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Leg length discrepency how do you measure clincally?

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Charlotte Darbyshire, Dec 4, 2007.

  1. Charlotte Darbyshire

    Charlotte Darbyshire Active Member


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    Hi fellow forum users,
    I have not wrote on the forum for such a long time.
    Finally embarking on my dissertation for my Msc I'm hopefully going to investigate the clinical measures used by different professions to establish whether a patient has a leg length discrepency. How accurate are these measures? how repeatable etc...
    I would be grateful for any ones in put on this as I first need to establish what methods are currently used.

    I would be glad to hear your thoughts soon

    many thanks charlotte :)
     
  2. Admin2

    Admin2 Administrator Staff Member

  3. trudi powell

    trudi powell Active Member

    From the list above I measure pretty much the same way as described in 'Measuring LLD'. However, after alligning the body and comparing, then measuring by tape I wouldn't see the need to xray and irradiate people if only to work out the exact 1mm difference. Is it really going to change your treatment.

    If by measuring by tape you find a difference between each leg ( ASIS to Med Mall ) then you can measure other boney prominences to determine if the difference is upper or lower leg or even joint spacing. Using Greater Troch, Lat Mall, Fibular or Femoral prominences at the knee....whatever you need to determine where the assymmetry is.

    Posturally I always look at the ASIS and look at the functional LLD, if not the actual LLD.

    What else do other people do ?? Would you xray for LLD ??
     
  4. Charlotte Darbyshire

    Charlotte Darbyshire Active Member

    I routinely get my pts in a supine position and look at the level of the medial malleolus. I also 'confirm' this by getting the pt to stand in RCSP using the PSIS as marker points estb. whether one side is lower than the other then add blocks of EVA at 2mm 4mm 6mm 10mm 12mm until the PSIS become level. I can also use a tape measure measuring from the ASIS to Med mall. However, this is very rare.
    With the block techinque above I also ensure I'm adding the raise to the correct side by applying the same build up to the opsite side (longer leg) expect the PSIS to increase in height on this side. I also check as above block under shorter leg and in NCSP
    With regards to Xray etc I have only come across one pt who has had this done. I am of the same thinking as yourself with this technique.

    thanks for the reply are there any others out there - It would be a great help to hear your thoughts
    charlotte
     
  5. Peter

    Peter Well-Known Member

    I use the PSIS in RCSP, and add blocks under the short side to balance the PSIS. This is my first and preferred technique.
    I often get referrals from Physios who diagnose LLD on bed testing, but I find this technique equivoval and will not rely on that measurement when treating symptoms secondary to LLD.
    I also will put the pt into NCSP and examine the PSIS when there is an asymmetric RCSP.
     
  6. Charlotte Darbyshire

    Charlotte Darbyshire Active Member

    Are there any other methods used clinically to measure leg length. I am attempting to establish which method ( if there is one) is used most frequently. I am very interested in peoples thoughts. Thanks to those who have replied already.

    Charlotte :)
     
  7. Stanley

    Stanley Well-Known Member

    The first attempt at a complete method of evaluating leg length in the podiatry literature appeared in this article:

    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 is an old article, and some things have changed, but it is a good place to start.

    Regards,

    Stanley
     
  8. Daniel Bagnall

    Daniel Bagnall Active Member

    Hi Charlotte,

    I pretty much utlilize the same methods as you have mentioned. I was previously troubled with measuring LLD as it is quite challenging to accurately quanitfy. I think the more thorough you are i.e. the more aseessments you do, the more accurate the outcome will be. Ultimately, as far accuracy goes, I think X-Rays (scanograms) are underutilized, especially in tricky cases when you want to be absolutely certain.

    Regards,

    Dan
     
  9. Boots n all

    Boots n all Well-Known Member

    l use the Skyline/Allis test, which Osteos also use.
     
  10. Daniel Bagnall

    Daniel Bagnall Active Member

    Hi David,

    I would appreciate it if you could elaborate a little further, regarding how to perform these tests. I tried to "google" it but no such luck...

    Regards,

    Dan
     
  11. Lawrence Bevan

    Lawrence Bevan Active Member

    Allis test

    Centre up your patient supine on the couch so hips, pelvis legs etc square.

    Flex knees to a 90 deg angle and compare height of knees. The reasoning is that a short tibia will show as a lower knee and a short femur will show as a knee retrograde to the other.

    Allis test does come up on google.
     
  12. Charlotte Darbyshire

    Charlotte Darbyshire Active Member

    thank you so much for the replies so far... i'm interested in the torsional ASIS PSIS comment could you please elaborate further as I do not routinely check ASIS as some pts it is very difficult to see.
    many thanks again
    charlotte
     
  13. Charlotte, I'm not trying to be awkward or a pain in the ass, but as this is toward your MSc dissertation its seems reasonable that a bit of research on your own part may be in order- try googling "pelvic torsion and limb length discrepancy"- lots on this.
     
  14. Boots n all

    Boots n all Well-Known Member

    "Centre up your patient supine on the couch so hips, pelvis legs etc square.

    Flex knees to a 90 deg angle and compare height of knees. The reasoning is that a short tibia will show as a lower knee and a short femur will show as a knee retrograde to the other."

    Lawrence is right, but before we put the knee flextion we "pull" on the cal. and lift them 5cm of the bench then ask the client to "lift your bottom of the bench please"
    whilst this allows for you to be certain that the pelvis is as straigth as possible, the test is not much good if the client has laid down a little crooked.

    Now flex the knees, you can then put a wedge or two under the Cal. giving you and the ever doubtful parent a great veiw of what you are looking for and how you will go about fixing it.
    (l just had a new client in with a 4.5cm LLD aged 6years and no intervention had been taken to this point:confused:)

    Book reference if you would like one
    "Assessment of the lower limb" second edition by Linda M. Merriman, Warren Turner page 207-209

    Question; When measuring of your ASIS can you get the exact same measurement twice on the same client a week later? or can your college walk into the room after you have finished and get the same result as you just did on that client?
     
    Last edited: Dec 7, 2007
  15. Daniel Bagnall

    Daniel Bagnall Active Member

    Hi Simon,

    Would there be any way that we could interpret (or approximate) this in a clinical setting i.e tests/assessments, or is this something that can only be achieved whilst conducting research?

    I'm just trying to get my head around it.

    Regards,

    Dan
     
  16. I don't understand your question Dan.
     
  17. Daniel Bagnall

    Daniel Bagnall Active Member

    Simon,

    Does pelvic torsion affect clinical outcomes? If your answer is, yes (which I'm assuming it will be), then, how do we factor pelvic torsion into our clinical assessments (if possible).

    Are you following me?

    Dan
     
  18. The literature suggests it does. The angle of pelvis torsion can be defined as the angle between the iliac and ischio-pubic planes relative to the axis formed by a straight line joining the mid point between the ASIS and the PSIS on the iliac crest to the midpoint between the symphysis and ischeal point on the ischio-pubic ramus.

    If you google pelvic torsion you get lots of hit, including some on clinical assessment (I was trying to get Charlotte to do this as it's her research!).
    http://findarticles.com/p/articles/mi_qa3841/is_200409/ai_n9438247

    Rich Bouche suggested that you may see clinically ASIS that are level, but PSIS which are not or vice versa due to pelvic torsion- hence you need to look at the level of both ASIS and PSIS.
     
  19. Daniel Bagnall

    Daniel Bagnall Active Member

    Simon,

    Further to my last post,

    I would assume that in most cases, pelvic torsion is a compensation for a LLD. How would we clinically determine/assess pelvic torsion? Does pelvic torsion change the way we treat a LLD i.e. using heel raises? Providing that pelvic torsion is a compensation, if, for example, we treated the LLD using a heel raise, should we anticipate that the torsion compensation will correct itself?

    In addition, when confronted with a LLD, rather than just assessing the limb lengths, is it just as important to assess the amount of torsion?

    I hope this clarifies things...

    Dan
     
  20. Daniel Bagnall

    Daniel Bagnall Active Member

    Thank you for elaborating Simon. I had just submitted my last post just before I read your reply. It was my intention to be a little more specific, incase you needed any further clarification.
     
  21. Charlotte Darbyshire

    Charlotte Darbyshire Active Member

    I take simon's comments on board - thank you :) ( I am not expecting members of the forum to provide me with all my literature evidence for my MSc) I have posted this topic question to determine the most favourable techinques used by fellow colleagues( I felt this was the place to do it). The torsional information and comments made above was what I anticipated my reply to be from the question I posed.
    Maybe I need to clarify my questioning a little further in future.
    Many thanks to every one who has contributed so far.
    Charlotte:)
     
  22. Leg length discrepancy and its "treatment" are probably one of the most mythical areas within the healing arts that treats lower extremity and postural pathology.

    I have to restrain my laughter when a patient comes to me and says that their chiropractor or other health specialist regularly adjusts their "leg length" by manipulation. What a joke!! Maybe this is psychic surgery?!:rolleyes:

    In other words, how does one "manipulate the leg" to lengthen the osseous structure of the femur and tibia???

    Other questions:

    Why put a heel lift inside a shoe when the whole foot should probably be raised to the ground if the limb is indeed short???

    Is there any solid scientific research that gives us an idea of how accurate all these unreliable measurement techniques (except for scanogram) are in determining the actual difference between the length of the two lower extremities???

    We need to attack this problem scientifically unless we are fully satisfied at allowing practitioners to continue to practice "voodoo manipulations" for leg length discrepancy.

    Just some thoughts for the holiday season.:drinks
     
  23. Ian Linane

    Ian Linane Well-Known Member

    Hi Charlotte

    Not sure that this fits what you are seeking but following on from Kevin's post above. Prof Jim Richards at Lancashire University has been doing some time on the use of heel lifts and pelvic function. (think I've mentioned this before so forgive me if I'm repeating myself - just after more points!!). His research appears to be indicating that in the case of LLD it is not necessary to equalize pelvic levels in order to get full pelvic function in gait. Quite what is meant by full pelvic function I'm not sure but he may well be worth contacting as no doubt they have spent time on looking specifically at LLD. (I believe he has a biomechanics book due out January time which may cover some of this as well)

    Cheers
    Ian
     
  24. I guess because in some patients this is successful, although I have found that in others it is not. Luckilly, I have an excellent "cobbler" who will split off the outer sole of running shoes and add in eva straight through the midsole.

    Unsurprisingly, the literature is a bit of a mixed bag, but my ten minute search on google gives these (i didn't go past the first page of results Charlotte ;)):

    http://www.ncbi.nlm.nih.gov/sites/e...dopt=AbstractPlus&holding=f1000,f1000m,isrctn

    http://www.jospt.org/issues/articleID.622,type.14/article_detail.asp

    http://www.blackwell-synergy.com/doi/abs/10.1111/j.1445-2197.2005.03349.x

    http://www.ptjournal.org/cgi/reprint/70/3/150.pdf
     
    Last edited: Dec 10, 2007
  25. Just re-read this statement and love it Kevin.:butcher:
     
  26. pgcarter

    pgcarter Well-Known Member

    I think it's worthwhile recognizing that the treatment parameters may be different based on the length of time the LLD has been present. A recently acquired trauma victim and a congenital issue that is now 45 yrs old are two very different issues. It's also worth saying that measuring is all well and good but it's the practical results and patient feedback that will determine what you should do over time, not some sort of pigeon hole theory of "type A requires treatment B". I often tell people that the process of lifting one short limb may take 12 months or more to reach a conclusion with multiple "lifts" along the way. I am not a fan of the long term heel lift, but 5mm in the shoe out to just distal to the met heads is often a good start to gauge any spinal reaction to introduced changes.
    Measuring an LLD of 1.5cm or 3.5cm won't really change the beginning of the process if the pt is symptomatic and has had it for many years.
    I have never seen it as necessary to get parallax corrected Xrays done to know "exactly" the LLD, because it won't change my treatment pattern much anyway. Unless of course there is some threshhold number for surgical lengthening via Lizzarov frames.

    regards Phill Carter
     
  27. Daniel Bagnall

    Daniel Bagnall Active Member

    Hi Phill,

    I just have a few queries,

    If your not in favour of using a heel lift long term, then what would you do for the pt after you have gauged their progress? (Assuming they have had a (+) result). Do you refer them?

    To me, this sounds like you are contractidcing what you said above. I dont understand why you would be prepared to experiment for up to 12 months using heel lifts if your not a fan of them. In addtion, 12 months is quite a considerable period, don't you think?

    Regards,

    Dan
     
    Last edited: Dec 11, 2007
  28. Stanley

    Stanley Well-Known Member

    Dear Colleagues,

    I just wanted to correct some myths.

    A myth is a story written to explain something that someone doesn't understand.

    They are changing the functional leg length which can be affected by the iliosacral joint, or any segment of the spine.

    If there is a compensatory equinus, you would initially just use a heel lift without the sole lift, until the equinus can be changed. This is why you should take a biomechanical exam.

    Most people have had some adaptations that will prevent them from accepting a full correction for their shortage. So why subject the patients pelvis to needless radiographs?

    Regarding the amount of lift to use, there are two ways to proceed. Start 1/8" and increase weekly depending on patient response. The other option is to look at the spine and place the amount of lift under the short side that negates the curve in the spine without causing a secondary curve or rotation of the pelvis in the horizontal plane.

    All this is meaningless if the shortage is a functional shortage caused by a restriction of the spine. The way to tell this is to watch a patient walk. If the head raises when the hip is dropping on the supposed short side, then the spine is the cause of the functional asymmetry. This is why you need a gait analysis for asymmetries.

    Regards,

    Stanley
     
  29. pgcarter

    pgcarter Well-Known Member

    If you have a long term LLD of multiple cm you cannot expect the change to happen rapidly, nor can you raise someone 20mm in one go, so I start with 5mm in the shoe, think of it as a lift to the met heads also, not a heel lift, if that is OK for a few weeks we add 10mm to the sole of the shoe, if that is OK add another 5mm in the shoe, then take it out and add another 10mm to the shoe sole, etc etc....as Stanley said you can't just measure or XRAY some one and add the difference. The full process may take a year....why rush if it's been there 45 years nothing is going to fall off, but a spine hurried can be a very angry thing.
     
  30. Daniel Bagnall

    Daniel Bagnall Active Member

    Hi Phill

    Thanks for clarifying your previous points. Apologies for misinterpreting a "lift to the met heads" as being a heel raise, however, I still think the terminology you've used is debatable. I would interpret that type of "lift" as being an anteriorly extended heel raise. Therefore, I would assume that you are not an advocate of using the standard heel raise, correct? I think the type of lift you have suggested is probably more effective though, as it provides greater sagittal and frontal plane control.

    I understand that it is inappropriate to try and correct 100% of the deformity in the initial stages of tx, as you've pointed out. In my opinion, in some cases (severely symptomatic cases), but not all, it is appropriate to perform XRAYS (scannogram), as it is essential to distinguish where the deformity is coming from i.e. spine, pelvis, femur etc, and to determine whether it is structural or functional in nature. In addition, I feel that it gives me greater confidence in determining the amount of correction I wish to initially prescribe. I usually start with 50% correction, or slightly less, then work progressively from there. I resort to using scanograms only when I need additional clarity, as I like to be as thorough as possible, due to the complexities of LLD.

    Regards,

    Dan
     
  31. trudi powell

    trudi powell Active Member

    Oh Kevin, Oh Kevin, Oh Kevin,
    I thought you were the Bee's Knees ( Aussie Slang for Everything True and Good ) but disputing the benefits of manipulating because my 'Back is out at the moment' and correcting the functional LLD isn't what I expected of you.

    Of course there is more to the body than just the legs and other factors can cause a LLD. Hence the Pelvic Torsion even if there is no actual LLD. That is why we test the ASIS level in stance and we measure the actual LLD when supine.

    I'm not laughing at Chiros or Physios or any other clever practitioners, who can help to reallign the body. We are all aiming for symmetry. Make the base symmetrical and it makes it easier for every other joint and movement above.

    However, caution to any newer practitioner. Never try and make a LLD correction exactly the actual or "guesstimated" difference. That is, if your pt has an 8mm LLD DON'T do an 8mm heel lift. If you are positive they have an 8mm LLD do a 6-7mm heel lift. Or you can really stuff up their spine !

    Trudi....still love you Kevin , but no more silly comments ?!
     
  32. Trudi:

    Sorry to disappoint you. I have absolutely no problem with manipulation done by trained health professionals. What I do have a problem is with is these same health professionas telling a patient that their manipulations for "leg length discrepancy" are actually changing the length of their legs, when, in actuality, they are altering the position of their pelvis or hip joint relative to their legs when they did their manipulations. But these people actually think their legs are changing in length with manipulation.

    Is it silly, Trudi, to want our patients to be told the truth about what their medical treatment is actually doing to their bodies?
     
  33. Dananberg

    Dananberg Active Member

    Kevin,

    While the "explanation" as to why "leg length" can be "adjusted" might create a smile, the concept is very valid and not one to simply "laugh off". Functional LLD due to pelvic torsions are often related to underlying amounts of true LLD. The total amount of difference can be reduced via manipulation to bring the subject back to the "underlying" amount. I have often referred chronic lower back pain patients for manipulation prior to my treatment as a failure to properly adjust these folks will only lead to orthotic treatment failure, as it is impossible to properly correct them while they remain in their torsional states.

    You are correct that the actual length of the bones is not adjustable, but fact that functional LLD exists is not a laughable matter to those who suffer with it.

    As far as assessment goes...try looking at arm swing. The arm that swings more is most often (never always) on the shorter of the two limbs. When functional LLD exists, this is a very helpful clinical sign to help determine the long from short side.

    Howard
     
  34. Ian Harvey

    Ian Harvey Active Member

    Howard said:-
    As far as assessment goes...try looking at arm swing. The arm that swings more is most often (never always) on the shorter of the two limbs. When functional LLD exists, this is a very helpful clinical sign to help determine the long from short side.

    Howard,
    Does the swing arm on the short side give more swing on the forward swing, or on the back swing, or on both forward and back?

    Cheers,
    Ian.
     
  35. Dananberg

    Dananberg Active Member

    Ian,

    It appears to move more in both directions. My theory as to why this is the case involves the function of the upper back muscles (traps, predominately) and their origin relative to the scapula. Since the longer side is harder to "vault over", there is a tendency for greater sagittal plane restriction. When this causes a forward head position, the trapezius must resist the head's forward flexion (forward head posture). When this occurs, and due to its origin from the scapula, it prevents the scapula's normal release of the shoulder, and arm swing is decreased.

    Hope that this answers your question.

    Howard
     
  36. Ian Harvey

    Ian Harvey Active Member

    Thanks Howard,

    Just been stalking round my clinic with strange simulated gaits to test your theory, and I think it stands up under my stringent laboratory controlled, non-blinded conditions.

    Cheers,
    Ian.
     
  37. markjohconley

    markjohconley Well-Known Member

    TOO MUCH SUN TRUDI, TOO, TOO MUCH SUN, emigrate before the damage is irreversible, love mark c
     
  38. Asher

    Asher Well-Known Member

    You are a funny guy Markjohconley, I enjoy your humour! :)

    Anyway,

    I have often wondered ... why do we call it a "Functional LLD"?

    Surely, there is either a "LLD" (which is termed structural LLD) or there's not. If it looks like a LLD but the leg bones are the same length, then its not a LLD.

    Call it what it is ie: contracture of whatever muscle, whatever tosion of the whatever bone. It just confuses the issue when you call it "Functional LLD".

    :empathy: OK I'm fine now, thanks.

    Rebecca
     
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