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Leg Length differences

Discussion in 'Biomechanics, Sports and Foot orthoses' started by admin, Feb 17, 2006.

  1. admin

    admin Administrator Staff Member

    Members do not see these Ads. Sign Up.
    We have had a few threads on this:
    Shoe inserts for LLD and chronic low back pain
    Leg Length Differences and Quality of Life
    Measuring LLD
    Functional propulsive phase limb length discrepancy.

    The lastest newsletter from ChiroWeb has this from a chiropractic perspective:
    The Lowdown on Short Legs
    Rest of story
  2. pgcarter

    pgcarter Well-Known Member

    Interesting....but when you find one do you necessarily assume that it underlies the reported symptoms....I tend to deal with this "last" if there are other obvious contributors to the stated problems.....how about you?
  3. This is what I do and I find it works best...first off if a patient ventures into 10 different clinics and is measured for LLD then they would probably get 10 different measurements. The funny thing is if that patient actually went back to those same practitioners and re-measured the LLD, you would in all liklihood get a different measurement! The more I read on LLD or LLI the more I get confused! So what I did was "KEPT IT SIMPLE". The first thing I have found was IF a person does indeed present with a LLD or LLI, do I worry about it or actually do anything about it??? No. The ONLY time I do anything about it is when that patient complains of symptoms in the LONGER leg. The pain or discomfort has to be BOTH at the knee and hip joint. I have found the longer leg will ( in about 98% of cases) present with the combined knee and hip pain. The longer leg will cause the neck of the femur to angle differently in the acetablum and this causes a great deal of pain especially when the patient stands for long periods. It also induces a wider Q-Angle and the knee begins to ouchy.

    Also, I have found that if there are symptoms on the longer side, I only place 1/2 of the correction on the shorter side ( so if 1/4" LLD then add only a 1/8" heel lift max...less is better is the rule) and all is well...I have had to shave down more heel lifts that were a little too high versus the other way around. I also discovered by experimenting with LLD that the body can almost compensate for 1-1.5 cm with no symptoms!! Another thing to remember, if you do put a heel lift in an orthotic and the patient does not do well right away and they so happen to see another health care provider for say an unrelated problem in 1-2 weeks ( say their shoulder) you will be condemned by "them" and they will literally cut you off at the knees by saying, " omgosh, that is way too high of a heel lift, etc. (Of course, this will usually be an office that you compete against for orthotics I have found) so do not give anyone ammunition. As an experiment I tell the patient to get an old deck of cards and round off one end and place 3 of them in their shoe (shorter leg obviously) and increase the cards by 2 per week and see if they do better or worse.

    If then do better in that 3-4 week period, THEN I make them their orthotics and add the heel lift as such.

    It works for me!!!

    NB> I also use a hip leveler in conjunction with a neat little sandal/boot I bought at a symposium/lecture and it has 1/8" insole increments to measure the LLD and I also use a static and dynamic gait plate that measures weight bearing pressures per limb and will also show if 1 heel lifts off the ground a lot sooner or later versus the other during ambulation.


  4. David Smith

    David Smith Well-Known Member

    Although I have many strategies for determining whether an apparent lld/hip level difference is functional or structural, then (barring the blindingly obvious) I find this simple strategy works well.
    1) Only treat if there is associated Pathology.(foot, leg, hip or back)
    2) Add heel lift unilateraly (short side) and monitor.
    3) If after 1 month hip levels are now equal then remove heel lift and monitor.
    3a) If after 1 month, hip levels still differ and lld is still apparent, Then if pain reduced leave it in, if pain got worse take it out. If no change leave in if gait and stance appear more symmetrical.
    4) If required do a more in depth assessment
    5) If still not sure e mail Dr Stanley Beekman, he know loads about this subject.

    Cheers Dave Smith
  5. Stanley

    Stanley Well-Known Member

    Evaluating Leg length differences

    Thanks Dave for the kind words.

    From what I have seen so far on this thread, there are some key ingredients to evaluating a leg length that should be mentioned.

    First is history. Is there an asymmetrical problem that has been present for more than 6 weeks? If so then you need to consider asymmetrical function/structure. If the patient is a runner, what is their best 10K time? Faster runners (faster than 40 minute 10K) tend to compensate by lengthening the leg. Slower runners tend to shorten the longer leg.

    Physical exam.

    Gait: To determine if the asymmetry is coming from the spine, watch the hips and the head. If you notice that the head is highest when one of the legs is in midstance, look to see where the weightbearing hip is. If the hip is lower (than the opposite hip at midstance), then the lengthening is coming from the spine, and your lift therapy (if you do not refer to someone that will mobilize the spine) will be under the higher hip (functionally shorter leg). I have seen a lot of holographic subluxations of the spine present this way.
    To determine sacroiliac dysfunction (more properly iliosacral dysfunction), look at the patient coming and going, and see which hip is lower. If the hip is low on the same side, then you probably do not have an iliosacral dysfunction. If you have a low hip anteriorly and the opposite hip is low posteriorly then you have to look for either a primary or secondary iliosacral dysfunction.
    By the way the sitting exam is invalidated by the fact that an iliosacral dysfunction will cause one side to be blocked, and in the sitting postition, the one side will appear longer.
    Standing examination: Stand the patient in neutral and evaluate the PSIS to the ground, and the ASIS to the ground. The results will be either level ASIS and PSIS (no primary leg length or iliosacral dysfunction), Ipsilateral ASIS and PSIS lowering (primary leg length), or Contralateral ASIS and PSIS lowering (primary iliosacral dysfunction). Then allow the feet to relax. If there is a level ASIS and PSIS, when before there was Ipsilateral lowering of the PSIS and ASIS, then the pronation is compensating for the leg length. (In this case, you better treat the shortage if you are treating the pronation, or you will cause other joints to compensate for the shortage). If there is now a Contralateral ASIS and PSIS lowering when before they were level, then we have a secondary iliosacral dysfunction (these are the sacro iliac patients that the chiropractors can only get better for a short period of time, and the orthotics "cure"). If in this relaxed position, we find a Ipsilateral lowering of the PSIS and ASIS, then we have a short leg secondary to the pronation.

    The amount of lift: The lift that will elimate the curve caused by the shortage, without causing a secondary curve. To do this necessitates looking at the entire spine. I have stopped doing this for because I am not comfortable asking a female to disrobe, but the idea of a gown that opens in the back will make me reconsider. Instead, I have been using as everyone else the 1/8" and reevaluating symptoms.
    Look for equinus. This will be important for lift therapy, and etiology of pronation. If a patient has a severe equinus that would require a 1/2" heel lift to correct, and a 1/2" shortage, the the entire lift can theoretically be a heel lift. Conversely, if there is no equinus, and a 1/2" shortage, then the heel and sole can theoretically be lifted 1/2". Typically a heel lift is used until patellar tendonitis develops (in running patients), and then a sole lift has to be added.

    I hope this helps.


  6. snoopy

    snoopy Welcome New Poster

    Dear Stanley,

    Re: Senile scoliosis secondary to post osteoporotic lumber vertebral fracture causing pelvic drop

    An elderly patient presented in clinic asking whether heel lift therapy would be beneficial. She feels the hip drop is increasing balance problems and also wonders whether it is responsible for unilateral hip pain. She is currently under a Rheumatologist & on appropriate medication and pathology is currently stable.
    I am obviously very nervous about the use of a heel lift. As the lumber spine is not flexible (fixed scoliosis) would a heel lift under the elivated hip be useful or definately not advisable?

    Thanks for help
  7. Stanley

    Stanley Well-Known Member

    Hi Snoopy,

    Good for you, you are thinking correctly. I know you are nervous, as this is something that is contrary to how you were taught.
    You first need to get the x-ray or report. If the report says that there is a compression fracture on one side, and that is the high hip side, then the high hip side is the side you put the lift. Just remember, there can be muscle spasms to guard the bone, and everything else I am writing has no application.
    The scenario that you are used to dealing with is a shortage below the pelvis. First of all most anatomic shortages are rare, that being said, if you do have one, then the compensations that are made are to allow the short leg to touch the ground while keeping the body upright. These are typically lengthening compensations of the short side or shortening compensations of the long side. Lifting the side of the low pelvis will prevent the need for these compensations.
    In the case of an anatomic curve in the spine (in this case your possibly compression fracture of one half the vertebra) the curve is causing the pelvis on the side of the concavity to hike up. This is the structure of that individual. The side of the high hip now acts short. Since we are not going to change this structure, we put a lift on the side of the high hip. If we don’t, to get the legs to touch the ground, the side of the high hip has to have lengthening compensations and/or the side of the low pelvis has to have shortening compensations, or a secondary curve develops just opposite in direction of the primary curve.
    I hope this makes the concept clear. Now you have to apply it to your patient. If you are uncertain start with small changes and add.
    Let me know how it turns out.


  8. snoopy

    snoopy Welcome New Poster

    Hi Stanley,

    Many thanks for constructive help. I shall get some info re X-Rays & try minimal wedging & review

    Cheers again

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