Leg length discrepency how do you measure clincally?

Howard:

I am never amused by a patient in pain. However, I am amused (kind of a "I can't believe that idiot practitioner told the patient that!", type of humor) by practitioners who continually tell their patients, and their patients believe, that by doing "adjustments" that the length of their legs change. Of course I have practiced with orthopedic surgeons for the past 22+ years so I suppose I would have even more amusement watching them react to a patient tell them about their chiropractor "fixing" their leg-length discrepancy by manipulating their bodies twice a month. As I said earlier, I have no problem with the manipulations especially if they are physically or psychologically therapeutic for the patient. However, I do have a problem with the practitioner saying they are doing something they actually aren't doing.

Also........I have been observing and teaching about the differences in arm swing with leg length discrepancy for many years now.......

 

[QUOTE

and their patients believe, that by doing "adjustments" that the length of their legs change. .......[/QUOTe

To them that is what the client is seeing, so that is what is happening.:morning:
Sometimes the most simplest explanation is the best:empathy:
It may not be correct but it helps the client sleep better at night

 

Hi Dan,
The way I approach these things(a long term LLD) is to sequentially raise the shorT side by putting 5mm in the shoe out to the met heads for a few weeks to guage response, then add 1cm to shoe sole and take out the insert, then add back the insert, then add another cm to the shoe sole, each change only being 5mm. You want to reduce the presenting trouble but not create new pain by changing things too much, as has been said some long term adaptive processes can't be reversed. On the other hand one of my brothers in law had an accident and was left with 3cm femoral shortening on one side. We put the full 3cm onto his shoes a month later and he happily runs 10 km on it fairly frequently...no long term LLD.
regards Phill Carter

 

David:

Then using your logic, it is perfectly ethical for a physician to tell a patient to put a live frog into a blender with shot of vodka, have them use the "puree" mode for 2 minutes, and then drink this concoction every night in order to rid them of all their bodily toxins. The simple explanation for their one hour of diarrhea every morning is that their Frodka Drink (pat. pending) has completely eliminated all their bodily toxins from the previous day. And you feel that even though this may not be medically correct, as long as it helps the client sleep better at night, then all is well??!! I hope you were joking!?!:bash:

Ribbet, ribbet, ribbet, whirrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr, gulp.

 

LOL, trust you to read in to the text what is not there yet again Kevin

Two completely different issues. if you can confuse the two WOW

What you are saying is you are giving them a cure, which as tasty as it sounds is not, its just a "Snake oil" type fix, money for nothing, your client is no better for the drink/treatment

The other is just a simple "explanation" of what has happened and they have already seen the results from or soon will, its real.

Personally when l see a "Functional" LLD or to quote Asher "..contracture of whatever muscle.." we refer this client onto the Osteo to help resolve the lower back issues for them before we do a thing

Pour me one of those drinks when you get a chance Kevin, it sounds pretty good and dont even drink.:wacko:

 

Dear all:
With regard to lift therapy and pelvic rotation,may I quote two issues from the books and tell me what you think.Quote" anterior lift therapy: pelvic rotation
An increase in the height of a shoe encourages rotation of the pelvis toward that same side. A unilateral heel lift rotates the pelvis to a lesser degree and rotates it away from the lifted side.FIGURE 43.20 Right anterior half-sole lift and/or left heel lift rotating pelvis to the right."Page 618, Foundations for Osteopathic Medicine,2nd edition, AOA, lippincott Williams and Wilkins. Quote" Malalignment can be corrected from the ground up,so to speak. A combination of appropriate postings, for example, may result in the correction of a rotational malalignment: 1. A lateral posting of the forefoot on the side of the externally rotated lower extremity would set up torquing force towards internal rotation.2. A medial posting of the forefoot on the side of the internally rotated extremity would have the opposite effect.Figure 7.30 An example of a simple approach using a forefoot posting of orthotics for the correction of malalignment: right lateral posting to counteract external rotation; left medial posting to counteract internal rotation." Page357 and 358, the Malalignment Syndrome, Implications for Medicene and Sport, Wolf Schamberger,churchill livingstone. Any thought is well appreciated.
respectfully
Scott Ma

 

Scott,

You bring up some excellent points. :good:

The pelvis can be corrected from the foot up, and the feet can be affected from the foot down. The question is how do you know which is affecting which.
The answer is in the evaluation which is shown in the article which I mentioned prior:

S Beekman, H Louis, JM Rosich, and N Coppola
A preliminary study on asymmetrical forces at the foot to ground interphase
J Am Podiatr Med Assoc 1985 75: 349-354.

It comprehensively evaluates for everything except the effect of the heel lift vs. heel and sole lift. As far as this aspect, if you measure dorsiflexion and remember that the sole lift should be inversely proportional to equinus, then there you will have this handled.

For the situation when you allow the foot to go into a relaxed calcaneal stance position (from a neutral calcaneal stance position) and one of the ASIS's drop (therefore either functional short leg or functional anterior innominate), you are dealing with a primary pronation. I used to use a Schuster type orthotic with massive forefoot posts which would balance the pelvis. I have found that the lateral cuneiform is subluxed in this configuration. I correct for this and the pelvis and associated equinus are corrected.

Regards,

Stanley

 

Dear Stanley:
Thank you very much for your reply. I do'nt have the access to JAPMA. Could you explain further? Another issue ,Quote" As a result of these factors, the shift in weight-bearing commonly seen in association with the ' alternate' presentations is one tending inwards on the right and outwards on the left. In 15-20 % of atheletes, the right foot will actually end up overtly pronating, and the left supinating( see FigsI.1 and 3.18A) If bilateral pronation persists, it will probably be worse on the right(see Fig. 3.19A); if bilateral supination persists, it will most likely be worse on the left( see Fig.3.19B). The reverse of these findings is seen with the left anterior and locked presentation." Page122, the malalignment Syndrome, Wolf Schamberger, churchill livingstone. Is the statement valid? Why the athletic population is so different from the general population that they can have such a high percentage of one foot pronation and the other foot supination? Thank you very much for your reply again.
respectfully
scott ma

 

Scott,

I can only guess as to what their terminology refers to without knowing their evaluation technique.
I will try and give you some basis for trying to answer this question, and then give you my best guess in interpreting it.
There are at least 3 different causes of asymmetry that they can be looking at (I will not discuss the asymmetry caused by the spine). The possibilities are asymmetrical pronation of the feet, leg length asymmetries, and iliosacral dysfunction.
Simply put, an arch that is lower will cause a functional shortage; a leg that is shorter will cause the leg to function shorter (in addition to being anatomically shorter), and a iliosacral dysfunction with the one hemi pelvis rotated posteriorly in the sagittal plane (a posterior innominate) will cause a shortage.
If we just look at what can happen with an anatomic asymmetry, we will see that every joint (or groups of joints working as one) in the lower can cause a compensatory shortening or lengthening. MTJ pronation-shortens a leg, STJ pronation shortens a leg, ankle plantarflexion lengthens a leg, knee flexion shortens a leg, hip abduction lengthens a leg (usually), and a posterior innominate shortens a leg.
If someone has a primary posterior innominate, then this is a functional shortage, and we can get shortening compensations on the long side, or shortening compensations on the long side. The only lengthening compensations are an anterior innominate and plantarflexion of the ankle.
They bring up the point of athletes being different. In the mid 1970’s Schuster would say that the long leg pronated, and Subotnik would say that the short leg pronated. They treated different patient subgroups. Schuster treated mostly weekend middle age patients who started running, and Subotnik treated a lot of real athletes. The real point about this is the body can either shorten or lengthen a leg to compensate for an asymmetry. It turns out that is someone is running quickly, it makes more sense to lengthen the short leg; and if someone is running slowly, it makes more sense to shorten the long leg. In practice, I found out that the point of transition is a 40-42min 10K. If someone runs slower than a 42 min 10K and has never run competitively, you will tend to find the long leg shortens. If someone is running a sub 40 minute 10K they will tend to lengthen the short side at the ankle, developing an equinus. Eventually the equinus will cause pronatory compensations. When this happens, a short leg with severe pronation will either develop a unilateral dropping of the pelvis (in the frontal plane) with severe trochanteric bursitis, or an anterior innominate. This anterior innominate configuration is a rather stable configuration, and if you have a patient with a plantar fasciitis with this configuration, you have to be mindful of the equinus, and of the leg length that is there.
With this in mind, how does this apply to what you found on page 122?
First we see that they make the distinction of an athlete, and now you know why. You also know the functional short leg on this patient will pronate more vs. the non athlete that will pronate less. He is saying that he finds a short right in 15-20% of his athletes (what the other 80-85% are he doesn’t say). He finds the reverse with a locked left anterior. An anterior innominate is usually caused by pronation of a foot. So in this case he sees pronation on the left with an anterior innominate (and as I said in a previous post this is caused by a lateral cuneiform subluxation), and this pelvic dysfunction does not respond well to manipulations.
This is my best guess as to what he is saying that he sees. There are many permutations of asymmetry. Start looking at the ASIS and the PSIS in neutral and relaxed calcaneal stance position, and check dorsiflexion, and you will see patterns. The only fly in the ointment is the asymmetry caused by the spine, in which the high ASIS and PSIS are on a functional short side.
I hope this helps.

Regards,
Stanley

 

Dear Stanley:
The following is quoted from the same book, page127, quote" A final observation on weight-bearing
Over the years, the author has been struck in clinical practice by the fact that a neutral to supination pattern of weight-bearing seems to be almost as prevalent as pronation in those who are in alignment. In one study(W. Schamberger, unpublished data, 1994), he looked at 120 athletes as they presented consecutively at the office and subsequently for follow-up after treatment. On the initial examination, 96(80%) of these atheletes proved to be out of alignment and 24(20%) in alignment. The results of this study as they relate specifically to the examination of wejght-bearing on walking,heel and toe-walking, and hopping were as follows:
1. Of those with initial malailgnment (n=96):
- 35% had bilateral pronation
- 8% had bilateral supination
- 35% had a neutral pattern of weight-bearing bilaterally, with no evident tendency to pronation or supination
- 17% had the right pronation, left supination pattern
- 5% had the left pronation, right supination pattern
2. On the initial reassessment following realignment(n= 96):
- 45% had bilateral pronation
- 11% had right pronation and left supination
- 11% had bilateral supination
- 33% had a neutral weight-bearing pattern
In other words, with realignment there was an increase in the number of those with bilateral pronation, from 35% to 45%, whereas the total of those in a neutral position or supination remained relatively unchanged at 44%."
Do you send a patient for chiropractor manipulation or physio realignment program before you implement orthotic therapy? Thank you very much for your elaborated reply,which is greatly appreciated.
respectfully
scott ma

 

Scott, I don’t send them out, I fix them myself, but that’s a long story.
With that in mind, I used to send patients out to chiropractors, but only when it was indicated on the physical exam. In other words, if they had a primary iliosacral dysfunction, then they would be referred to a chiropractor, but I would prescribe the exercises to balance the pelvis at that time (for a posterior innominate in runners, I would prescribe hamstring stretching for that side [because I would normally find the tightness]. If it was a weightlifter, I would prescribe quadriceps or psoas strengthening for that side [because I would normally find a weakness]).
To tell if it is a primary iliosacral dysfunction, palpate ASIS and PSIS to the ground in NCSP (neutral calcaneal stance position. If one ASIS is dropped and the ipsilateral PSIS is elevated, then this is a primary iliosacral dysfunction.

Regards,

Stanley

 

Because the pelvis moves and one can get discrepancies in the heights of ASIS or PSIS I actually measure from the umbilicus, which does not move. It is not leg length but is a measurement related to the leg length and is taken from the same fixed point

 

There are several tests that I don't use, only because they duplicate the information that I would gather other ways. I can see where it can be used, which is for any case you suspect a functional leg length of the the pelvis and/or spine; but the problem would be in cases where one side of the transversus abdominus is contracted.

Regards,

Stanley

 

Hello

I don't have the answer for you, but that is a very interesting question, I have recently graduated and am in my first band 5 graduate position and that has quite often possped into my head. If you have any leads on this I would be greatful to hear of them.

Regards fellow forum member

 

Hi All
I've been very interested to read the discussion on LLD. I'm just writing up my BSc. dissertation. I looked to see if there was any correlation between limb length discrepancy and low back pain ( and found none) although anecdotally I think there may be a relationship but it is difficult to prove causality. Researching through Pub Med and Science Direct etc. there are a lot of papers re. LLD and its effects on the musculoskeletal system and how much LLD is required to generate symptoms. Golightly et al. 2007 found improvement in function and reduction in LBP symptoms with use of heel lifts but much of the published research is contradictory. I do agree with Kevin Kirby re. adjustment of leg length and pelvic tilt by manipulation as I feel that the problems may occur from the feet up ie. Rothbart 2006. I was very interested in the comment also from Kevin Kirby re. using heel lifts only rather than lifting the whole foot. Any thoughts appreciated as I can find no published papers on this - maybe one for the MSc. ! Kind Regards Deborah Ferguson

 

Hi All
I've been very interested to read the discussion on LLD. I'm just writing up my BSc. dissertation. I looked to see if there was any correlation between limb length discrepancy and low back pain ( and found none) although anecdotally I think there may be a relationship but it is difficult to prove causality. Researching through Pub Med and Science Direct etc. there are a lot of papers re. LLD and its effects on the musculoskeletal system and how much LLD is required to generate symptoms. Golightly et al. 2007 found improvement in function and reduction in LBP symptoms with use of heel lifts but much of the published research is contradictory. I do agree with Kevin Kirby re. adjustment of leg length and pelvic tilt by manipulation as I feel that the problems may occur from the feet up ie. Rothbart 2006. I was very interested in the comment also from Kevin Kirby re. using heel lifts only rather than lifting the whole foot. Any thoughts appreciated as I can find no published papers on this - maybe one for the MSc. !

Kind Regards Deborah Ferguson

 

Ms. Darbenshire:
IYears ago, I pulsed the US orthotic labs and discovered that 4% of their orthotics had a lift in place for a short limb.
Anecdotally, I have tried to develop a strategy for safely treating LLD (your question of diagnisis and its responses on this thread continue to reveal how poorly we are about measuring and therefore, how poorly we treat LLD.
Warning: If you have followed my threads on this Arena, please realize that there has very vociferous posting agaist the value of anything I say, so please be very leary about trying or even worse about implementing anything you are about to read. Consider all of the following snake oil.
Dennis

I could not figure out how to publish the illustrations and bibliography that goes with this paper but since the Arena readership is so well educated and versed in physics and mechanics yI'n sure you can all see them clearly as you read the text.

The Inclined Posture, The Neoteric Biomechanical Key to Diagnosing Frontal Plane Lower Extremity Imbalance

Dennis Shavelson, D.P.M.

Abstract

One of the tenets of Neoteric Biomechanics is that the two limbs need to be balanced to each other. The Inclined Posture is a new and fresh paradigm for diagnosing and treating frontal plane imbalances of the lower extremity commonly that have been called “Limb Length Discrepancy until now.

Deviations in Lower Extremity symmetry on the frontal plane are common, and require compensation by the body to function efficiently. With time, repetitive compensations for asymmetry are pathologic and produce predictable signs and symptoms. When differences in the length, strength and/or structure of a person’s limbs lead to pathologic compensation, the clinical entity is defined as The Inclined PostureTM. A subject has The Inclined Posture until proven otherwise when the clinical signs and symptoms are apparent.

This paper presents a simple test for diagnosing The Inclined PostureTM (TIP) as well as additional tests and signs that confirm the diagnosis. Treatment options for TIP at the foot/shoe interface are presented, which reduce the need for internal compensation. By controlling TIP we can decompensate its pathological compensations and prevent it from impacting performance and quality of life as we age.

Introduction

Neoteric Biomechanics is a new and fresh paradigm for practicing Functional Lower Extremity Biomechanics 1. The tenets of Neoteric Biomechanics include the need to balance one lower extremity to the other when weightbearing. Until now, no organized or efficient manner in which to diagnose and treat what is currently called Limb Length Discrepancy (LLD) has surfaced. The Inclined Posture does not involve itself in the debate over structural vs. functional origin. It simply determines if a subject has made pathological compensations due to the influence of a short leg in closed chain and presents a quick method of compensating imbalance by the use of lifts and platforms at the shoe/foot interphase. It does not prevent skilled practitioners from balancing for TIP internally by lengthening the bones or stretching tight ligaments, capsules and musculotendonous units over time to cure TIP internally

The Definition and Relevance of TIP

Human function requires shifts in the center of gravity from one side of the body to the other. Thus, a symmetrical body has the most efficient gait2. Deviations on all three body planes are compensated internally by the body in order to remain centered and balanced3. These compensations tax the system progressively, reduce performance and efficiency and eventually causing degenerative signs and symptoms. Deviations on the frontal plane compensate by making predictable compensatory adjustments in the posture as the body leans to one side. The resultant clinical entity with its signs and symptoms is defined as The Inclined PostureTM or TIP for short.

The literature points to the fact that humans are not symmetrical3,4. When measured, a person’s two feet are not the same length and width and the muscle mass of almost any region on the left side, is different than that of the right. This paper focuses on the fact that the majority of our population exhibits some amount of variation when it comes to the lengths of our limbs, while functioning and The Inclined Posture deserves early recognition and treatment due to the fact that our population is living longer lives and extending its quality of life.

The Leaning Tower of Pisa has no internal compensatory mechanism and so its structure has continued to lean more and more over the centuries. Biomechanically, the human race has built in mechanisms such as the ability to shift the spine and hips, tilt the pelvic and shoulder girdles and pronate or supinate the feet in order to maintain our center of balance and erect posture in reaction to postural deviation on the frontal plane (figure 1) 5. Unfortunately, since our ability to compensate internally is limited, leaning forces that make us lopsided often become excessive and if left untreated, symptomatic. This leads to pathology in predictable locations within the postural chain6.

Clinically, unless the difference in limbs is greater than 1.5 centimeters (the true definition of a limb length discrepancy or LLD), it is difficult to determine its origin and impossible to accurately measure its existence. This means that The Inclined PostureTM is a clinical entity diagnosed by confirming the existence of specific compensatory signs and symptoms that develop in affected subjects as they try to maintain center of gravity and balanced posture over a lifetime.

The Inclined PostureTM compensates at specific locations of the postural chain when performing specific activities. For example, when standing still, the pelvis tilts downward to the short side and when walking, the short side supinates at the subtalar joint as the long side pronates2. It is important to note that if closed chain asymmetry is present in subjects without taxing the posture, the signs and symptoms of TIP do not develop and by definition The Inclined Posture does not exist. On the other hand, when the signs and symptoms of the inclined posture are present in subjects they reflect the existence of pathology in the postural chain and therefore, by definition, TIP exists. The effects of The Inclined Posture are progressive and degenerative and since it affects a majority of people, TIP plays an important role as a component of many overuse syndromes, postural degenerations, deformities, and performance issues.

When it comes to limb length, the literature continues to debate two issues; how to measure limb length accurately and what amount of asymmetry needs diagnosis and treatment5,7,8. These questions remain unanswered. We believe this debate diverts us from appreciating the clinical impact when one limb is functioning longer than its mate, even if the difference is seemingly immeasurable. Simply put, if there is asymmetry in a pair of limbs is creating pedal and postural sequelae, it deserves diagnosis and treatment.

Until now, The Inclined Posture has not been considered as an entity even though there has been active debate about the importance of diagnosing and treating limb asymmetry4,5,7,8. Studies have shown that limb length discrepancies of less than 25 mm are not observed during routine musculoskeletal examinations5. Discrepancies of this level go unnoticed by the patient as well5. Since almost everyone has TIP and less than 4% of the population has a diagnosed Leg length Discrepancy (LLD) actively being treated9, the importance of the inclined posture and its need to be treated is being underestimated.

In an evolutionary sense, ambulating on uneven surfaces and performing tasks that require uneven function (i.e. going up a flight of stairs) has forced the human posture to adapt to unequal stresses. This adaptation comes in the form of biomechanical and muscular compensation.

When standing still, a person with The Inclined Posture (TIP) leans towards the short side on the frontal plane in order to maintain an erect posture. When active (i.e. walking or running), this same person functions more long sided, developing a “super” side. An example of this type of biomechanical compensation is the “super” arm, shoulder, and torso that a tennis player develops on the functionally dominant racket side.

To make things even more complicated, there are concomitant factors that influence how much TIP affects subjects. This means that The Inclined Posture alone does not determine the amount of biomechanical compensation needed or the amount of compensatory pathology that is produced. Some of the concomitants affecting The Inclined Posture are excess weight, underlying biomechanical pathology, activity level, compensatory equipment (i.e. shoes, orthotics), reduced health state, and environmental factors such as inclines in the road. Concomitant influence must be considered because the need for treating TIP increases as the number and magnitude of these factors increases.

Daily activities, such as washing dishes, waiting on line, or walking about will have a cumulative adverse effect upon the posture when performed lopsided. Add to this the negative effects that a lifetime of play, sport and exercise have when performed lopsided, and you can begin to sense the value of diagnosing and treating TIP.

Perhaps the concomitant factor influence upon TIP can be better understood if we examine an example. When we talk about TIP being impacted by activity level, we know that when a person walks, maximum heel strike is one times the body weight but when running, heel strike is three times the body weight. This means that functionally, a 5mm TIP difference in our limbs in stance converts to a 15mm TIP when running. This means that additional treatment may be necessary at specific times of exertion. In our example, a small amount of additional heel lift on the short side when the subject is running eliminates the need for internal compensation.

Until now, practitioners have focused on the chief complaints that result from a posture influenced by The Inclined Posture and treat the unilateral bunion, the long sided knee arthritis, the low back pain and sciatica, as well as the generalized postural aches and fatigue without diagnosing and treating the root problem. Treatment protocols for the inclined posture will prevent many predictable neurological, orthopedic and postural problems from appearing and will assist in the treatment of those that exist.

Diagnosing TIP: The FEJA Test

The author has developed an accurate, reproducible test for the diagnosis of TIP called the Functional Equinovarus of the Joints of the Ankle or FEJA Test.

The test is based upon the fact that functionally, if TIP exists, the long side is compensating to shorten and the short side is compensating to lengthen. Eventually there are soft tissue and adaptive osseous changes, in specific locations, that can be used diagnostically.

In the functional lower extremity biomechanics (FLEB) literature, Mann and Inman call the ankle joint and the subtalar joint “the joints of the ankle” and located them as the primary compensators of the lower extremities10. These two joints, as a unit, become the first line of compensation and the first areas where fixed changes occur in reaction to the inclined posture. When comparing a pair of limbs, The Inclined Posture exists if there is a relative Equinus deformity between Ankle Joints and a relative Varus deformity between Subtalar Joints, until proven otherwise. This diagnostic test for The Inclined Posture is called The Functional Equinovarus of the Joints of the Ankle or FEJA Test for short.

The Inclined PostureTM compensates in the sagital plane of the long side ankle joint by dorsiflexing in order to shorten its limb. On the other hand, the short side ankle joint compensates by plantarflexing in order to lengthen its limb. This balances the incline on the sagital plane seen in TIP. In time, soft tissue contractures create a relative difference in dorsi/plantar flexion of both ankles with the short side being plantarflexed (in relative equinus). The Functional Equinus portion of The FEJA Test is performed by forcibly dorsiflexing the ankle joint of both limbs and noting any difference when measured (Figure 2). If the inclined posture and its concomitant factors are enough to cause internal compensation, the side with a relative plantarflexion (equinus) in relation to its mate is the short side until proven otherwise.

The Inclined Posture compensates in the frontal plane of the long side subtalar joint by pronating (inverting) in order to shorten its limb. On the other hand, the short side subtalar joint compensates by supinating (everting) in order to lengthen its limb. In time, soft tissue contractures create a relative difference in inversion/eversion of both subtalar joints with the short side being inverted (in relative varus). The Functional Varus portion of The FEJA Test is performed by forcibly inverting the subtalar joint of both feet and noting any difference when measured (Figure 3). If the inclined posture and its concomitant factors are enough to cause internal compensation, the side with a relative varus position in relation to its mate is the short side until proven otherwise.

In summary, a positive FEJA test exists when one limb (the short side until proven otherwise) has both a relative plantarflexion (reduced dorsiflexion) when comparing the ankle joints and a relative varus (increased inversion) when comparing the subtalar joints.
The REJA test would be reported as a positive test for the short side of The Inclined Posture (i.e. FEJA +, Left). Since the amount of Equinus and Varus are relative, exact measurements are not necessary for a positive FEJA Test.

The Confirmatory Signs and Tests for TIP

1. Weighing Scales
Observe the patient marching in angle and base of gait for 10 seconds and then ask the patient to freeze. The separation of the feet and the angle which they sit determine the angle and base of gait. Trace the patient’s footprints, and in those footprints, put two weigh scales. Then ask the patient to step on the scales. Since TIP causes a person to shift weight to the short side in stance, if the scales do not read the same, the greater of the two readings will be on the short side.


1. Gait Pattern Confirmatories

TIP shows predictable changes in gait that reflect the asymmetry in the feet and posture. There is a longer stride length on the long side with a longer foot plant. There is a relative external rotation of the hip and limb on the short side with a greater arm swing when comparing the short side to the long side. There is a relative flatter arch (pronation) when comparing the long side to the short (or a relative higher arcj on the short side (supination).


2. A Unilateral Postural Complaint, or a bilateral complaint that develops from a one sided complaint. i.e. unilateral Bunion, heel spur, plantar fascitis, ankle, knee and hip arthritis and pain syndromes. Unilateral nerve problems such as sciatica

The increased work accepted by the longer side with every active step and movement, in subjects with TIP, places greater stress upon the joints, muscles, tendons, and ligaments of the long side. Overuse syndromes and progressive degenerative syndromes attack overstressed locations in the posture with the most force and early. This results in additional compensation in these locations in the posture with early pathology and symptoms.

For example, when examining the feet of subjects with TIP, the long sided foot performs more work than the short sided foot in supporting and moving the posture. This increased demand exposes any biomechanical weaknesses to overuse and degeneration. Since the long side foot is pronated, more force is applied to that medial column. If other deforming forces such as a hypermobile first ray have predisposed this subject to develop bilateral bunions, a more pronounced Bunion (hallux abducto valgus) deformity develops on the long side. Similarly, the increased pronatory forces of the long side cause additional collapse of the medial arch and compensatory pull of the plantar fascia on the long side. Thus, plantar fasciitis and heel spur syndrome develop on the long side first.

3. Unequal Shoe Wear Pattern
With the increased inversion noted at the subtalar joint of the short side, bony adaptation in addition to contactures of the associated musculature, capsular, tendon and ligament soft tissue structures fix the subtalar joint in more varus than its mate. During the heel contact phase of the gait cycle the short sided heel is contacting the ground more supinated and this leads to additional lateral wear of the shoe.
The additional weight and time that the long side spends in active function in subjects with TIP leads to increased total shoe wear on the long side.

4. Excess Lateral Column Callus on the short side
The increased weight on the lateral column as a result of the varus loading on the short sided heel, in gait, results in the existence of a unilateral or a more extensive 5th metatarsal callus on the short side. In Flexible FootTypes, this can also lead to increased callus under the 2nd metatarsal.

5. Low Back Pain or one side dominated sciatica, A Pelvic Tilt in angle and base of gait, to the short side and/ or A Shoulder Girdle Tilt in angle and base of gait, to the long side
In TIP, at the level of the pelvis, one limb is functionally (or structurally) longer than its mate. This fact causes a downward tilt in the pelvic girdle from the vertical lopsided towards the short side (figure 1.) This can be measured or “eyeballed” by placing markers on both anterior superior iliac spines (ASIS’s) and noting the presence of the incline (i.e. The Leaning Tower of Pisa). This incline of the pelvic girdle with the short side lower causes L-5/S-1 and L-4/L-5 degeneration and low back pain and radiculopathy. In order to maintain the center of gravity and erect posture, the lumbar vertebrae shift towards the long side and form a concavity. This compresses the lumbar nerves on the long side and leads to compression and eventual sciatica on the long side. The curvature in the spine tapers and becomes less exaggerated as it extends all the way to the shoulder girdle. At the shoulder girdle, the compensatory need to keep the center of gravity causes a tilt with the long side lower.

6. The Long Sided Foot is Larger, longer and/or wider and reveals an Increase in Pronation when compared to the short side in angle and base of gait.
The long sided foot accepts a dominant role in stance and in function and performs more work than its mate. Over a lifetime, this is reflected with greater muscle mass, bone density, supportive tissue as well as a widening of the longer foot. This translates into the fact that the long sided foot, in TIP, is larger than its mate both in length and girth.

As stated previously, the long sided subtalar joint compensates by pronation in order to functionally shorten the limb. This additional pronation places more of the limbs weight on the medial column and drives additional stress into the midtarsal joint. In patients with a flexible forefoot, this force will unlock the midtarsal joint and create a hypermobility in the forefoot that will cause it to stretch and spread. Over time the long sided foot will become larger and wider.

7. Larger Mass on the Long Sided Limb (i.e. calf, thigh)
Since, functionally, the long side dominants in subjects with TIP, the compensatory increase in muscle mass, bone density and connective tissue strength leads to the long sided limb developing larger than its mate.

Measure the diameter of both calves 5 cms below the tibial tubercle to record calf girth. Measure the diameter of both thighs 5 cms above the proximal patella to record thigh girth. The side with the higher measurements is the long side until proven otherwise.

8. Walking Down Stairs
Observe the subject walking down a flight of stairs. Due to the compensatory abduction of the short sided hip, the angle of gait will appear windswept to the short side if TIP is present. If it is no t present the angle of gait will appear relatively straight.

The Diagnosis of The Inclined Posture

The Inclined Posture exists in a subject when there is a positive fEJA Test and the existence of two or more of the confirmatory tests and signs, until proven otherwise.

TABLE 1 See Table 1 In Appendix

Concomitant Factors affecting TIP Syndrome
1. Excess Weight
A subject’s weight determines how heavy a body the posture must support and carry. The amount of compensation necessary for a body to overcome biomechanical pathology, including TIP, increases proportionally to its weight. Therefore the more overweight a subject is, the more exaggerated the signs and symptoms of TIP will be.

2. Environmental Factors
Uneven terrain causes the need for more compensatory reaction in order to maintain the center of gravity and balance. Increased incline and tilt in surfaces, the hardness of the surface, and even the friction coefficient of the surface play a part in determining how much compensatory energy is needed in order to function on that terrain. Compare the effort needed to run the same distance on a flat straight surface in hot weather to running that same distance up a hill, tilted to the left, in cold weather, when the ground is hard. This comparison can show you the impact of the environment on function and on The Inclined Posture.

3. Equipment Factors
Scientists, designers and manufacturers have developed equipment that can compensate for biomechanical pathology, including TIP. These products reduce the impact of TIP by absorbing shock or controlling motion. Running Shoes, foot orthotics and therapeutic socks are just some of the products available.

Both the quality of the products and the level of wear must be considered as well as the specificity of matching the compensatory need with a products ability to decompensate specific problems.

4. Functional Foot Type Classification and Treatment

The feet of every human being can be placed into one of ten groups known as The Functional Foot Types (FFT) 11. FFT classification is based upon the open chain and closed chain positions of the joints in the rearfoot and forefoot of the foot when divided in two by the talocalcaneal and calcaneocuboid joints (the midtarsal joint). Rearfoot position is determined by noting the position of the subtalar joint at its end range of motion in open and closed chain. Fore foot position is determined by noting the end range of motion of the medial column of the foot with the rearfoot neutral and the lateral column at its end range of motion in both open and closed chain. In this manner, the rearfoot and forefoot can be classified as rigid, stable, flat or flexible. Each of the nine Functional FootTypes has its own predictable signs, symptoms, compensations, pathology and treatment. Once classified, every patient can have their foot type decompensated with FFT specific plaster casting techniques and a prescription that is incorporated into a foot orthotic.


5. Activity Level

The impact of TIP and its need for treatment increases in direct proportion to the activity level of the subject. The time of performance, the frequency of performance and the intensity of each activity must all be considered. The object of treatment is to maintain or increase activity level while reducing the impact of TIP.

6. Reduced Health State and/or Fitness Level

When dealing with quality of life issues there are two distinct factors that determine ones ability to be active. They are health and fitness. It is just as possible to be fit and in poor health as it is to be healthy and unfit. The health state of a subject can deteriorate to the point that it will have a negative impact on compensatory reserves and so if a subject has a poor health state it must be treated simultaneously and the treatment plan for the inclined posture must take health state into account. Simultaneously, fitness level must be determined and if weak it must be treated simultaneously and the treatment plan for the inclined posture must take functional condition into account.

Treatment for The Inclined Posture

1. TIP Paddings
Initially, The Inclined Posture can be compensated by placing a heel pad of one eighth to one quarter of an inch thick in the heel of the shoe on the side showing a positive FEJA Test. Materials can vary but adhesive felt is a readily available option. There should be an immediate improvement of most of the signs of TIP and the pad can be adhered to the shoe or moved from shoe to shoe daily.
Simultaneously, rearfoot, medial arch and forefoot pads can be adhered to a shoe to decompensate the subjects Functional FootType, if pathologic.
2. Custom Foot Orthotics
Custom Foot Orthotics used to treat The Inclined Posture are fabricated in pairs and have three basic components, a semi rigid thermoplastic shell created from an non weightbearing neutral or cast corrected plaster cast for each foot, asymmetric rearfoot posting and/or a heel lift on the limb having the positive FEJA test.
The semi rigid thermoplastic shell should be fabricated from an non weightbearing neutral or cast corrected plaster cast in order to capture the Functional Foot TypeTM of the subject and the anatomical differences in the two feet.
The assymetric rearfoot posts should be fabricated in shock absorbing crepe or a similar material and should reflect the neutral position of the subtalar joint of each foot since the short side (+FEJA) will have a neutral position that measures greater in varus than the long side. The thicker rearfoot posting on the short side will add lift to the short side as it compensates for the additional varus deformity on the frontal plane.
A heel lift fabricated in shock absorbing crepe or a similar material can be added to the rearfoot of the short side (+ FEJA) if the amount of TIP deformity needing compensation is greater than the asymmetric rearfoot posts can accomplish.
3. Sole Heel Lifts or a Sole Platform Raising The Short Side Shoe
If The Inclined Posture is excessive (i.e. A Limb Length Discrepancy) and cannot be compensated in the inside of a shoe than a heel lift tapered to the heads of the metatarsals or a platform lift of appropriate thickness can be added to the Outer Sole of the shoe on the short side.

Discussion

10,000 years ago, man became civilized and created paved roads, cities, shoes and playing fields to satisfy a desire to expand life and add to its quality. At the same time the medical and physical sciences committed to extend the human lifespan and make it more productive and comfortable.

The civilized forces of unyielding ground surfaces and hard shoe boxes, when added to the pull of gravity, create an unyielding negative force that challenges our bony and soft tissue structures with every step we take during our entire lives. Genetics and compensatory mechanisms that exist in all of us work to prevent these forces from reducing our performance and quality of life. To these, we have added external equipment to compensate negative forces before they impact our bodies and postures.

We ask you to imagine “The Inclined Road”. Imagine the cumulative negative forces that would occur in one lifetime, as we took millions of steps, if all of our roads were paved with even the slightest amount of incline to one side. Pelvic tilt, low back pain and scoliosis would develop. Compensatory heel, ankle, knee and hip asymmetry and degeneration as well as muscular and soft tissue compensations would reduce our performance and quality of life. We would be functioning on a lopsided surface. “The Inclined Road” doesn’t exist because as much as possible, our hard, unyielding roads and floors are level.

Now we ask you to imagine “The Inclined Posture”. Imagine the cumulative negative forces that would occur in a lifetime, as we took millions of steps, if functionally, our limbs had even the slightest difference in length and were inclined to one side. Pelvic tilt, low back pain, scoliosis would develop. Compensatory heel, ankle, knee and hip asymmetry and degeneration as well as muscular and soft tissue compensations would reduce our performance and quality of life. We would be lopsided people. In reality, The Inclined Posture exists in a majority of the human race. Until now, there has not been any focus or energy placed in the direction of diagnosis and treatmentfor The Inclined Posture in order to make people level and remove this never ending deforming force from impacting our performance and quality of life.

Stimulated by personal experience, the senior author has been studying and teaching about “The Inclined Posture” for more than two decades. This paper is meant to alert the medical and scientific communities of the importance of TIP and its diagnosis and treatment, as we expand our lifetimes and upgrade our quality of life.

Since examination, diagnosis and treatment for The Inclined Posture is easily accomplished without invasion or discomfort to the patient, we strongly advise that practitioners dealing with the posture as well as the orthopedic, podiatric and biomechanical arts and sciences, become familiar with and take the time to diagnose and treat The Inclined Posture.

Conclusion

This paper discusses leg length asymmetry, no matter how small and calls the compensatory result The Inclined PostureTM (TIP). Limb length discrepancies less than 25 mm are rarely discussed in the literature yet they are almost universal in functional subjects5.

Investigators should perform the FEJA test for TIP whenever performing a biomechanical evaluation but especially where deformity, degeneration and symptoms are unilateral or assymetrical.

TIP exists if there is a positive FEJA test accompanied by two positive confirmatory tests or signs. All cases of TIP deserve treatment. It is our opinion that semi rigid custom foot orthotics with asymmetric extrinsic rearfoot posting and heel lift modifications are the gold standard for treating TIP.

As our population ages, quality of life issues deserve more and more attention. If you had a table with one leg just a little short of its mates, you could let the table wobble and tilt as you ate on it or you could put a small amount of material under the short leg and eat your dinner in comfort. The diagnosis and treatment of TIP will extend us a more injury free, better performing improved quality of life with less postural breakdown over our lifetimes.

 

Interestingly, the owner of an orthotic lab here in the UK is doing a PhD in LLD.

He has absorbed a practise from kinesiology (yes, it's true!) where you get your patient to stand with different heel raise levels under the short limb and "press" on their out-stretched arm. At the point they can resist the operator's downward pressing the strongest, they are considered to be standing on the best heel raise (or sole raise) for them !!!

Interesting thing is though, that while he has brought this in from kinesiology, an orthopaedic lower limb surgeon I work with, suggested that it may simply be that our upper body and torso is strongest when our sacral base is level. (ie, back to the ASIS/PSIS exam for a LLD)

Maybe something for you to critique Charlotte in your MSc

 

I believe that I understand what Kevin is saying here and I find no issue with it at all (being that I am a chiropractor that might surprise some people, perhaps even Kevin ).

I feel that many of my colleagues are very imprecise in determining what is an Leg Length Difference (LLD) and what is a purely functional LLD (FnLLD) as well as explaining the rationale behind what they are treating, why it is therapeutic and how it benefits the patient. I also believe that podiatry has many of the same issues with precision in nomenclature and long held beliefs, such as the short leg always pronates. Keeping patients coming back week after week with no resolution of a FnLLD is not good clinical practice. It is good for the wallet as was suggested but ethically it is reprobate.

Getting back to the discussion though, manipulation can be very useful with FnLLD but it is not a panacea of course. FnLLD problems arise from myriad factors such as muscular involvement, congenital anomalies such as scoliosis, trauma and lumbar dysfunction. While manipulation will help in many cases, in others approaches other than weekly adjustments need to be explored. I do firmly believe that certain foot pathologies contribute to compensatory lumbar and pelvic dysfunction that acts on the hemipelvis and produces a chronic short leg in some patients. As Howard stated in these patients a team approach is obligatory and clinically useful.

 

What about the good old ideomotor effect?! Tested and repeatable (very). Be interesting to see the methodology but I wonder how this very very powerful effect has been eliminated from the methodology?!

The ideomotor effect, for them as don't know, is the mechanism for subconscious movement. These are movements which happen below the level of awareness and the subject is not aware they are making them. The classical experiment is the Ouija board wherein people can honestly believe that the glass is moving under its own power and not being pushed by them.

An experiment was carried out wherein a Ouija was used but the tester had placed a thin glass disk atop the glass so the fingers rested on this. Who can guess what moved, the glass or the disk?

The effect is also easily reproducible under hypnosis and is often used by hypnotists who believe the "special state" model to "prove" their position. Again, it has been shown that appropriately motivated individuals can achieve all of the phenomena without recourse to hypnosis.

Pendulum dowsing is another example. With a modestly suggestable subject you can cause a pendulum held by them to swing in a line or a circle as you suggest to them that it should be so. However many a pregnant mother will do this to try to derive the gender of her child and beleive that it happens because her body "knows" what it is carrying. *

As Occam points out "Pluralitas non est ponenda sine neccesitate". One should look first to the known and established reasons for the changes in muscle power (ideomotor) before seeking the esoteric! Standardise the strength of the pull, eliminate the patients, and the clinicians knowledge of what wedges are where (double blind) and test for repeatability and we may have an area of interest! Perhaps that is what he is doing.

Regards
Skeptical Bob


* my wife, to my considerable frustration (which i'm sure is why she did it), did this both times she was pregnant. It worked precisely half the time .

 

This thread points out the philosphical difference between research based EBM DPM's and those who are more pure clinicians who I am sarcastically calling DTT's (Dying To Treat).

If we can agree that 70% of us has a limb length discrepancy (Spooner Chime In) and that the body will either use up a portion of its compensatory reserve to offset it from affecting our lifestyles or exhibit symptoms due to LLD,
Then I question each one of you as to how often you are treating LLD?

I polled the four largest USA labs 6-8 years ago and they were using lifts approximatley 4% of the time?

I ask this question personally to The Arena Members: Are you closer to 70% or 4%?

If you were told that you (or your children) had one leg shorter than the other and that you had two cloices for care:
1. Compensating for your lopsidedness within your body or
2. Compensating for your lopsidedness between your foot and your shoe (or the ground)
Which would you choose?

I have been convinced by 100 + years of literature that it's very difficult to measure and diagnose LLD! Why are you still trying?

Is that a reason not to treat it, especially if there is a circumstantial case that an LLD is in play.

Let's take heel pain. Logically (?)

Premise:
A unilateral heel pain should be considered to be accompanied by an LLD what % of the time?
Which side would be the dominant symtomatic, Long or Short?

Clinically (please debate), I find that the longer side dominates beginning heel pain 1st more than the shorter side ( with eventual bilateralization).

What would be the harm in including a small lift (1/8"- 3/16" into the care of heel pain (and I mean HARM, not Unproven) on the non painful side for the first ten days to note its impact. Stop when you feel that it is clinically not a good idea and take out the heel lift if symptoms get worse (for the painful heel).

There is a difference between proving that an LLD exists and clinically realizing that there are left/right diferences clinically.

Has anyone tried my two scales test for TIP? (another thread) or noted that one leg is more abducted in stance or gait, or uneven armswing or ditto... ditto?

We have spent thirty years balancing the rearfoot to the forefoot. Why are we so casual about balancing the right foot to the left?

Summary:
While you are trying to determine how to measure LLD, I will have treated hundreds of cases of LLD and POTENTIALLY reduced its pathological influence from existing in my community.

LLD vs, DTT
:drinks
Dr Sha

 

Dennis, I think I speak for a good portion of the forum population (chime in if i'm wrong guys and girls) when I say...



What do you want to hear? We prostrate ourselves at the feet of the professions greatest member who has seen what we cannot? The arrogance of your last sentance is astounding!

How about
3. Accept that the body does not function symetrically and that the body is designed to accomodate undulating terrain.

4. Have concerns about going between a "corrected" and "uncorrected" state going between wearing and not wearing the devices.

5. Disagree that merely not being able to measure small LLD's reliably is not reason not to "have a go".

6. Not wish to experiment on patients and possibly put them in a worse situation on the strength of your unpublished, unsupported say so.

7. Not be comfortable with your trial and error, "stick it in and take it out if the patient gets worse " approach.

8. Not fancy defending a decision to add a heel raise to what turned out to be the longer leg when the patient falls over, breaks her leg and sues us.

Besides, you've been telling us for ages that mere pain releif is not a good enough treatment outcome. Now you prescribe a heel raise without measuring anything based on... oh yeah, pain releif.

Sorry. Tough day.

Robert

 

Thank you for continuing to try to break a hole in my thick head to get through'

I understand my faults but am finding it difficult to repair.

I have actually put in energy to reduce #'s 1-8 and obviously continue to podiatrically put my foot in my mouth.

I am going to make one last stab at the request of The Arena and try to explain my rational for "how bunions develop and can be prevented on the appropriate thread.

I continue to back off unsuccessfully.

One additional question of The Arena:
Should I stop developing New Threads? I can certainly do that easily.

Dennis

 

Yes please.

 

Dennis

No! please don't, I thoroughly enjoy the entertaining threads that develop. ( in a sado-masochistic way) The delicious pain / pleasure combination is delightful and almost addictive. Its like how I always tune in to watch CSI and then complain all the way through about how rubbish the story lines and technical content are, but next episode I'm tuned in again ?????

Faint heart never won fair maiden they say and Dennis, I admire your thick skin, persistence and tenacity,which are astounding and a credit to you. I'm sure that one day, like the under dog Eddie the Eagle and his buffoonish skiing triumphs, your character will soar to heights undreamed of and be forever romanticised in popular folklore. A national treasure to be lovingly cosseted and on occasion, polished bright for nostalgic irreverence and salvation of trod down souls in need of inspiration.

Three Cheers for the apocryphal prose of DrSha

LoL Dave Smith

 

For those that have not taken any course work in applied kinesiology taught by certified instructors, the test described above is not taught. The main reason is that the muscle test is used on one muscle, not a group of muscles.

Regards,

Stanley

 

I was very interested to read the various techniques utilized to evaluate leg length discrepancy. Most of those contributing to this thread indicate that the anterior superior spine is the key anatomical site to evaluate limb discrepancies. I would suggest that in addition to these measurement the practitioner should observe the level of the inferior boarder of both scapulas as well as the Iliac crest. Additionally they should observe from the posterior aspect both the superior Iliac crest as well as the posterior sacro iliac tubercles. Observing from the posterior aspect should provide the practitioner a clear indication of both the sagital plane deformity as well as any transverse plane rotational deformities. Then by placing plastazote or cork elevations the practitioner can equalize the limb discrepancy as well as observing the affect upon the pelvis, spine and scapula margins. It should also give the practitioner an idea and degree of the transverse plane rotational changes. In years past some practitioners actually used "Scantograms" in weight bearing to verify the various measurement (tibial, femoral) of the osseous structures. This however exposed the patient to excessive radiation.

Finally I think it is a good practice when placing the various cork or plastazote elevations to simulate the correct heel- toe attitude. Therefore when a patient has a measurable 1" limb shortage (determined by measurement) the elevation should be a heel elevation of 1", ball elevation of 1/2" and toe elevation of 1/2" in a weight bearing.

Richard

 

Richard:

Welcome to Podiatry Arena. Your contributions should be quite valuable for all of us.:drinks

 

Hi Richard,

Welcome aboard.

What does all these measurements mean to you? In other words, you collect all your measurements, then how does this determine your treatment? I guess what I am saying is that sometimes you will put a lift under a heel and the pelvis will twist anteriorly on one side, or the ASIS is high on one side, but the PSIS is low on the same side as the high ASIS. How do you treat this?

Regards,

Stanley

 

I use the basic measuring techniques as a guide to LLD and if I find a significant difference ( over 4mm) then I ask for a weight bearing ray of the pelvis.
This allows me to get an acurate position of the Femur heads in weight bearing.
I do not often ask for a scan as the cost is too great and the acuracy within 1mm is in my opinion not necessary.
Obviously this is only requested when the patient presents with symptoms that point to leg length as a possible cause.
After putting all the info together if I still consider that the LLD is a contributing cause I will usually make Orthotics incorporating the required heel lift.
Richard L

 

I'm developing a certain cynicism about measuring and "correcting" LLDs (I've recently upgraded it from skepticism to cynicism).

I had a patient only this week referred me from a Pod Surgeon with a 1cm LLD, L short (based on eyeballing ASIS). When I measured it I made it very slightly the other way (based on pelvic level resting on ASIS). I asked the Surgeon to show me his technique, which was the same as mine. With my fingers on the asis he swore that it was still lower on the left. I couldn't see it and when I rested the pelvic level on his fingers it showed dead level (as opposed to when I had rested it on the ASIS a few mins earlier when it showed the left to be fractionally LONGER).

The sources of error here are HUGE! That patient came away with 3 observations, Left higher (by a bit), dead level and right higher (by 10mm) on the same day! Two of those were taken using the same measurement, the same fingers on the same ASIS at the same time, one by eyeball and the other by spirit level. We can't all have been right! And I struggle to take seriously a measurement with such a gross unrepeatibility (ironically my colleague swears his method IS repeatable). It cracks me up when I read somebody elses file and they talk about a clinically measured LLD of 7mm or similar! 7mm you say. Not 8mm then.

And if there IS a discrepancy of less than, say, 1cm how significant is it clinically? Most serious walking is done outside, how many pavements are level within that kind of tolerance?

Is there any evidence that LLD is predictive of anything or that correction of an (apparent) LLD has theraputic value?

Regards
Robert

 

Richard,

Since you are basing your measurements on the weight bearing radiograph, do you think you have to know what the feet are doing? Do you have the patient in neutral position or in relaxed position?
Regards,

Stanley

 

Robert,

You have some very interesting reasoning. If two people take a measurement that is not close or repeatable, then the thing being measured is of questionable value. What in podiatric biomechanics is accurately measured by any two practitioners of unknown training?

Stanley

 

Hi Charlotte
might be a little late with a reply but I found a couple of things when looking for LLD - I use a combination of ways to assess - first of all I lie the patient supine and then eyeball the level of the malleoli I then get them to sit up and see if it changes and then get them to lie back down and eye ball again - I then (if poss) do the measurements from the ASIS - nowadays with growing obesity this is getting more difficult - if this isn't possible I measure from the sternum - this is not done in isolation though I also check levels of patella and hips. In reality I don't think that any one test can be reliable on it's own as there are so many factors in measuring LLDs, but I do think its important to understand the difference between functional and anatomical and correct accordingly. Good luck with your MSc
Claire
Oh one more thing before you check the LLD you need to check posture and spinal alignment as this can scew your other results significantly

 

Hi Claire,

Could you expound on this? I for one don't quite understand what you mean by this. Could you also relate this to your exam.

Regards,

Stanley

 

Sorry, I missed this 1st time around.

I would say there is one thing which is fundamental to the assessment (and yet which gets neglected sometimes) which should be repeatable. That is the diagnosis, what is wrong in what structure. The prescription (IMO) should be designed to reduce that force in that tissue. So if you understand how the foot works and what structure does what then there are few (if any) measurements you need!

In general we seem to be moving away from "returning the foot to normal" I have no problem with using raises if I can see a specific tissue stress will be ameliorated with it but unless it's a big and unmistakable one I don't tend to do it just to restore the "normal" of perfect symmetry especially when I don't trust the measurement.

Has lld of 10mm> been shown to be predictive of anything?


Regards
Robert

 

Hi Stanley
anatomical would be an actual difference in the bones of the lower limb which can be tested by measurment, eye balling and checking the lengths of femur/tibia etc
functional - this is one that is sometimes overlooked - muscle tightness can be a contributing factor to LLD and should be checked especially around the pelvis and hips - if there is anything specific found I will get my physio colleague to help loosen off the affected muscles - this can result in a reduced correction in the long term - sorry for any typos - I think my computer puts them in when I'm not looking!

 

Hi Robert. I agree with what you are saying. So how would you treat a unilateral IT band syndrome in a runner based on what you are saying?

Robert, I haven't used lift therapy in the last 7 years or so, but a lot of what I do is based on measuring the ASIS to the ground and the PSIS to the ground. I actually think that these measurements are more exacting than eversion and inversion of the foot, or subtalar neutral, ankle dorsiflexion, or forefoot to rearfoot relationships. The real problem is who is our teacher for this, and/or who is really qualified to teach leg length evaluations.

Robert, I don't know of a study that shows this. You seem to be concerned about the force in the tissue. I did a study back in JAPMA that was published in 1985:
S Beekman, H Louis, JM Rosich, and N Coppola
A preliminary study on asymmetrical forces at the foot to ground interphase
J Am Podiatr Med Assoc 1985 75: 349-354.
One of the interesting things was that my evaluation correlated with the forces at heel contact.


Regards,
Stanley

 

Hi Claire,

What muscles do you check around the hips?
Do you check the effect of the foot on the pelvis or iliosacral joint?

Regards,

Stanley