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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 :)

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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 ??

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

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.

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 :)

Pelvic level. Great toy.

http://www.algeos.com/cgi-bin/sh0000...LA2188#aLA2188

Regards
Robert

Would need to use this on ASIS and PSIS to differentiate torsion within the pelvis

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"My mission drive is to open up my eyes, 'cause the wicked lies and all the sh!te you say..." http://www.youtube.com/watch?v=V4NW5S1UTPQ

"Science is the antidote to the poison of enthusiasm and superstition."

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

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

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

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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

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.

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

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.

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Who? What? When? Why? Yeah? And? So? What?

"My mission drive is to open up my eyes, 'cause the wicked lies and all the sh!te you say..." http://www.youtube.com/watch?v=V4NW5S1UTPQ

"Science is the antidote to the poison of enthusiasm and superstition."

"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)

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?

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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

I don't understand your question Dan.

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Who? What? When? Why? Yeah? And? So? What?

"My mission drive is to open up my eyes, 'cause the wicked lies and all the sh!te you say..." http://www.youtube.com/watch?v=V4NW5S1UTPQ

"Science is the antidote to the poison of enthusiasm and superstition."

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

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/m...09/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.

__________________
Who? What? When? Why? Yeah? And? So? What?

"My mission drive is to open up my eyes, 'cause the wicked lies and all the sh!te you say..." http://www.youtube.com/watch?v=V4NW5S1UTPQ

"Science is the antidote to the poison of enthusiasm and superstition."

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

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.

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:)

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?!

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.

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Sincerely,

Kevin

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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

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/en...1000m%2Cisrctn

http://www.jospt.org/issues/articleI...cle_detail.asp

http://www.blackwell-synergy.com/doi...7.2005.03349.x

http://www.ptjournal.org/cgi/reprint/70/3/150.pdf

__________________
Who? What? When? Why? Yeah? And? So? What?

"My mission drive is to open up my eyes, 'cause the wicked lies and all the sh!te you say..." http://www.youtube.com/watch?v=V4NW5S1UTPQ

"Science is the antidote to the poison of enthusiasm and superstition."

Just re-read this statement and love it Kevin.

__________________
Who? What? When? Why? Yeah? And? So? What?

"My mission drive is to open up my eyes, 'cause the wicked lies and all the sh!te you say..." http://www.youtube.com/watch?v=V4NW5S1UTPQ

"Science is the antidote to the poison of enthusiasm and superstition."

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

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

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