Treatment of a functional limb length discrepancy

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Hi all.

just wondering what all of you fellow podiatrists think the CONSERVATIVE management / treatment of FUNCTIONAL lld is... in a 11 year old child with <1cm

as far as i know, the best conservative treatment for STRUCTURAL lld would be adding heel raises in their shoes.

what about in FUNCTIONAL cases? im thinking a good pair of modified roots?

any help would be appreciated.

thanks

 

Where is the functional LLD coming from? Foot? knee? SI joint? Hip?

 

hmm, assessments show a left shoulder drop , right abducted foot, also (R) weak tib ant and peroneal longus, right leg appears longer then left, pronated (L) foot - pronounced medial malleoli. RCSP (L) is 11 deg everted and (R) is 9 deg inverted.
im thinking its coming from the foot...
any thoughts?

 

ok, the reason why i dont agree with adding a heel lift is that everytime i add a heel lift, (keep in mind that this is a FUNCTIONAL) it just throws everything out of order, ie pelvic tilts the other way , and it doesnt get rid of the leg pain...
so im thinking a pair of mod root having the SAME heel raises?

 

I do not see how foot orthoses will help a functional LLD unless the foot is the source of the difference. Find the source and get it treated (eg sacroiliac manipulation).

 

well , manage, not treat, and also keep in mind that this is a 11 yr old child. from all the journal articles from google scholar that i pulled up , most seem to say orthotic intervention is the best.

 

It is, if the functional LLD is coming from the foot. How does a foot orthotic affect a functional LLD due to one knee being more flexed than the other? How does a foot orthotic affect a functional LLD due to a malposition/rotation at the SI joint? etc

 

it IS coming from the foot though....
"pronated (L) foot - pronounced medial malleoli. RCSP (L) is 11 deg everted and (R) is 9 deg inverted."
did that turn up ?
i thought i posted it

 

Go ahead and manage this child

Podder123,
If you have eliminated any pathology proximal to the feet, why don't you try some temporary in-shoe padding (triplane heel pad and/or forefoot padding across the metatarsal heads)? Diagnosis in children sometimes takes time and careful observation. No offense to anyone, but pelvic manipulation in an 11 year old or anyone else, sounds hopeless.

 

Don't forget, the more material you put into the shoe to stop the "pronation", the more you might have to add to the short side.

How about a full through raise to the short side?. This might affect pelvic tilt less.

Also consider that the foot that pronates more "might" be a compensation technique.

I would examine the PSIS with the feet in talo-navicular congruency, or at least with the feet symmetrical, and legs abducted to the same degree.

Re-examine the PSIS sitting in case of pelvic obliquity.

Let us know how you get on.

PS is this child symptomatic, and how long has this LLD been monitored?

 

I agree with this before any heel raise greater than 8mm is used. Also reccommend shoe with high shock absorption material. Hip contracture can be detected with good stretching and measurement both lying supine and prone and sitting (legs dangling). Need firm bed. Also need to check iliopsoas and tight quads as these can also distort hip position.
Robin Hoodigs:

 

Where is he experiencing his leg pain? What structure(s) do you think is the source of the pain? When does the pain occur?

Calcaneal bisection differential of 2 deg and functional LLD of <1cm may be of little significance, particularly as we know how unreliable these measurements are.

More information regarding the structure involved will help us provide you with better advice re assessment and management of this child.

Tim

 

If it is the (L) Leg that is pronating more would it not suggest that the (L) is the longer?

Even so you could treat with a Function Insole; Perhaps 4 Degree Medial Posting on the Left, with Valgus Dome. THEN in the (R) provide a full length flat insole of about 3mm or something fairly solid Medium Density EVA.

If it turns out the (L) is the longer, the pronation being corrected will force the hip even higher, but the insole in the (R) should reduce, if not balance this out. After say 2-4 weeks monitoring, you could re-asses, possibly sooner if pain isn't reduced. At the re-assessment phase if the (R) hip is now too high simply remove the 3mm Insole.

While both are provide Emphasis a full-lower limb stretching scheme, by stretching all the muscles you could then start to hone in if it is more pelvis/spine issues. Or alternatively if might suggest a tight illiopsoas: Emphasis on the might, as i'm working in theory town.

Curious: Where exactly was the pain?

Ideas, thoughts and inputs from the more experience MSK experts very welcome.

 

go to the chiro for the initial adjustment then stay with the physical therapist for continued support in combination with stretching and strengthening. check into yoga.