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Leg Length difference in runners

Discussion in 'Biomechanics, Sports and Foot orthoses' started by issy1, Sep 17, 2013.

  1. issy1

    issy1 Active Member

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    I am treating a 32yr old runner training for the marathon next year. She developed right heel pain in area of medial tubercle about 2 months ago. New Trainers have not helped.

    On examination she does not have everted heels/ excessive rearfoot pronation but she does have forefoot valgus. She also has a very small leg length difference of about 8mm shorter on right. As most of her pain seems to occur due to excessive load at heel strike I have prescribed her neutral semi-rigid polyproylene orthotics with shock absorbing heel plug on right, closely conforming arch height to foot and forefoot valgus posting to reduce tension on plantarfascia. Have also advised on stretching of plantarfascia.

    My question is would you treat the small limb length difference? I wouldn't normally treat such a small leg length difference but wondered if this difference would be exaggerated whilst running?
  2. Craig Payne

    Craig Payne Moderator

  3. issy1

    issy1 Active Member

    Good Point!

    However I am a runner and suffered from unilateral IT Band pain last year. I knew I had a very slightly shorter limb on the affected side which I had never considered significant. I decided to add a small heel raise of 3-4mm into the affected side and had INSTANT relief when running. Wasn't altogether sure why at the time but there must be something in it. Thanks for this link some interesting viewpoints.
    Last edited: Sep 17, 2013
  4. The central nervous system (CNS) may adjust the lower extremity stiffness of each limb differently in an individual with a limb length discrepancy (LLD) since the "height of the fall" of the center of mass from the middle of the double float phase to foot contact would likely be different for each limb with a LLD. The CNS may also adjust for different propulsion mechanics from the short limb to the long limb. The bottom line is that heel lifts/full sole lifts for short limbs do seem to make many runners heal from their running injuries, even though the research is unclear as to how each runner responds mechanically to LLD and how these lifts actually accomplish these therapeutic results.

    And, by the way, Issy, I wouldn't call an 8 mm LLD a "very small" LLD in a runner. I've seen as much as a 3-6 mm LLD cause running symptoms in some runners. I would call a 1-3 mm LLD to be a "very small" LLD for a runner. However, I have also seen 10 mm LLDs in runners cause absolutely no problems. More research is definitely needed.

    In addition, I've also heard more experienced sports podiatrists than myself claim that a 1/4" LLD in a runner is more like a 1/2" LLD in a walking individual, meaning that the mechanical effects of LLD are magnified in runners vs walkers. My 30 years of treating runners seems to support this anecdotal clinical observation.

    For the runner patient described, Issy, the plantar heel pain is probably due to the short limb falling from a larger height and hitting the ground harder than the longer side. I would use a 1/4" (6 mm) neoprene heel lift on the affected side to equalize the LLD and reduce the impact of heel contact of the painful side. My guess is that this treatment has about a 90% chance of resolving her symptoms.
  5. issy1

    issy1 Active Member

    Thanks for this Craig and Kevin. I think I'll try a small heel raise and see how it goes.
  6. BEN-HUR

    BEN-HUR Well-Known Member

    All good points Kevin (that I resonate within my views/treatment i.e. CNS/limb stiffness point, LLD exacerbation within runners - particularly doing high mileage). That said, Craig makes an interesting point also (i.e. float phase/single leg stance implications on milder LLD) of which I have wondered this myself - albeit, there is the potential longer limb push-off implications. Hence, I don't always address LLD (within the smaller realm i.e. < 6mm) - I see how the orthotics performs (i.e. alleviating symptoms e.g. ITB Syndrome) & if need be, add the desired foot lift (heel - tapered sulcus lift) to the shorter side later.

    On the issue of ITB Syndrome - I tend to find that this usually affects the shorter side from my (personal & clinical) experience (not always, but usually). Hence the LLD scenario needs to be holistically assessed (i.e. functional/structural LLD, muscle tightness/weakness, habitual running surface/camber issues etc.).
  7. Trevor Prior

    Trevor Prior Active Member

    I do not propose to know why the LLD would make a difference but would tend to agree with Kevin that the body would recognise the altered drop and thus the effect on CoM. When we perform inshoe pressure analysis on runners with LLD it is not uncommon to find an asymmetry in the CoP lines - generally with the shorter limb having the CoP line start more anteriorly / reduced heel contact. Controlling the LLD will provide more symmetry.

    If your patient demonstrated the above pattern, the cause of the pain may be due to the shortened contact time and subsequent loading through the fascia although increased impact forces are a reasonable option - that can be tested easily as plantar pressure analysis will show you what is happening.

    I would agree with Kevin and incorporate a heel lift with cushioning (I prefer Poron but that is a subjective opinion) - you will address both factors with the same treatment. My orthotic would be different to yours but that too is subjective conjecture and a whole other discussion which I am sure has been had on these pages over the years.

  8. andreaguerrini

    andreaguerrini Welcome New Poster

    hi Kevin,
    how about a forefoot striker runner? would you suggest something else than a heel lift to solve problems related to LLD? it seems to me that a heel lift wouldnt fix the problem...
  9. BEN-HUR

    BEN-HUR Well-Known Member

    Whilst the above is addressed to Dr Kirby, I would like to put my opinion forward (being I have an interest in the above scenario).

    I personally am not a fan of heel lifts when it comes to addressing LLDs (particularly in runners) because of the likes of the above scenario... as well as the fact that heel strikers still need to push/lift off from the forefoot anyway (as well as ascend up hills/inclines on their forefoot). Hence why I tend to do the following...

    ... with the use of flexible type materials such as EVA, cork, PPT/poron (at desired thickness). Most running shoes can accommodate (being deep enough) a full length lift - albeit, tapered (grinded thinner) to the toes (if need be).

    Heel lifts still have their place... but I tend to use them for the likes of Achilles issues & Sever's Disease (Calcaneal Apophysitis).

    In re-reading Dr Kirby's post on this, he may also use a type of full foot lift of some sort...

  10. andreaguerrini

    andreaguerrini Welcome New Poster

    thanks Matthew,
    I appreciated your answer
  11. Andrea:

    In a true forefoot striking runner (of which there are very few), then you may add a full length lift inside the shoe or have a full sole lift added to the running shoe, both of which may be difficult for the runner.

    Another option would be to put the runner in a shoe with a higher heel height differential so that their heel did contact the ground during running so you can then use a heel lift inside these higher heeled shoes.

    Hope this helps.:drinks
  12. andreaguerrini

    andreaguerrini Welcome New Poster

    thanks Kevin for your kind reply,

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