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Compensating for leg length difference

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

  1. jdbs3

    jdbs3 Welcome New Poster


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    I have searched the web, but have not found anything on this topic ...

    The person has one leg 1/2 inch shorter than the other. When they buy shoes, they have a shoemaker build up the shoe heel for the shorter foot by the 1/2 inch.

    Recently a shoemaker suggested that instead of adding 1/2 inch to one shoe heel, that he add 1/4 inch to that heel and take 1/4 inch off the other heel.

    This sounds logical, that is, raise my shorter foot by 1/4 inch, and lower the longer foot by 1/4 inch. The hips should now be level.

    BUT, is this alternative okay to use rather than just making the 1/2 inch adjustment on the shorter leg?

    thanks
     
  2. Dear Jdbs 3'
    i work at a NHS clinic in Uk, treating a wide variety od pts for biomech' pathologies, please consider the following Q?s

    1) 1/2" is a lot. How old is your pt ie how adapted will they be to large, sudden alterations to their current (assumedly symptomatic) musculo-skeletal "system"?I find corrcting half of your "Found" discrepancy is usually a safe way of correcting this problem
    .
    2) Any history of spinal injury/intensive stress (ie lifting/ running/lower back pathologies),if so TREAD V.CAREFULLY, WE LIVE IN WORLD WHERE LAWYERS THRIVE, UNFORTUNATELY.

    3) Why does pt want this, if it is for aesthetic reasons, consider that an assymetric gait mmay appear worse (from a greater distance) than a 1/4-1/2" shoe build-up, other factors ie over pronating may need correction, if so an orthosis incorporating a heel raise may be the answer but consider that:

    4) These in their more drastic forms tend to pop out of the shoe (consider sharing heel raise betwen shoe & orthosis) and that:

    5) sometimes better to experiment with a simple heel raise first, at the risk of pt disapearing happy with a job half done.

    60 Just rambling, but i hope this helps. Darren
     
  3. Admin2

    Admin2 Administrator Staff Member

  4. Richard Chasen

    Richard Chasen Active Member

    I've seen this done but although it makes logical sense, there's absolutely no difference between either way of doing it (assuming, as Darren pointed out, that it's indicated in the first place). A more relevant question for the bootmaker is whether the shoes can afford to have 1/4 inch taken out of the sole without leaving your patient walking on roughly 2-3mm?

    Just a thought,
    Richard
     
  5. Nikki

    Nikki Active Member

    I agree with Darren that providing the build up is indicated then as Richard says it makes no actual difference which way it is done. However consider a whole shoe raise rather than a heel raise alone.

    I have had experience with two or three patients with measurable limb length differences. All had been treated successfully with a whole shoe raise. Two out of the three had had half the leg difference added to one shoe and half removed from the other. It is only possible with certain shoe styles (as Richard has alluded to), and with the help of a good shoe repairer / cobbler cosmetically better from the patient perspective. As patient acceptance of a shoe raise is often difficult then the half / half way may be better.

    Nikki
     
  6. The amount of leg length difference noted in patient's exam should not necessarily be the amount of shoe sole height differential added to the patient's shoes with a limb length discrepancy. This is because are a number of confounding factors in measuring and putting lifts into or onto patient's shoes.

    First of all, the clinical measurement of limb length discrepancy is notoriously innaccurate, unless a scanogram is performed. Therefore, I am reluctant to add anything permanently to the sole of a patient's shoes unless they have first trialed a lift inside their shoe first to make sure it 1) relieves symptoms, 2) improves the gait pattern and 3) does not cause other symptoms/pathology to occur.

    Second, adding just a heel lift to one shoe and not the other greatly changes the dynamics of gait of the heel-lifted limb so that it is generally best if a full sole lift is added to the sole of the shoe especially when the lift needs to be over 1/4" (6 mm). In other words, when I determine that a lift over 1/4" is necessary, I may try to put some of the lift as a full sole lift in the shoe sole and some as a heel lift inside the shoe.

    Third, if foot orthoses are also being used, adding an additional heel lift to the shoe or under the orthosis will affect the function of the foot on the orthosis. In general, when an orthosis is worn with an additional heel lift the patient will not feel as much pressure in the medial arch and the foot may actually have increased supination-related problems on the orthosis (i.e. a sensation of lateral instability). This is most likely due to the relative plantarflexion of the first ray and stiffening of the medial longitudinal arch of the foot that occurs with increased hallux dorsiflexion and the decreased Achilles tendon tension, all of which would tend to increase the magnitude of subtalar joint supination moment, that occurs with additional heel lift added to the shoe/orthosis.

    Lastly, the only time that I will use the same amount of lift that I measure is if the patient is either a child under the age of 20 or if the adult patient has just recently had trauma or surgery that has caused the limb to shorten. Otherwise, I will use a lift of about 50% to 75% of the measured limb difference depending on the patient's gait and symptomatic response to the lift. The theory here is that the more years that an individual walks with an unequal leg length then the adaptations made in the individual's musculoskeletal system over time should not be attempted to be suddenly corrected all at once. For example, a patient who is 45 years old who has just been diagnosed with a 1/2" limb length discepancy, will probably function initially very well with a 1/4" full sole lift added to the sole of the short limb shoe or a 1/4" heel lift added inside the shoe. After 6 month or more, an additional lift of 1/8" could be added if the patient is interested in further correction and no other problems result from the additional lift. However, external shoe sole lifts are not without their problems (i.e. cost, possible gait instability, additional shoe weight, increased shoe sole stiffness, cosmetics) and these potentially negative factors should always be taken into account when the treatment of limb length discrepancy is being considered by the clinician.

    Hope this helps.
     
  7. Lld

    A few questions on correcting LLD's for kevin or anyone else.

    1.
    What is the smallest LLD you would consider to be significant and therefore justify correction.

    2.
    What is your opinion on the osteopathic view of LLD? I tend to find they report LLDs as significantly higher than i measure and believe they can reduce it, sometimes by a matter of inches, by manipulation. Also that they seem obsessive about symmetry. Anyone else have similar findings or is it just the Osteopaths in my corner of the world?

    3.
    I totally agree with Kevin and Darren that you have to be careful correcting a LLD that the patient has become used to over years. Can Physiotherapy / osteopathy attenuate this?

    4.
    If attempting to treat LBP by correcting a LLD do you treat muscular pain differently from nerve entrapment pain? Would you correct an LLD in a patient with a recently prolapsed disc?

    Would appreciate any views anyone has on this.

    Kind regards

    Robert
     
  8. The smallest limb length discrepancy (LLD) that I would treat would be that amount that I could reliably measure clinically. I estimate my clinical measurements are +/- 3 mm. Under 3 mm (1/8") LLD probably is not signficant for walking. However, I generally will treat smaller amounts of LLD in runners than in non-runners due to the two-fold increase in mangitude of ground reaction force when comparing running to walking.

    I find it hard to believe that any manipulation techniques can shorten or lengthen the distance from the femoral head to the femoral condyles, can shorten or lengthen the distance from the tibial plateau to the tibial plafond or can shorten or lengthen the distance from the talar dome to the plantar calcaneus. I believe that this is one of those long-believed and long-taught myths of the chiropractic and osteopathic professions that will be disproven over time but also is one of those long believed myths that is held in utter contempt by all the orthopedic surgeons that I have worked with over the past 20+ years. Do these "manipulation-based" medical professionals actually truly believe they are doing anything other than rotating each hemi-pelvis around the femoral head when they say "I am now going to adjust your limb length" ?!! I shake my head in disbelief everytime I have a patient come into my office and say that their chiropractor or osteopath has been "adjusting their leg length" once monthly for the past few years. What a joke!! If I wasn't so sure that many of these individuals don't really know what they are doing, then possibly I could consider that maybe they are using poor terminology to describe the results of their manipulation technique. However, if this is the case, then why not just say "I am now going to adjust the angle of your pelvis over your hip joint", if they really wanted to accurately reflect what they are doing with their manipulations. It reminds me of those practitioners who think they are moving the cuboid relative to the calcaneus and/or 4th metatarsal-5th metatarsal by doing cuboid manipulation....show me some good radiograph evidence of the osseous changes that are occurring pre and post manipulation, and then I will believe it. Until then, I will consider your opinions to be myth-based, not reality-based.


    I would think so, but I don't know.


    I would do this with caution, but certainly it is worth a try, especially if the patient is given good instructions on immediate removal of the lifts from the shoes if the symptoms worsen.
     
  9. Atlas

    Atlas Well-Known Member

    You make some great points Kevin.

    However, the view that one should not correct the entire assymetry (in over 20's for instance), and only a portion, is unfortunately entrenched in our psyche.

    If I landed on Gilligan's island, and the Thurston Howell was wearing one shoe (and had been for 20 years), I would have no hestitiation in giving him a new pair to wear.

    My point is, no matter how chronic, I don't think the world will cave in if we all correct the entire assymetry.

    Let us look at it another way. Kevin, do you turn a 50 year old away, and deny them a pair of Kirbyesque orthotics, even though they have (for example) a medially deviated STJ (that may have been for 30 years); post-tib overuse; medial achilles tendinopathy etc.? And this 50 year old has a hard SRT? Are we going to wimp it with a poron device because we are worried about correcting the deformity, in full, that this person has lived with for years?
     
  10. Ron:

    I don't believe I said I would turn a patient away without treatment. However, what I did say was that I have found from my clinical experience that if you try and take a 50 year old patient that has been walking around his or her whole life with a 1/2" LLD (for example) and then try to give them a 1/2" heel or full sole lift, you will probably have a very unhappy patient in about a week. Believe me, this has happened to me (or should I say, I have done this to some of my unfortunate patients) more than a few times over the past 22 years of practice. Therefore, when I have used 50% of the correction initially in this type of scenario, they routinely have a decrease in symptoms, have improved gait function and also don't come back to me in a week thinking I am trying to kill them off slowly.

    Also, in answer to your analogy of using "Kirbyesque orthotics" (whatever they are since I use at least 1,000 permutations of orthosis designs??!!), I would not take a patient with a 50 year history of an asymmetric flatfoot deformity with a medially deviated STJ axis and try to make them walk in STJ neutral. No, I would instead design the orthosis to reduce the pathological internal forces that are causing their symptoms, design the orthosis to make them function better and design the orthosis so that they would not have any new pathologies occur from my orthosis treatment. This may mean that they are functioning only 1 degrees from the maximally pronated STJ position but this position may be the optimal position for them to ambulate in with a foot orthosis.

    Put another way, Ron, I would not just simply treat my patient that has any assymetrical structural deformity so that their "measurements" would exactly match the other limb's "measurements", even though that is what you seem to be advocating. Instead, for the past 15 years or so, I have been using more of a tissue stress approach, where my concern is not the externally measurable "deformities" that the patient possesses, but rather my concern is focused on the forces, moments and stresses that are produced internally within the structural components of my patient's foot and lower extremity, during their weightbearing activities.

    Now, Ron, if you want to treat all your patients who have been walking and standing with unequal leg length for over 20+ years and have been asymptomatic the vast majority of that time with a with full LLD correction in one visit to your office, then you may certainly choose to do so. However, unless the gravitational acceleration acting upon and the viscoelastic properties of the structural components of the locomotor apparatus of the humans you treat is substantially different from the humans I treat in the part of our planet that I reside in, then I would expect that you will be causing a lot of unneccessary pain in your patients in doing so.
     
    Last edited: Dec 10, 2006
  11. Atlas

    Atlas Well-Known Member

    In those 'more than a few', I would retrospectively question the accruacy of the original LLD assessment.

    Of course patient pain is the highest priority, and if a patient returned and was exacerbated by full restoration, then simply removing the heel raise should return symptoms to pre-therapy levels pretty quickly.

    The typical podiatrist is 'happy' to allow their orthotic therapy patient 'wear in' their devices. They are happy to allow the patient to endure 'adjusting symptoms'. But attempting to restore an LLD fully? We shy away like dracula to a wooden stake.

    I just find it inconguous that we are so concerned about viscoelastic properties in restoring leg length equality; but no so concerned when restoring biomechanical function.
     
    Last edited by a moderator: Dec 10, 2006
  12. Ron:

    I think I see your point better now. However, even though this may seem incongrous to you, it is fairly consistent with how I treat other problems, such as an excessive STJ pronation. For example, in a 9 year child that has a pes planus deformity that is maximally pronated at the STJ and has a significantly medially deviated STJ axis, I am much more likely to use higher degrees of orthosis correction (i.e. balance the cast more inverted, use higher amounts of medial heel skive, plantarflex the first ray during casting, using minimal arch fill) than I would if I was seeing the same type of foot in a 50 year old man or woman that has never worn foot orthoses. As the patient ages, I tend to be less aggressive in orthosis treatment initially because I have found that most older individuals simply don't adapt to this sudden correction in foot posture as well as children do. In other words, what I am saying about treating LLD that you should start out with a full correction in children and a partial correction initially in an older adults and then, over time, gradually increase the correction as time goes on, is not very different from how I treat excessive STJ pronation in children and adults.

    You must also remember that a very important difference in treating LLD versus treating abnormal STJ pronation is that with treating LLD, the amount of lift placed in or on the shoe is the amount of lift the limb is increased in height (unless just a heel lift is used as opposed to a full sole lift). However, when treating abnormal STJ pronation with foot orthoses, even though you may be using a 35 degree inverted Blake orthosis the foot may only supinate 2-3 degrees because of this orthosis. Therefore, the degree of correction you place into the shoe with an anti-pronation foot orthosis is not necessarily translated into the same amount of STJ supination correction in the patient's foot. In other words, the frontal plane control of the foot with an orthosis has much more "slop" in it than the vertical control of the foot and lower extremity with a full sole lift. This may be another reason why most experienced clinicians are reluctant to place a full LLD correction into an older adult's shoe on the first visit, rather than placing a partial correction into the shoe and then increasing that correction as time goes on.
     
  13. I think in Michauds book on foot orthoses he advocates increasing the lift by 33% of the measured LLD.
     
  14. Atlas

    Atlas Well-Known Member

    Agree, if the density is firm enough to withstand body weight.

    I have seen the odd patient who tells me that their physio/chiro/podiatrist issued this 1/2 inch heel raise, that was supposed to have balanced/corrected their 1/2 inch discrepancy. But the heel raise is soft compressible foam of low density.
     
  15. To correct or not

    Atlas

    I will hold my hands up to being far more nervous about correcting a lld than a distil biomechanical abnormality. This is because correcting a lld will inevitably realign the pelvis and thus, the spine.

    I justify my cowardice with ignorance.

    I understand what will happen with frontal or saggital plane adjustment of the ST / MT joints tolerably well. I am familier with most of the anatomy. I could describe the effect of my orthotic on the kinetic chain in some detail. However my knowledge of spinal anatomy knows no beginning! I would struggle, were a patient to describe back pain to me, to identify by name and function exactly which muscle / nerve / insertion or whatever was hurting and why. I may hypothesise that the lbp and the LLD may be linked but i could not, in most cases describe exactly what was wrong in the back and therefor establish a firm causal link. I therefor tread very carefully (no pun intended) and correct only by degrees.

    As i say, a combination of cowardice and ignorance. I'm sure others have better reasons but thats mine. :eek:

    and thanks for the pearls Kevin

    Regards

    Robert

    Regards
     
  16. caf002

    caf002 Active Member

    Lld

    Greetings from Down Under

    As you guys have just lost the Ashes, I thought I would respond to the vexed question of LLD

    I am in the orthopoaedic shoe business both prefabricated and custom made. The alteration of footwear for LLD is a common task here. The problem is that that there is absolutely no consensus as to what constitutes a "significant LLD", i.e one that needs to be addressed with a shoe modification

    The Orthopods say anything less than 2.5 cm is not significant
    The Chiropractors view is that the achievement of bi lateral symetry is the only out come
    The Physios say anything over a cm needs adjustment
    The Osteopaths have a similar view

    etc, etc.

    Our approach has always been that a health professional needs to determine the LLD and whether it is a functional or an anatomic LLD

    Our approach has always been that a shoe raise should be about 25% less than the actual diagnosed LLD. Further more, it is possible that a heel raise only will impact the glutes on the affectred side. It has been our standard practise for a shoe raise for 1 cm that the raise goes right through from heel to ball, tapered at the toe. For higher shoe raises, the build up under the ball will deminish proportionately relative to the heel height.

    The only time we do a heel raise only if the there is a fixed plantar flexion or shortening due to disease such as polio

    Lowering the heels and reducing the raise on the other is also common practice especially if the cosmesis is very important. The important factor is that "normal" gait is achieved.

    I hope this helps mate

    Cheers


    PS. Good research material here
     
    Last edited by a moderator: Dec 18, 2006
  17. Ashes

    B*****D F****** stupid bloody A***holing damn Bloody A***ing stupid F****** Cricket! :mad: :mad: :mad: We did'nt want the stupid ashes anyway. You can keep the sodding things. Can't beleive i stayed up to watch that S**T. :mad: :mad: :mad:
     
  18. Berms

    Berms Active Member

    Is it LOSING the Ashes that enrages you so? or do you just hate cricket?
    BTW some of these "words" you stated I have never even heard before - what does A***ing mean?? and B****D??.... :)

    Getting back to the topic of this thread... I would agree with Caf002, there seems to be
    1. no concensus in what constitutes a significant LLD
    2. what % of the LLD to correct.
    3. the effect on the lower limb musculature / alignment of using heel raises
    Vs full length sole modifications.

    I am guilty myself of treating relatively small LLDs with a heel raise (usually 50% of the lld) , not giving much thought to the biomechanical implications of lifting the heel only on the lowerlimb and pelvis?
    Anyone?
     
  19. Berms

    Berms Active Member

    Dear Kevin,
    How did you estimate +/- 3mm as the amount of LLD that you could reliably measure clinically? Has there been any studies on the reliability / reproducibility of measuring limb length?

    The accuracy of my limb length measuring (functional and structural) has always bothered me... :eek:
    Adam.
     
  20. My assessment techniques for limb length discrepancy include the following four clinical techniques:

    1. Lying flat supine, lower extremities parallel to midsagittal plane, ankles dorsiflexed 90 degrees, measure difference of heel fat pad plantar aspects within midsagittal plane.

    2. Sitting on table with buttocks pressed against wall, lower extremities parallel to midsagittal plane (hips 90 degrees flexed, knees extended, ankles dorsiflexed 90 degrees), measure difference of plantar aspect of heel fat pad within midsagittal plane.

    3. Standing in relaxed bipedal stance, palpate levels of anterior superior iliac spines.

    4. Standing in relaxed bipedal stance, palpate levels of posterior superior iliac spines.

    In some patients, I will have the results from a scanogram http://www.indyrad.iupui.edu/public/kbuck/leglength/leglength.htm
    that I will compare my clinical results to. Normally I am within 2 mm of the scanogram results, but probably +/- 3 mm is more realistic measurement error for myself. Today, I had a 33 year old male patient with a scanogram measurement of 10 mm shorter left limb that I measured using the techniques listed above as between 8-10 mm of limb length discrepancy.

    By the way, one other clinical method of detecting limb length discrepancy is that the arm opposite the longer lower limb will swing more than the opposite arm. In my patient today, with a 10 mm shorter left limb, his left arm swing was probably 50% more than the right arm swing. This is most likely due to the extra mass and moment of inertia that the longer right limb had that then required increased angular acceleration of the left arm to keep his head from rotating in the transverse plane while he walked...this theory is in its infancy and requires some work....any other suggestions??
     
  21. Robert:

    The times I have tried to watch cricket while visiting the UK and Australia, I can see why you are frustrated. Cricket's distant cousin, baseball, is fun to watch (sometimes), fun to play (most of the time), and doesn't take more than a day to play a game. :p Hitting a baseball thrown by a talented pitcher is one of the hardest things to do in sports. I played for five years as a youth and loved it until the parent-managers spoiled the fun for me when I was 14. Of course, this is an definite American bias, but just couldn't resist commenting on the "great American pastime" especially considering your multiple expletive deleteds regarding cricket.
     
    Last edited: Dec 19, 2006
  22. Berms

    Berms Active Member

    measuring limb length

    Kevin, thanks for the input. You didn't mention the clinical method of measuring (with tape) the lengths from the ASIS to the medial malleolus of both limbs for comparison... Do you ever use this method? What do you think of this method? :confused:
    ps I wouldn't mind one of those scanograms.

    Regards,
    Adam
     
  23. Adam:

    I think it the ASIS to medial malleolus length is not very useful since it doesn't take into account the distance from the plantar foot to the medial malleolus.

    I still can't believe that no one with a manipulation-type practice has commented on how you can manipulate one leg to be longer than before manipulation?? I suppose it is as I suspected, "manipulating for leg length" is just one of those treatment myths that the adjustment-manipulation health professionals want the public to continue to believe so that they can continue to have these people pay a fee to their practice every few weeks to "readjust their leg length"??!! :eek:
     
  24. Cricket

    Berms and Kevin

    My Vexation is purely rooted in the fact that I stayed up (well if i'm honest the baby kept me up but the principle stands!) to watch my team play like a bunch of Dyspraxic halfwits! :mad: Whilst i'll agree with Kevin that Cricket can be frustrating to watch it's less so if your team figure out that it's not the same as catch with bats and you get no points for thumping the ball directly at a fielder. :mad: I can see how they would be confused, after all the bowler throws the ball at the batter so why no hit it back at the fielder? W*****s! :mad: :mad:

    And regarding the american Bias Kevin i take your point that baseball may be a better game. It might make up for the fact that you over the pond wear 200 lbs of protective gear to play a game of rugby. ;)

    Regards
    Robert
     
  25. Stanley

    Stanley Well-Known Member

    Hi all,

    I just wanted to fill in some blanks in this discussion.
    1. Determining leg length. If you are not going to change the structure or function of the axial skeleton, then you should know which side is functioning long and which one is functioning short. Symptoms plus gait analysis is the best way to make this detrmination. An example of this is finding an Achilles tendonitis on a side with a high ASIS and PSIS. This should make you suspicious of a functional shortage. Watch the head when someone walks. If the head is raised up when the low hip side is in midstance, then this leg is functionally long. The etiology of the functional long leg can be spinal dysfunction or muscular dysfunction (ie tight Quadratus lumborum). I agree with Kevin that the static examination should consist of the ASIS-Ground in neutral and relaxed position, and PSIS-ground in neutral and relaxed position. I have an X-ray machine for standing leg length evaluation, but I have never used it, as it will not tell me where and how much to lift the leg. I also do not measure ASIS to MM in the supine position, as this was shown years ago to be grossly inaccurate. Sitting evaluation is another test that I find superfluous. If used with other tests, it will show a blockage of the sacroiliac joint. The standing examination will let you know that there is a dysfunction of the Iliosacral joint, and usually there is a blockage when this occurs.
    2. The amount of heel lift for a shortage. Assuming that you have determined the low hip side is the functionally short side. Then the amount of lift (theoretically) should be the maximum amount without causing a secondary curve in the spine or a rotation of the pelvis in the transverse plane. I say theoretically, because there is a maximum you can place inside a shoe, and the assumption is that your eyeballs are 100% accurate.
    3. Heel lift/Sole lift. The sole lift is determined after the heel lift is determined. The sole lift is inversely proportional to the amount of equinus.
    4. Correcting leg length with manipulation. The terminology should really be “correcting an asymmetrical lower extremity with manipulation”. The lower extremity functions as a foundation for the axial skeleton, so the top of the lower extremity is at the sacroiliac joint. Manipulations can affect the position of on hemi pelvis relative to another. Since the leg is at the anterior aspect of the hemi pelvis, and the spine is at the posterior aspect, rotation of the hemi pelvis anteriorly in the sagittal plane will lengthen the leg, and conversely, posterior rotation will shorten the leg. I refer these to a chiropractor, but I will treat the causes so they do not recur.

    I hope this helps.

    Regards,

    Stanley
     
  26. suha

    suha Welcome New Poster

    Hi, there is another option for this issue, reply to me and I will send a you a document which explains it.

    Thanks
     
  27. DaVinci

    DaVinci Well-Known Member

    Why be cryptic? Why not post the document here, either as a message or as an attachment.
     
  28. :D

    Or just change your name to eileen
     
  29. Rick Woodland

    Rick Woodland Member


    This is a common situation in my practice as a Board Certifed Pedorthist. It is proper as long as the shoe stays in balance. Also 1/4 in the heel of the shoe and 1/4"inside the shoe under the heel of the foot could work. Make sure the leading edge of the heel lift inside the shoe goes all the way to just behind the ball of the foot. also make sure the heel of the foot does not want to slip out of the shoe even with 1/4" placed inside the shoe under the heel of the foot. It sounds like the shoe maker you have is a good one to work with.
    Hope this helps
     
  30. podoalf

    podoalf Active Member

    Interestin Thread.

    Let me little time to translate correctly from my poor English ... I want to explain my experience.
     
  31. Boots n all

    Boots n all Well-Known Member

  32. David Wedemeyer

    David Wedemeyer Well-Known Member

    This subject is complex clinically and deserves in depth discussion. I would directly quote in the thread except I have not yet figured out how to quote multiple posts as I see some are accomplished at.

    First I believe that terminology is critical here and that a true anatomic (structural) leg length difference (LLD) is obviously much rarer than a functional (apparent) leg length inequality (LLI). Even rarer still is a congenital defect of leg length as measured ASIS to medial malleolus. I believe that this can be determined adequately with plain film recumbent films and CT scanography, the latter being considered more clinically accurate.

    That in mind I do check leg lengths of patients supine and standing. If a patient has an LLI supine that corrects standing why would we try to correct this weight-bearing in a shoe? It is not clinically relevant if a patient is asymptomatic in the low back/pelvis or foot/ankle and has a mild LLI supine. Much of this is of a musculoskeletal origin and it is poorly understood by any profession. In LLI there is almost always a functional distortion of the lumbar spine and illia and compensatory muscular component and I believe that the LLI develops as a righting mechanism similar to handedness. Again this is a subject where there are several theories and hypotheses but proof is lacking.

    I would propose that podiatrists and chiropractors each have an inherent inadequacy in their training out of school to see the entire clinical picture with regard to LLI; podiatrists are less trained/focused the axial causes of this finding and chiropractors although well versed in orthopedic assessment of the entire body, receive inadequate training of the foot and ankle specifically.

    We should be very cognizant of how congenital, idiopathic and traumatic influences can influence a LLI. Examples would be scoliosis, disc wedging, sacralization of the lumbar spine, facet tropism etc. Each of these findings influences the attitude of the lumbar spine, pelvis and ultimately the leg length. Once these contributory factors are ruled out, we can begin to search for the cause of the apparent LLI further down the chain and postulate the correct treatment. I believe that often well meaning providers treat this condition without ruling out the causes mentioned above and that is why there are numerous failed outcomes with heel lifts.

    The major point here is that not every LLI is entirely due to lumbar and pelvic distortion (axial) and the same is true of the lower extremity (appendicular). I found early on in my practice that foot and ankle anomalies and dysfunction can and do contribute to LLI but not nearly as frequently as axial and congenital causes. I typically do not utilize a heel lift in apparent LLI except in cases of idiopathic scoliosis where there is an acquired LLI and the short leg side is on the side of the convexity of the lumbar curvature.

    One has to be very careful not to treat with a lift on the short leg side into the concavity. I am also extremely hesitant to fit skeletally immature individuals with either category of leg length discrepancy with any type of lift or shoe modification unless they present with scoliosis, are symptomatic and the benefit outweighs the risk of iatrogenic injury.

    Example: The symbol below represents a dextrorotary (right) lumbar scoliotic curvature as seen from the back prone;
    concavity > ) < convexity
    In this case if the short leg side is on the left, I would never utilize a heel lift or a shoe build-up on the left.

    With regard to a verified LLD and subsequent treatment I believe that Kevin has covered this topic in his usual excellent manner. I would add that any LLD over ¼” that is symptomatic deserves consideration for treatment regardless. Are there other considerations such as hip, knee or foot pain? Is this an adolescent or an adult? As Kevin pointed out a person who is well into their years is less tolerant of correction and we should be mindful of this when prescribing. I also begin with ½ height correction of the structural difference and review their progress over a period of months. I would not advocate splitting the difference of a large LLD between the shoes of the affected and unaffected sides, you could cause the patient more insult than you bargain for by creating grave postural changes. .

    Kevin wrote:

    “I still can't believe that no one with a manipulation-type practice has commented on how you can manipulate one leg to be longer than before manipulation?? I suppose it is as I suspected, "manipulating for leg length" is just one of those treatment myths that the adjustment-manipulation health professionals want the public to continue to believe so that they can continue to have these people pay a fee to their practice every few weeks to "readjust their leg length"??!!

    I would like to place my head on the chopping block regarding Kevin’s comments about us “manipulation-type practitioners”. Much of what he says is true, pointing out a patient’s short leg is great for business but often it is irrelevant and a somewhat normal finding. Look at your shoulder height. I bet dollars to donuts that it is lower on the side of your dominant hand. This is not correctable and is in my opinion a normal exam finding. Patients often have minor LLI’s that are asymptomatic and do not need any sort of lift. I see patients who have major LLI’s up to 1”) due to rotary lumbar misalignments and compensatory pelvic nutation, coupled with muscular involvement that are completely level post-treatment and remain that way for weeks or longer.

    Manipulation alone in these cases will not always correct this type of patient’s presentation in the long term but I would enjoy disproving the notion that specific spinal manipulation does not correct LLI (at least in the short term) to anyone willing to witness this phenomenon first hand. A simple explanation is that the vertebrae of the lumbar spine favor displacement in the posterior direction coupled with rotation (and often the same patient exhibits this same pattern repeatedly (again this could be related to handedness but I cannot confirm this. I feel that it is a feature of our hard wiring in some form).

    Often these patients also require specific therapeutic manual therapy and exercise to restore their postural musculature. I could write an entire book on this subject but for this discussion enough said.

    I have also found that many patients with dysfunction in the feet and gait present with LLI and after they are fitted with the appropriate orthoses, their LLI levels out and their spinal complaints resolve more quickly. Many of these patients require less “manipulation-type” care in the long term and stabilize rather well. Someday I would like to conduct a study as to why this occurs. Perhaps some of you have your own theories on that and if so please share.

    :drinks

    Regards
     
  33. Mark W

    Mark W Welcome New Poster

    Hi There
    I like what Rick said but, too often I've had a patient walk or run out of the shoes with that method. I will usually remove the factory sole and apply the lift. You would need to grind a heel roll and a forefoot rocker. Finish up by reglueing the factory sole back on. I would use the half out half in way if cosmeisis were an issue. I also have had my share of trying to use the full amount of lift needed, but as was pointed out before many older patients will trip or stumble before they get used to picking up the affected side enough to clear the ground. Thats when it's a good idea to arrive at the needed lift in increments.
    Mark W Orthotist, C.Ped.
     
  34. JamesP

    JamesP Welcome New Poster

    What would you guys suggest for a 2.3 cm LLD. A CT scan was performed and the difference is in the left femur from a break 8 years ago. The patient is 32 years old, 5'11" 200lbs. He has been fairly active all his life but has had upper back pain in the rhomboids, especially after running. After the CT scan he had a shoe lift put in to match the difference of 2.3cm.

    However, now he is having upper back rhomboid pain after walking in the shoe for only a short period of time.

    Do you suggest we start with a 50% lift since the LLD is so much?

    Any feedback would be appreciated.
     
  35. DaVinci

    DaVinci Well-Known Member

    The body is really good at adapting to LLD's. My best guess is that is the problem. Perhaps start with a much smaller lift and progressively increase it if indicated.
     
  36. JamesP

    JamesP Welcome New Poster

    So would you suggest 50% or go even lower?
     
  37. DaVinci

    DaVinci Well-Known Member

    I generally only treat 50% of the measured difference usually if I think that the LLD is actually contributing to their problems.
     
  38. JamesP

    JamesP Welcome New Poster

    interesting, so you do not usually take them past the 50% marker regardless of what percent of the difference you start them off at?

    The dilema I have is that correcting the full LLD is obviously not working out well for him right now and due to the large difference a shoe lift is the only option. I would hate to see him waste money and time having another shoe lift made if 50% is not a good option.

    Any suggestions on what you usually start someone out with that has this large of a LLD would be appreciated.
     
  39. I´d be inclined to go with 18 mm - Ive a patient at the moment 23 mm LLD and I´m starting at 18 mm.

    I get 1 pair of shoes do 1st and work from that point -add or subtrack a few mm till the body gives the right indications. There is no science but 23mm is alot and 12 mm in my option not going to be enough.

    yes a fullshoe lift is required or the bodys COM will be changed too much and you maybe adding to the patients pain. But you may not get it right fro the start, be upfront with the patient about this

    Good luck
     
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