Limb length discrepency

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I have an interesting case i cant get my head around

16 year old male with lower back pain referred by chiropractor
AP pelvic weightbearing exam shows a 25mm pelvic tilt with the Left ASIS being higher than the right.
Xrays indicate no structural differences at the femur or the tibia. however a supine non weightbearing exam shows a LLD with the Left side being 15mm longer than the right.
How can this be so if there is no structural difference in either tib or fib?? Am i missing something?

 

Is there a genu varum or valgum present?

 

No varum or valgum but i am thinking posible superimposition of the xray cause ther is a recurvatum present.
I guess the only true way of assessing a LLD is CT

 

Supine position alters the alignment pattern of the spine and the pelvis which creates an optical illusion of LLD on the film. This is a 2D image of a 3D structure, so if the set up for the film is poor ie: the distance from the tube to the bucky is altered, the patient is lying in anatomically incorrect position, or the tube is centred in a different position to the AP WB film it will alter findings. If there are an radiological experts out there they wil be able to expand on these points more eloquently.

The question to this then is, how does it influence your treatment? You already have an AP WB film, presuming done with correct tube/bucky, centred beam why do you need exact information to the mm.? How will it influence treatment and will it improve clinical outcome?

DaFlip
'But You Can Call Me Poddy'

 

Get chiropractor or osteopath or physiotherapist to check and/or manipulate sacroiliac joint.

Basic screen test I do is have patient stand facing you. Get them to rotate trunk to left while keeping pelvis facing forward. Then have them do it to the left. Note any asymmetries in the RoM between the two sides.

If the sacroiliac joint is the problem, a heel raise will perpetuate the problem, not help it.

 

What does this tell you?
If you are suggesting this test specifically identifies SI joint pathology/'dysfunction' then this may not be correct.

DaFlip
'But You Can Call Me Poddy'

 

It nothing more tham a screening test thats easy to do to look for asymmetries. Its discussed in depth in "Malalignment Syndrome: Biomechanical and Clinical Implications for Medicine and Sports" - Wolfgang Schamberger

 

You can have a small hemipelvis causing a pelvic tilt and this has no bearing on femur or tibia length. Just like feet are often different sizes, the pelvis can also be less than symetrical.

 

Dear LCG

Leg lenght differences are extremely common when viewed as an apparent dysfunction.

In standing and lying there are apparent differences. This is not that an uncommon finding.

The best bet after having the SI joint looked at in standing and seated forward flexion test along with the stork test, and then corrected is to have the pelvis looked at for either a torsion or flexion of the pelvis.

Flexions are not uncommon while a torsion is always associated with trauma of some kind.

After this look at the quadratus lumborum on the same side and the psoas on the opposite side, usually the side of the dysfunctional SI.

There is a German system called the Zones of Sell named after its founder a doctor Sell pronounced Zell. He says that SI and psoas go hand in hand.

This in standing you can have the Ql pulling the hip up while the psoas pulls the innominate down by anterior rotating the pelvis and thus gives your findings.

Dry needling of the Ql and stretching of the psoas usually dissolves these apparent anomolies then and there.

Hemi pelvises although Travell and Simons talk about them in their book as if they are common, they are in fact very rare.

zHope this helps
Paul Conneely
www.musmed.com.au
Paul Conneely
www.musmed.com.au

 

From the perspective of a Physical Therapist...
If the xrays definitely show no difference in bony length between the two tibias and between the two femurs then this patient does not have a true structural leg length difference. You are seeing a functional difference probably due to a pelvic obliquity. Left ASIS being higher than right may indicate an upslip of the ilium, a posterior tilt of the left ilium, or an anterior tilt of the right ilium. Where are the PSISs in relation to each other and in relation to the ASISs? Assuming the patient is lying straight on the table when you determined the left side to be long, what happens when the patient sits up (supine to sit test)? What happens at the PSIS with standing forward bend vs. sitting forward bend (iliosacral motion vs. sacroilial motion)? There are a lot of variables to look at to determine this patient's mechanical dysfunction. I believe a Orthopedic Physical Therapist is the professional with the most expertise in this area. Hope this helps!

Ann

 

Thanks for that. My opinion is that the hemi pelvis and significantly smaller calcanueus is more common than opinion would have - just not observed because too many stick patients on the computer gait scan instead of physical exam.
Robyn Hoodigs: