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The lastest newsletter from ChiroWeb has this from a chiropractic perspective: The Lowdown on Short Legs
Quote:
Probably no area of clinical practice is more confusing to chiropractic patients than the subject of short leg. Even among the chiropractic profession, there are differing opinions regarding this phenomenon.
Practitioners who commonly utilize the "Derifield-Thompson" test of comparing heel lengths with a patient prone often do not explain to their patients that any appearance of leg-length inequality using this method is usually functional – a result of muscle imbalance, rather than a true difference in the length of the long bones. Those who use this test to confirm or dispel the rebalancing of the spine and pelvis give credence to its validity, although most studies have found little reliability or reproducibility using the exam.
The whole process has always been somewhat of a mystery to me. My instructor at Palmer could not explain the mechanism, and the only possible way I know to explain the appearance of change in heel height with a patient prone and knees flexed is as a difference in quadriceps tonus.
Anatomical leg-length inequality (LLI) is a very different matter. Often overlooked on initial examination and unappreciated, LLI can have a significant effect on the pelvis and spine from both an anatomical and biomechanical perspective.
The advantage of open-back gowning for all new patients is that one can make a comprehensive structural and postural visual exam with a patient erect, beginning with the feet and ankles and working up. Ignoring this essential first step in examination has resulted in many overlooked factors to chronic pelvic and spinal pain. I have patients disrobe to their underwear and ask female patients to remove their bra for an unobstructed view of the spine.
One telling sign of possible anatomical leg-length inequality is declination to one side of the underwear or panty line that follows the inferior tilt of the sacrum and pelvis. Another consistent sign of LLI is asymmetry of the flank fat fold. Also, one commonly sees an elevated shoulder on the side of the anatomically short leg, a result of compensatory rotoscoliosis. Palpating the crest of the ilia simultaneously will often reveal pelvic imbalance, as it appears pelvic torsion and obliquity almost always accompanies LLI. As a method to help confirm the probability of anatomical short leg, I place the patient supine on a flat table with shoes on. I then have them draw their knees to their chest, roll into a ball, and then carefully extend lumbar, pelvis and lower extremities, eventually lying flat with the feet slightly off the table. With my thumbs on the bottom of the patient's shoes, under the arch, pressing lightly cephalid, I can assess any appearance of true LLI by viewing heel discrepancy.
Measurements for LLI using a tape measure and various landmasses have proven quite unreliable, showing no consistency of findings or even the ability to correctly identify the side of the short leg. I consider visual and palpatory signs of a short leg while erect, combined with a confirming supine leg-length test, to be justification for X-ray to validate the impression and make measurements for possible lift therapy.
It seems universally accepted that the only accurate measurement for LLI is an erect A-P pelvic X-ray with center beam through the top of the femur heads. Great care should be taken in proper patient placement and posture. Once in position, I instruct a patient to fully extend both knees, bring them forward equally to a point of comfort, and then hold. One also should be aware of the effect unilateral hyperpronation of the ankle and foot may have on leg-length measurement. To compensate for such a development, I instruct the patient to roll both feet outward and then slowly lower them until both feet are properly balanced with a vertical Achilles' tendon. The X-ray tube should be absolutely perpendicular to the film with the center of the beam at the ilio-femoral joint space, hitting the middle of the film.
Once a good image has been secured, measuring from the bottom of the film to a horizontal line drawn at the top of the femur heads will give a comparative difference indicating true leg-length inequality. One also may measure a line at the sacral base against horizontal for the angle of sacral base declination. For those wishing to identify which of the lower extremity long bones is short or in what combination, one may use the same technique to get an A-P bilateral knee view. I have even done this combined, using collimation for a split-screen view on 14"x17" film mounted vertically. ...
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?
Phill
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.
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.
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.
Leg Length differences
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