perform a retrospective meta-analysis of the literature that I believe will reinforce my view that LLD should be diagnosed clinically by "compensatory patterns" and not measurement.

I would be glad to assist you if limb length is your chosen subject.

Good fortune, no matter what.

Dr Sha

 

Your first post is both relevant and useful. Additionally your avatar is cool! Therefore, Welcome indeed.

Is your work to be published anywhere? It sounds useful!

 

Hi Robert,

Thank you for your comments - I am actually looking at putting this information together and then publishing it but our audit department have recommended increasing the number of patients to make the outcome data more valid. Which we intend to do.

Graham

 

Welcome Graham,

Just a couple of thoughts on the tapered lift. A full length lift will make the shoe stiffer and heavier. Now, if they need a rocker too, then that is not such a bad thing.

Very few people have inadequate ankle plantar flexion. Most people are going to have over 30 degrees of ankle plantar flexion. A quarter inch lift (6mm) is going to plantar flex the ankle estimate 5 degrees. This will not effect normal walking. It probably is not going to effect jumping as most people will flex their knees and ankles before jumping and there will be enough range of motion to create power to jump.

Interesting post on the measurement data. Did you mean the GP's were least accurate?

Eric

 

If in fact, The FEJA Test has validity, the short sided ankle will be in relative equinus to its mate often.

This means that its total ROM is reduced in closed chain (used to call it pseudoequinus, now functional equinus {The FE in FEJA}).

By using a tapered lift, in addition to compensating for The Inclined Posture vertically, we are placing the ankle joint in a plantarflexed stance position increasing its available ROM in the direction of dorsiflexion in closed chain, giving it a better functional ROM in gait by reducing the FE.

Dr Sha

 

Assuming the tapered lift doesn't result in muscle shortening by holding the plantarflexor muscles in a shortened position. Which it will. End result = increased ankle dorsiflexion stiffness on the lifted side. Meanwhile tibialis anterior and the other dorsiflexors are held in a lengthened position and will add sarcomeres in series, resulting in their functional weakness in inner range. Nice work.

Now, let me quickly gouge out my eyeballs and replace them with hot toffee apples before Dennis replies to my posting. Ultimately this will be less of pain than engaging in a discussion with him.

 

1. The muscles have already shortened as compensation for the short limb, hence the relative dropped foot on the short side.

2. By simultaneously treating the patients FFT, the compensatory patterns can be reduced in scope and proliferation by Vaulting and ORF's and concomittant drilling and training of the primary muscles to become stronger and more functional in phase, reducing or eliminating the need for compensatory patterns to exist, actually correcting the biomechanics.

Simon: if the TIP is structural, short of heroic surgery, the lift is necessary especially during high level activity, permanently for performance and try to prevent tissue stress from reaching clinical levels (where they would finally get treated by PA guru's).
if the TIP is functional, reducing or eliminating the compensatory patterns by temporarily using short sided lifts, foot type-specific Foot Centerings and muscle engine training, even eliminating or reducing compensatory unhealthy sarcomere series expansion (why you always have to make things more difficult, scientific and Ph.D. arrogant as you simultaneously drag us away from a clinical discussion is where we differ so).

Your discussion seems to suppose that I am adding a lift under a heel that is not already compensated for TIP into equinus (The + FEJA Test).
In that sense, sir, you are just wrong and living in your personal sarcomere red herring.

Dr Sha

 

The lift may be necessary, but by having that as an angled lift you are increasing the muscle shortening of the plantarflexor group and increasing the functional weakness of the dorsiflexor group. Adding to the problem. End of story. Adding the lift doesn't change the length-tension relationships of the muscles in your world, clearly Dennis. Yet, in the real world it does.

I don't make it more difficult (perhaps thats only for you Dennis), I point out the facts, Dennis. If your brain can't cope with that....

Like I said... Hot toffee apples in my eye sockets... That'll be a more enlightening discussion than talking to you, Dennis.

 

Hi Eric,

Thanks for the reply and sorry about delay getting back to you - clinic's just really get in the way.
Unfortunetly yes I did mean that the GP's were the least accurate of the patients reviewed. One of the reasons that we will be doing the audit, is to see if there is a specific reason for the difference.

Graham

 

End of Story..
Clinically, in biomechanics, few stories end.....they compensate ad infinitum.
Is your declaration of "End of Story" evidentiary or just your arrogance and ego thinking that is an acceptable comment in debate.

Sarcomeres didn't make it more difficult as I responded to you with an obvious knowledge base of sarcomeres, I was merely stating that it was a diversion from a clinical discussion in order to hide, I may wrongly assume, your weakness as a clinician.

In my world we say Wolfs and Davis' Laws and don't get microscopic.
What gives you the ability to call that fantasy, you bully?

So if you do not use angled lifts for TIP or LLD on the short side, what do you use in your practice and explain their biomechanical soundness for us all.

Dr Sha

 

Keep going with the personal attacks, Dennis. If I don't use angled lifts, what do you think I use? 'nough, Dennis. Mind how you go.

P.S. "and if you shout, I'll only hear you"

 

Graham:

I am interested to know what your radiographic gold standard was for comparing the clinical measurements for LLD to the radiographic measurements. Please tell me the exact radiographic methods you used for assessing limb length in the radiographs (i.e. standing, lying, scanogram, landmarks for measurement, etc). I am very interested in your research.

 

Hi Simon,

I know you have references for everything you write. Could you kindly post the reference for the serial addition of sarcomeres?
It would be nice to know the methodology for increasing the structural length of muscles.

Regards,

Stanley

 

Tabary JC et al.: Physiological and structural changes in the cat's soleus muscle due to immobilization at different lengths by plaster cast. J Physiol (London) 1972

I'm pretty certain Janda discusses this too

 

See below - add a stretching program changes the outcome. Not that much 15min every 2 days.

 

I can only assume that you are using level lifts for LLD at the foot/shoe interface.
BUT,
You could also use asymmetric varus posting higher on the short side which have 1/2 lift impact.
You could also shorten the heel on the other sides device.
You could also be using lifts at the shoe/ground interface.
You could also use kinesiological care to stretch tight tissue in FLLD cases as our PT and DC brethren often do.
and
I'm sure there are others.

Could you be more specific as only you know what you use.

and then...

Could you explain how the method you use has less or no potential negative compensatory biomechanical effect than angled heel lifts?

Thank you,
in advance.

Dr Sha

Simon:
I am making this clinical request because I sense that if I advocated level heel lifts, or asymmetric varus wedges, etc., you would list their biomechanical faults or potential compensatory dangers intimating that my choice was bad or there was a better option and I think whatever method any of us use has inherent biomechanical trade-offs making your point vindictive as opposed to constructive.

 

symptomatic structural LLD >20mm straight through lift internal; and or external.

 

Thank you for the reference for SLLD as usual.

1. So do you not measure for, address or treat FLLD?

If you do, please advise your care.
If you don't, I am leaning (pun intended) that you are supporting my claims.

2. As to my point,
Doesn't your through lifting (Heel to toe, I assume) foster pseudoequinus, achilles tendonitis tissue stress, insertional plantar fascial tissue stress, lowering of the CIA, STJ pronatory moments, increased 1st ray dorsiflectory stiffness, ankle pain and stiffness and shortened stride and cadence in gait off the top of my head?

3. Your Brady Reference in the first sentence of its conclusion states:
Little agreement exists concerning the most accurate and useful method for detection of limb length inequality.
Does that support a contention that the level of Evidence of this paper to be low and of little clinical impact?

Finally, the two illustrations of using the subject seem to demonstrate compensations leading me to believe that he has a short right side and in fact, the practitioner is holding the instruments inappropriately showing a short left side for the picture (confirmed if the x-rays are for the same individual).

Dr Sha

 

Take it up with the authors, Dennis.

Please carry on posting on the Arena, Dennis. Just don't bother trying to communicate with me on here as I have absolutely no interest in anything you have to say. I made the mistake of posting a comment on this thread last night which led to the inevitable. Thanks, but no thanks. I really have no time for you or anything you have to say and have no desire to attempt to discuss anything with you neither in this thread nor any other. I hope that I am making myself clear and that you understand and respect that, Dennis.



Enough.

 

Ditto,

except I value you greatly as a researcher and EBMer.

Dr Sha