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Leg length discrepency how do you measure clincally?

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Charlotte Darbyshire, Dec 4, 2007.

  1. grahammoore26

    grahammoore26 Member

    Hi Kevin,

    Sorry about the delay in getting back to you, but wanted to check everything with the x-ray techs.
    Ok so because this was originally just a simple review of why we all came up with different measures, we went with an established method of a standing anteriorposterior radiograph, with feet placed under the femoral heads (approximate position) to reduce effect of weight shift. A bob line was added to give a vertical reference, complete with a scale. The x-ray tech completed a simple questionnaire, indicating age of patient, height, weight, patients posture and confirmations to ensure patinet stood with knees straight.
    The patient was a set distance and focal length to improve consistent across all subjects.
    Radiograph was taken to include pelvis, a tangential reference line was added and reference lines added to the superior aspect of the femoral heads, this was then measured and compared to the scale to give the actual measurement

    (The x-ray techs have given me all the focal info if you would like that)

    However even in the limited number that we have done this way we have highlighted lots of issues, if the patient has a structural or rotational element in the tibia or the femur, it is not fully included. Alignment of the foot is not included and can give an apparent LLD that can be removed by foot orthotics.
    If there is a flexion contracture of the knee, (or not able to fully extened the knee), the radiograph is less informative.

    We have therefore decided to follow the supine slit scanogram method, however we cannot at this moment agree on land marks, the original plan was to use iliac crest to apex of the the medial malleoli, but there is concern over the fact we don't walk on medial malleoli and there are structures between the measurement referance and the weightbearing structure. So at this moment we are in limbo as all research is pulled and then we can make the final decision, the NHS moves at the speed of a leaping glacier.

    Sorry Kevin I've read through this and it's very ramberling, once all that is worked out I will send you all the research protocol details.

    Graham
     
  2. HansMassage

    HansMassage Active Member

    As I commented in previous post this was the advantage of having 36 inch chiropractic full spine film and cassets.
     
  3. Graham:

    You have covered my concerns about landmarks. I would think that the best method of assessing leg length radiographically would be a standing AP of the hips with a vertically placed scanogram ruler on the plate. Then a horizontal tangent line is drawn to superior pole of the femoral head on each side and the femoral head heights compared. The standing x-ray would incorporate the distance between the ground and the malleoli which, as you know, can be quite different between feet especially in significantly asymmetrical feet. An excellent study would be to have two or three examiners clinically assess leg length and compare their results to the radiographic measurement to see the differences. I think the differences might be very interesting and this would be an excellent paper for JAPMA.
     
  4. Delcam-Healthcare

    Delcam-Healthcare Active Member

    Clifton Bradeley from Sub 4 will be presenting their new biomechanical evaluation devices and related theories, including a new measurement device for leg length discrepency at the Orthotics Technology Forum in Bath on 19th & 20th May if this would be of interest to followers of this thread.

    In short - 2 days, 13 speakers, £50 registration fee including drinks and 3 course meal at Roman Baths. :drinks

    See more details and register for this event at www.orthotics-technology-forum.com or see discussion about this event on the Podiatry Arena at http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=62869

    I hope this helps. ;)
     
  5. footsiegirl

    footsiegirl Active Member

    How important is remeasuring over a period of time?
     
  6. If the person has stopped growing in length why would the legs change ?

    So if and it is a big if your measurement in accurate then it should be the same for the rest of their life, people generally get shorter from back related issues.
     
  7. Peter

    Peter Well-Known Member

    Apparent leg length can change over time. If someone has scoliosis, and the angle worsens, this could affect the pelvic asymmetry. How about, issomeone has a LLd and uses say a 1cm raise to balance their PSIS, and laets say the pt has a mild scoliosis to begin with. I can't do Dave Smith type fancy forces drawings, but if a force of 1cm raise is pushing under the short leg, this could make the scoliosis worsen, and change the APPARENT LLD change.
     
  8. From my mind and My discussions with my sister an osteopath and David Wedemeyer a Chiro.

    I look at this way we have leg length and then we have back related issues or even some walking with a more flexed knee, OA type conditions etc but leg length is leg length and then we have other reasons, some refer to this a functional length length discrepancy. But legs don´t get longer or shorter after the person has stopped growing without trauma or surgical intervention.

    ( maybe loss of cartilage or meniscus could be argued but I guess is happens to both sides at a close enough rate not to effect LL.)
     
  9. Peter

    Peter Well-Known Member

    Agreed, legs don't lengthen over time, but a LLD measurement can
     
  10. I would say that the legs can function with different lengths over time rather that a LLD can, because the measurements are taken from the same anatomic position.

    Does that make sense ?
     
  11. Peter

    Peter Well-Known Member

    I'd buy that Mike.

    Cheers
     
  12. drsha

    drsha Banned

    This sends an arrow though my work and theories that live above orthodoxy.

    1. Dr. Weber, whose measurements are accurate, accepted, viable and clinically relevant? Not mine, are yours?

    Prevention, performance enhancement and quality of life issues that have nothing to do with No Pain/No Problem

    Do you have evidence for your absurd statement, Dr. Weber?
    Do you even have anecdotal confirmation of what is obviously opinion and ego driven.

    Analogy 1.:

    If bone growth stops in feet at lets say 20 and a persons shoe size if lets say 8..

    Are you telling me that there's no reason to measure your shoe size from then on because their feet should be the same size for the rest of their life????

    They won't eventually be a 9?

    Theoretical Case Study 1.
    A 59 year old has a ruptured tendo achilles repaired surgically and then casted and rehabbed for 12 weeks.
    No functional shortening in this limb?

    Theoretical Case Study 2.
    An obsessive compulsive 47 year old gets into the habit of walking in counterclockwise circles to release tension for hours on end, daily. he overworks and strengthens his left side and now walks with a limp.
    Any TIP here?


    While you're waiting for pain and tissue stress and level I Evidence, you guys/gals are missing the bus.

    To Footsiegirl I would comment that monitoring the clinical picture, compensatory patterns that reflect TIP and relating them to present and future clinical events (low back problems, one sided hip pain, etc.) for me, is much more important to measurements because measurements have been proven to fail and have not been answered to consensus, even on this thread.

    Dr Sha
     
  13. footsiegirl

    footsiegirl Active Member

    Dr Sha,

    Thanks for your post.

    As I am a Foot Health Practitioner, could you please explain the abbreviation T.I.P. for me?

    Thanks
     
  14. Dennis the leg that we measure is made up of two bones and 2 joints which is different from the foot in so many ways.

    If we have a leg of 91 cm in structural length I would say from the ages of 25 till 75 it will not differ worth measuring. As I stated there most likly will be similar measurment change on both legs and as I stated most of this change would occur at the knee. This is structural

    Functionally there may be changes ie if one knee flexes more than the other - this does not mean the leg is shorter it means it functions at a shorther length.

    Dennis I did say if and its a big if your measurments are accurate - this is another way of saying LL measurement by tape measure is not accurate.

    Whats TIP any peer reviewed study on TIP , if TIP is a functional leg length discrepancy Peter and I already discussed this.
     
  15. footsiegirl

    footsiegirl Active Member

    Mike,

    Supposing the measurements had not changed, but not been correctly taken - my patient cannot remember having measurements of any sort taken, but it was back in 1991, so perhaps she has forgotten? What may be the potential problems for her back and feet?
     
  16. Its a depends one.

    1st measurments taken using a tape measure are not accurate, so if your patient wants it done right she needs to get some xrays or scanogram done. This will give her the leg length LL to the nearest half mm.

    If we find a LL does that mean she will have problems in the future we have no idea or what they might be. Most people use the 10 mm rule for LL and then treat, no idea where this came from or if there is any research to back it up.

    Hope that helps

    But if she is conserned I would recommend a examination with a Pod or back specialist to look. Closer at things
     
  17. footsiegirl

    footsiegirl Active Member

    Hi Mike

    Thanks for your response. I did refer her for a gait analysis via her GP. I guess her doctor will refer her on.

    She has problems with back pain, and I have to treat and offload pressure from a heloma durum on the 4th apices of left foot, but I was wondering whether this was more to do with her LLD than the foot function itself?
     
  18. I could not say anymore than could be, impossible to say without seeing the pt. You did the right thing referring on.
     
  19. drsha

    drsha Banned

    Again, different box we live in.

    If Footsie treats the 4th toe corn and doesn't practice addressing the impact of the patient being lopsided (LLD or FLLD) and refers that patient for gait eval, she will remain a 4th toe corn specialist and never gain practical experience with dealing with The Inclined Posture.

    I would try something (a lift, muscle testing, uneven padding or a brace of some kind) on what you perceive is the short side and follow up clinically with the patient on a short leash. Look at the pelvic incline on the frontal plane after your treatment, look for improved, more symmetrical gait and other clinical tests and signs (see the thread on TIP on The Arena).
    Eventually, instead of being on the sidelines you will be playing on the field and your personal EBP will grow.

    oh and as I admit I have no peer reviewed studies on TIP, Dr. Weber, can you list the peer reviewed studies, that form a consensus or deliver a reproducible, accurate method for measuring LLD or FLLD?
    If you can, I will consider changing my protocol appropriately. If you can't stop preaching and asking me for peer review evidence for mine.

    Dr Sha
     
  20. not sure if this have been posted before.

    Methods for assessing leg length Discrepency -


     
  21. Yawn, etc....

    Less than a minute on google.
     

    Attached Files:

  22. David Wedemeyer

    David Wedemeyer Well-Known Member

    Round and round we go!

    I had the most peculiar case of LLD step into my office last week, 29 yo male that returned yesterday with his scanogram on disc as well as a spinal film series. In his history he relates a tibial fracture on the right age @ 10 but when I examined him the left side leg is dramatically shorter visually.

    I haven't received the reports and measurements yet but will post when I do. Initial observation is that his ilia are the same height and his femur appear the same length (well approximately anyway). This is where it gets odd, his left tibia appears shorter than the right at the ankle, recall the right tibia suffered the fracture those years ago. I can't wait for the radiologist to get to the film so I am calling the imaging center to ask them to rush it. I should have more info later today hopefully.

    He saw another chiropractor who uses SS because his previous DC sent him to a C.Ped for a lift many years back (he is retired and on the card it says "1/2 - 1" heel lift on the right). On the right! On an aside he was casted (sic) for a SS device and what he described to me sure as Hell didn't pass the smell test for a SS practitioner certified in their system. The patient didn't feel comfortable with the absence of an foot exam, he just plopped him in the foam and charged him $275.00 (no gait analysis, no exam, no explanation and NO lift on the sheet). I questioned him at length about the casting method and he did not supinate the midfoot in the cast, WTH? Even the patient felt something was amiss and he found my website and came in for a consult last week. Fascinating.

    I'll check back in when I have more to share.
     
  23. So what...? Why should this be deemed necessary? New thread probably. I'm on to it...
     
  24. footsiegirl

    footsiegirl Active Member

    It is interesting that the good old tape measure was accurate...although user error could let it down
     
  25. Malpractice makes perfect.
     
  26. David Wedemeyer

    David Wedemeyer Well-Known Member

    It is only necessary if you send your casts to Ed Glaser's lab Simon....
     
  27. David Wedemeyer

    David Wedemeyer Well-Known Member

    I saw the patient today, hx of low back and left sided hip pain. Hx right tibial compound fracture age 7. Recall the previous order was for a right lift of 1/2" to 1". Initially I felt this must be a FnLLD until I evaluated him and sent him out for study.

    The results back from the scanogram:

    Femur length:
    Right: 54.6 cm
    Left: 53.9 cm

    Tibia length:
    Right: 41.8 cm
    Left: 40.4 cm

    Total leg length:
    Right; 97.1 cm
    Left: 95.0 cm

    He has an anatomic LLD of 2.1 cm on the left. I provided a 10mm lift and will follow while his orthoses are being manufactured. He has endured this for years and wore a right lift for a time but removed it due to pain. Based on his right tibia being previously fractured I was surprised that was the long leg side. Just goes to show trust your instincts and findings and not your eyes, leg length checks are worthless for FnLLD and only radiographs give you truly accurate measurements for an anatomic LLD.
     
  28. Brian A. Rothbart

    Brian A. Rothbart Well-Known Member

    Great Thread. Just can not resist, I need to add my own two cents worth.

    First question, what exactly is the clinical significance of the LLD. I view a LLD as a Symptom of an unlevel pelvis (two years ago I published a paper in the JAPMA about this).

    Second question, if indeed a LLD is a symptom of an unlevel pelvis, what is the cause of the unleveling. If you are a follower of Posturology, Cranial Mechanics, and Orthodontic Biomechanics, the answer would go something like this:

    Unleveling of the pelvis can come from two directions: Ascending (from the feet) and Descending (most commonly from a malocclusion). Since this is a Podiatry forum, let's focus on the Ascending possibility.

    I have described (and published on) how abnormal pronation (what I define as pronation occuring during late stance phase of gait) can unlevel the pelvis. However, abnormal pronation is a symptom, not a cause.

    So my final question would be, what is the cause (source) of this abnormal pronation. There are many potential causes. I believe the most common causes of abnormal pronation are two abnormal inherited foot structures: The PreClinical Clubfoot Deformity and the Primus Metatarsus Supinatus foot structure.

    In a previous thread I described a reliability study done at George University (1997) that describes a methodology that can quantify the presence and severity of these foot structures.

    Brian R
     
  29. David Wedemeyer

    David Wedemeyer Well-Known Member

    Eureka; I've discovered the Rothbart's Brain! It's unlevel and preclinically crazier than a **** house rat!:craig:
     
  30. Kursh Mohammed

    Kursh Mohammed Active Member

    Great to see a lengthy discussion.

    You could contact Clifton Bradeley at Sub 4, though he is on paternity leave at the moment.

    He has developed a pelvic inclinometer and his PHD has been around this subject.

    He would be very good to talk to and maybe you could share this?

    Also dont agree with how Clifton prescribes his orthoses though this is discussion for another day!
     
  31. jsm

    jsm Active Member

    Hi all from Spain!
    Trying to bring some peace to this discussion. . . I have a very special patient (myself :D) and I discovered that I have dysmetria of -7 mm (2 inches) in his right leg as x-ray, and dig right foot supinated and twin overhead right leg as well as discomfort back more or less frequent. "you advise me to put up at the bottom right would? what extent?" only in the heel or complete for the entire foot?
    Excuse my English please. . .
    :drinks
     
  32. David Wedemeyer

    David Wedemeyer Well-Known Member

    JSM is that correct, -7mm = 2 inches? I believe that 7 mm = .7 cm or .27 inches? 2 inches is about 50 mm. Either way I don't usually add a lift for anything under 1/4 inch LLD.
     
  33. jsm

    jsm Active Member

    Oh sorry David, 0'27 inches
     
  34. Stanley

    Stanley Well-Known Member

    Hi JSM,

    When I used to use lift therapy for leg length, I would use a sole lift equal to the heel lift when there was no equinus present on the short side. If there was an equinus that required a heel lift equal to the shortage, I would not use a sole lift. If the heel lift required for the equinus was 1/2 of the amount of shortage, then the sole lift would be 1/2 the height of the heel lift. In other words, the sole lift was inversely proportional to the amount of equinus.
    If the shortage was enough to handle within a shoe (1/4") then I would just use a heel lift within the shoe.
    As far as the amount of heel lift I would use, it would be the maximum amount that would not cause either a secondary curve in the spine, or a secondary rotation of the pelvis on the transverse plane.

    I hope this helps.

    Regards,

    Stanley
     
  35. mokgatle

    mokgatle Member

    I practically use the plantar of both heels:
    With patient supine, pull & push legs to make sure they are straight, shoulders, and ASIS are on the same level and the head is straight,
    hold the heels close together & move tongue depressor from heel plantar of the shorter side to the longer one.
    While holding the wooden t-depressor on the longer side, mark where the heel cuts the broad side, measure the to note the difference.

    X-rays are good, but will it change the treatment? The cost ....

    Factors like unilateral mild knock knee must be considered when using things like the traditional tape measure, as it can always make the shorter limb to appear longer if there is this unilat. knock knee.
    There are many issues around limb length difference, so it ends up being difficult to really state which method is correct
     
  36. MJJ

    MJJ Active Member

    I find that it's more important to determine how much of a lift is required than to accurately determine the difference. To do this I use Ballert Build-Ups, which I was lucky enough to first use at one of my clinical sites as a student. You just strap it to their shoe and get them to walk around a bit. Usually the amount of lift that feels the best to them is the amount that looks the most even to me when they walk. It isn't perfect but it gives a very good starting point with no guessing.
     

    Attached Files:

  37. mokgatle

    mokgatle Member

    its for the first time that I hear about something of this sort. I think I will have to try it at some point. You just opened my eyes. thanks a million times
     
  38. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Comparison of Supine and Prone Methods of Leg Length Inequality Assessment
    Robert Cooperstein, MA, DC etal
    Journal of Chiropractic Medicine Article in Press
     
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