Hip Pain with LLD - A Tough Case!

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Hi all

I have a challenging case at present - would be grateful for any ideas you may have.

My patient is a healthy and mobile 60 year old lady.

She has (R) hip and inguinal pain after walking, and this seems to be due to a LLD - her (R ) leg is 25mm longer when measured from sternum to both medial malleoli. The difference is the same when measured from the ASIS point to the med mall too. (Also when she's lying prone, supine and in stance. )

The pain has been present for about a year and is unrelated to any localised injury.

She sought some topical work from a Physio who provided a UCBL type prefab device to wear in her (L) shoe only. This made the (R) hip pain actually worse.

After my assessment, I provided her with semi-flexible orthoses, shallow heel cup, with a 5mm (L) heel raise.

On review a couple of months on, she is finding the orthoses very comfortable, but the (R) hip pain remains. (In my previous experience, I have usually found that a long leg can present with hip and groin pain, and that this can reduce when the LLD is reduced).

To rule out any underlying issues, I referred her for a Hip and Back XR, which was reported as normal... in fact, with no narrowing of joint spaces noted.

I also referred for baseline Rheum serology: FBC, CRP, HLA B27, ANA, LATEX, ESR..... and these were all normal too.

Several months of physio and then Chiropractic have also been of little use.

So, any ideas on how to help with the (R)hip and groin pain please?

 

Have you tried increasing the heel lift a little at the time.

25 mm LLD but your only using 5 mm lift.

Also a bit of a pain but maybe you need to look at getting the lift built into shoes not just a heel lift.

just some random thoughts

Goodluck

 

Hi Michael

Thanks for the quick reply!

Yes, increasing the lift seems to be a good plan - I was just hoping to see some better results at 5mm, which I could then increase further every couple of months.

Thanks for the confirmation though,
Pete

 

I have always found LLD to be a very difficult and stubborn condition to treat, :deadhorse:

I think from some information that i have once read about, it is best to first classify the different LLDs:

Structural-1 limb is structurely/anatomically longer than the other.
Functionally-both limbs are of equal lenth but one leg functions shorter or longer than the other, i.e STJ pronation shortening a leg.
Combined-elements of both structural and functional.
Environmental-both limbs are of equal length but the athelete may function asymmetrically as a result of the environment or surface they are running on, such as the side of a crested road, side of hill, etc, and most definately in this case the 6o odd yaer old might not be doing much of running, i guess,

from the above analysis then we might have to delve into the typical limb compensations that occur in a structurely long limb, :hammer:
MTJ pronation
STJ perronation
Excessive midstance knee flexion
Excessive Hip flexion and / or internal rotation.

Now probably the treatment options will be as follows: in a functional descrepancy, one would need to identify the functional etiology, (i,e intrinsic foot biomechanical abnomality, equinus, and muscle imbalance and treat the the aetiology directly. In a structural descrepancy a lift is added to the shorter side, and always with a lift generally 1/4 to 1/4 (some say half????) the amount of the measured difference so i guess the 5mm will be a 1/5, so it might need some increament only as needed to reduce the symptoms.

reference:
Donald Kushner (2006) Podiatric Medicine and Surgery Part 2, National Board review, 2nd Ed. McGraw-Hill Co, pp252-3).

 

thought i might say it first... there is no evidence that proves STJ pronation makes a leg shorter. it's a myth.

 

Assuming that any functional component has been addressed with the orthoses, at least to a degree, then you need a lift. The tough part is definitely out how much of a lift you need. I have found that the measured difference is almost worthless when it comes to figuring that out, as it is not a reliable measurement and there is no magic number regarding what percentage of that difference will feel right to the patient.

I have found that Ballert Build-ups are great for figuring out how much of a lift is needed. They have different thicknesses of lifts (different combinations from 1/8" to 3 1/8") that you can strap to the patient's shoe and then have them wander around your office. Your patient can quickly tell you what feels like the right amount of lift, which is almost always the amount that looks the most even as they are walking. I find that this gives a really good starting point.

These things are very handy to have but don't seem to be very common. Sorry if I sound like a salesman (I'm not) but I love these things. I have attached a picture of mine.

 

If the pt has a 25mm LLD, I would start her off with a 12mm midsole raise of HD EVA, increasing to 18, then 25mm dependant upon the pts ability to tolerate the raise/symptoms.

In my experience only balancing 5mm of a 25mm LLD rarely reduces symptoms.

let us know how it goes!