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Leg length discrepancy caused by knee flexion

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Thomas Woods, Jul 30, 2011.

  1. Thomas Woods

    Thomas Woods Member

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    Hi I am new to Podiarty arena, I am a student studying P&O. My girlfriends father has a leg length discrepancy with obvious asymetric gait. When I assessed his leg there was a leg length discrepancy of 2.5cm on the right side. This was caused by an injury he had at 18 (he is now 56) where his right knee was ran over by a bus! in surgery they replaced his ACL with carbon fibre. This has meant he cannot fully extend his right leg, His full extension is 160 degrees.

    His GP told him that his left knee is deteriorating because of the compensation and he will need an operation when it gets worse in the future. The only orthotic advice the GP gave was for him to see a cobbler to add a quarter of an inch to the bottom of his shoe!

    I supplied a heel raise of 9mm made out of EVA, he has used it for about a month and he is now complaining of more (Right) knee pain, pain in the medial arch (I think Plantar fasciitis), and pain on the calcaneocuboid joint(dorso-lateral) and talonavicular joint (dorso-medial). Is this pain linked to the peroneal muscles?

    since then I have reduced the heel raise to the minimum I can of 3mm. Is this pain a side effect of a heel raise? Is there any other way of treating a leg legth discrepancy caused by a contracture? Thanks :D
  2. efuller

    efuller MVP

    It's hard to give advice without knowing why the knee is hurting. One possible cause is that a constantly flexed knee will have to have constant tension in the quads to keep the knee from flexing. More tension than if the knee was straight. This quadriceps tension will increase compressive forces at the knee and lead to accelerated cartilage wear. How's the cartilage? The pain could be also from frontal plane alignment issues. How's that? If the pain is from a constantly flexed knee, then a lift won't help if the knee can't get to 180, because the knee will still be flexed and the quads still contracting.

  3. RobinP

    RobinP Well-Known Member

    Welcome to Podiatry Arena. It took me 8 years to start following biomechanics on a site like this so you have a flying start. Are you Strathclyde or Salford?

    Did he follow the doctors advice and wear a lift on the bottom of his shoe? If so, was it a through raise or just under the heel? Or has he managed with nothing then swiftly changed to having a 9mm raise?

    I'm not clear what the EVA raise is doing. Is it merely accommodating the knee flexion contracture? Or is part of it accommodating the discrepancy i.e. how much heel rasie does it take to accommodate the contracture. Did he previously walk on his toe to make up the discrepancy?

    Eric makes a very good point. Raising the heel may be subtely altering the ground reaction vector to pass further behind the knee joint centre which will ultimately increase the load on the quadriceps.

    I'm not sure how it ties in with the other symptoms although if the heel was raised only at the very back and the intrinsic arch structures are weak, you could arguably be increasing the load on the plantar tensile structures and also increasing the load on the dorsal bony structures as is the case for Dorsal Midfoot Interosseus COmpression Syndrome(DMICS) click here for the link.

    Perhaps something with greater conformity to the foot which provides a forefoot plantarflexion moment might reduce the dorsal and plantar structure loads. The raise could be built in to this assuming you could source appropriate footwear.

    As Eric said, we are just speculating. You need to find out what the injured structure is and reduce the pathological forces.

    Good luck

  4. Thomas Woods

    Thomas Woods Member

    Thank you for your reply Eric. I think the cartilage is badly as crunching sounds are made when the knee is moved and the joint is very swolen. Also he has had an operation on the knee to remove the meniscus.

    Would stretching be the best course of action? I am unsure if the knee will ever fully straighten.

    on his contracted leg the foot is in a supine postion on weight baring and on the left side the foot is pronated. from assessment of the foot both are fully correctable.
  5. Thomas Woods

    Thomas Woods Member

    Hi Robin
    I don't think I'm quite following the biomechanics fully but I'm trying:D! I've just completed my first year at Salford on the new 3 year course. I'm really enjoying it and it's great being on placement throughout the year to see real cases in clinic.

    After he visited the doctor I baught the intrinsic heel lift that could be adjusted by 3mm strips of EVA. He has been managing for over 20 years with no heel lift, but he cannot walk very far before his knee is too sore.

    Previously his gait was very asymetrical on his right foot (injured knee) he has very little heel strike and no toe off what so ever. Throughout the step phase his ankle remains slightly dorsi-flexed. also the period of time spent on the right leg was significantly shorter than on the left. Because of this I was considering advising rocker bottom shoes to assist with toe off.

    Thank you for the post on Dorsal Midfoot Interosseus COmpression Syndrome(DMICS). I will have to assess him to see if there is tightness in the achillies tendon.

    cheers Robin :drinks
  6. falconegian

    falconegian Active Member

    Dear Thomas,
    I think that in this case the best thing is to manage the arthritis of the knee. Probably the best solution for the patient is a total knee arthroplasty!!!

    Gianluca Falcone
  7. RobinP

    RobinP Well-Known Member

    Pretty good suggestion that
  8. Thomas Woods

    Thomas Woods Member

    Cheers guys :) thank you for the help
  9. physiocolin

    physiocolin Active Member

    Hi THomas

    Two definite muscle groups (knee extensors and flexors) will have been in long term demand with the inevitable demand on the knee joint. whether a conservative approach can be successful at this stage is another matter. If not possible then 'Z plasty' for the hamstrings may need discussing with the orthopod.
    Before that I would at least try a PNF loading approach in order to try and restore normal muscle length. It works with many chronically,extremely tight muscle groups and may take a couple of months with bags of input from the patient. A drop in the ocean compared with the length of time he has suffered.

    It never surprises me the number of diagnosed OA knees that make dramatic recovery applying the technique.


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