Leg length discrepancy

Badda Bing Badda Boom 

As you can see, this gal has an anatomical leg length discrepancy on the left side which is tibial. Can you see the other finding?

Look carefully both of her feet. Can you see the bunion on the left but not on the right? This is a common finding on the shorter leg side of a true, anatomical leg length discrepancy it. Because of the leg length discrepancy, that foot is often in supination and the head of the first ray does not make it to the ground thus the pull of the adductor hallucis muscle pulls the great toe west.

Look for bunions on the short leg side of true, anatomical leg length discrepancies.

#lld #leglengthdifference #leglengthdiscrepancy #shortleg #bunions #bunion #gaitevaluation 

Got Short leg?

Ahhhh. They get it!

Our favorite quote from this article " Understanding limb-length compensation
We encourage you to pay as much attention to any abnormal compensation pattern as you do to the LLD itself. It is well documented that abnormal biomechanics, such as you would find in a compensatory pattern, can result in vibratory forces and microtrauma along the closed kinetic chain (Figure 1). The spinal facet; hip, knee, ankle and foot joints; and their associated muscles may suffer repetitive microtrauma resulting in sprain, strain, or degenerative joint disease. By addressing compensatory neuro-musculoskeletal function, you may be able to assist the patient with a cascade of dysfunction through the musculoskeletal system.

We also encourage you to make use of gait assessment technology to quantify, document, and monitor patients’ progress. Application of reproducible, documented metrics is essential to communicate effectively within a multidisciplinary system that is committed to practicing evidence-based medicine."

http://lermagazine.com/cover_story/assessing-limb-length-discrepenacy

A visual example of the consequences of a leg length discrepancy.

This patient has an anatomical (femoral) discrepancy between three and 5 mm. She has occasional lower back discomfort and also describes being very “aware” of her second and third metatarsals on the left foot during running.

You can clearly see the difference in where patterns on her flip-flops. Note how much more in varus wear on the left side compared to the right. This is most likely in compensation for an increased supination moment on that side. She is constantly trying to lengthen her left side by anteriorly rotated pelvis on that side and supinating her foot  and trying to “short” the right side by rotating the pelvis posteriorly and pronating the foot.

With the pelvic rotation present described above (which is what we found in the exam) you can see how she has intermittent low back pain. Combine this with the fact that she runs a daycare and is extremely right-handed and you can see part of the problem.

Leg length discrepancies become clinically important when they resulting in a compensation pattern that no longer works for the patient. Be on the lookout for differences and wear patterns from side to side.

Pain on the outside of one leg, inside of the other. 

Whenever you see this pattern of discomfort, compensation is almost always at play and it is your job to sort it out. 

This patient presents with with right sided discomfort lateral aspect of the right fibula and in the left calf medially. Pain does not interfere with sleep.  He is a side sleeper 6 to 8 hours. His shoulders can become numb; left shoulder bothers him more than right.

PAST HISTORY: L shoulder surgery, rotator cuff with residual adhesive capsulitis. 

GAIT AND CLINICAL EVALUATION: see video. reveals an increased foot progression angle on the right side. Diminished arm swing from the right side. A definite body lean to the right upon weight bearing at midstance on that side.

He has external tibial torsion bi-lat., right greater than left with a right short leg which appears to be at least partially femoral. Bi-lat. femoral retrotorsion is present. Internal rotation approx. 4 to 6 degrees on each side. He has an uncompensated forefoot varus on the right hand side, partially compensated on the left. In standing, he pronates more on the left side through the midfoot. Ankle dorsiflexion is 5 degrees on each side. 

trigger points in the peroneus longus, gastroc (medial) and soles. 

Weak long toe extensors and short toe flexors; weak toe abductors. 

pathomechanics in the talk crural articulation b/l, superior tip/fib articulation on the right, SI joints b/l

WHAT WE THINK:  

1.    This patient has a leg length discrepancy right sided which is affecting his walking mechanics. He supinates this extremity as can be seen on video, especially at terminal stance/pre swing (ie toe off),  in an attempt to lengthen it; as a result, he has peroneal tendonitis on the right (peroneus is a plantar flexor supinator and dorsiflexor/supinator; see post here). The left medial gastroc is tender most likely due to trying to attenuate the midfoot pronation on the left (as it fires in an attempt to invert the calcaneus and create more supination). see here for gastroc info

2.    Left shoulder:  Frozen shoulder/injury may be playing into this as well as it is altering arm swing.

WHAT WE DID INITIALLY (key in mind, there is ALWAYS MORE we can do):    

•  build intrinsic strength in his foot in attempt to work on getting the first ray down to the ground; EHB, the lift/spread/reach exercises to perform.
• address the leg length discrepancy with a 3 mm sole lift
• address pathomechanics with mobilization and manipulation. 
• improve proprioception: one leg balancing work
• needled the peroneus longus brevis as well as medial gastroc and soles. 
• follow up in 1 week to 10 days.

Pretty straight forward, eh? Look for this pattern in your clients and patients

Can you believe they missed this? Sometimes you just need to look. This gal has knee pain on the R a “funny gait” and right sided low back pain in the sacro iliac joint fr the last 3 years. She felt like she needed to keep her right leg bent and her left straight all the time. She was unable to hike or walk distances longer than 1 mile or time longer than 30 minutes without slowing down and having pain. She has had reconstructive surgery on the right knee for an ACL/MCL, physical therapy, medication, counseling and even stroke rehabilitation/gait retraining. On exam she has a marked genu varus bilaterally. Knee stability is good anterior/posterior drawer; valgus/varus stress. One leg standing with both eyes open is less than 15 seconds, eyes closed is negligible. She has an anatomically short L leg; at least 2 cm which is both tibial and femoral. She was unaware of this and noone had adressed it in any way. She was given a 10mm sole length lift for the L leg and propriosensory exercises. She was encouraged to walk with a heel to toe gait. She felt 50% better immediately and another 20% after 2 weeks of doing the exercises. She had gone on several 5 mile hikes for over 2 hours with minimal discomfort. Nothing earth shaking here. Just an exam which covered the basics and some common sense treatment. Too bad they are not all that easy, eh? The takeaway? Look and listen. The problem was on the side opposite her complaint, as it can be many times. Look at the area of chief complaint 1st, but then look everywhere else : ).

So a patient presents to your office with a recent history of a L total knee replacement 8 weeks ago AND a recent history of a resurgence of low back pain, supra iliac area on the L side. Hmmmm. Hope the flags went up for you too!

His global lumbar ROM’s were 70/90 flexion with low back discomfort at the lumbo sacral junction, 20/30 extension with lumbosacral discomfort, left lateral bending 10 degrees with increased pain (reproduction); right lateral bending 20 degrees with a pulling sensation on the right. Extension and axial compression of the lumbar spine in left lateral bending reproduced his pain.

Neurologically he had an absent patellar reflex on the left, with diminished sensation over the knee medially and laterally. Muscle strength 5/5 in LE; sl impaired balance in Left single leg standing. There was incomplete extension of the left knee, being at 5 degrees flexion (right side was zero).

He has a right sided leg length deficiency (or a left sided excess!) of 5 mm. Take a look at the tibial lengths in the 1st 3 pictures. See how the left is longer? In the next shot, do you see how the knee cannot completely extend? Can you imagine that the discrepancy would probably be larger if it did?

Now look at the x rays. We drew a line across from the non surgical leg to make things clearer.

Now, think about the mechanics of a longer leg. That leg will usually pronate more in an attempt to shorten the leg, and the opposite side will supinate to attempt to lengthen. Can you see how this would cause clockwise pelvic rotation (in addition to anterior pelvic rotation)? Can you see this patients in the view of the knees from the top? Do you understand that the lumbar spine has very limited rotation (about 5-10 degrees, with more movement superiorly (1)  ). Does it make sense that the increased range of motion could effect the disc and facet joints and increase the patients low back pain?

So, how do we fix it? Have you seen the movie “Gattica”? Hmmm….A bit extreme. How about a full length 3mm sole lift to start, along with specific joint manipulation to restore normal motion and some acupuncture to reduce inflammation? We say that is a good start.

The Gait Guys. Increasing your gait literacy with each and every post. If you liked this post, please send it to someone else for them to enjoy and learn. 

(1) Three-Dimensional In Vivo Measurement of Lumbar Spine Segmental Motion Ruth S. Ochia, PhD, Nozomu Inoue, MD, PhD, Susan M. Renner, MS, Eric P. Lorenz, MS, Tae-Hong Lim, PhD, Gunnar B. Andersson, J. MD, PhD, Howard S. An, MD Spine. 2006;31(15):2073-2078.

More on Leg Length Discrepancies

Hi Guys,

I hope you guys are well?

I have a question I hope you can help me with?

Last week I assessed an entire football team, and over 90% have some sort of Leg Length Discrepancy (LLD). I am working with the physiotherapist to improve their weaknesses, including using sole lifts.

My question is if it’s a tibial short leg, then a lift with align the knee and hip. But a lift in a leg with a short femur will align the pelvis but raise the knee higher than the other side. Would you still insert a sole raise, and if not, what would you do?

Kind Regards

Luke

____________

Hi Luke

Yes, you are correct in your assumption of the change in mechanics, and yes, most often, we prescribe a sole lift, if a lift is indicated. Keep in mind that if they are asymptomatic and test out well, a lift may not be indicated. Hope that helps. You can also search LLD on the blog; we have written extensively on it: http://thegaitguys.tumblr.com

Remember sole lifts will correct the LLD but it could shift the pelvis off further…….many LLDs are from pelvic asymmetry and core weakness, this encompasses hip rotation differences which is a typical response to the core and pelvis that is distorted. 
merely forcing a change at the Sole does not mean you are making the positive change at the top……however it may in some cases……you have to determine that with your evaluations.

Most folks legs are of symmetrical length……..the changes at the top (core / pelvis/ hip) is what throws the apparent length off.

i wish i had a good answer for your great insight……..but it is about
1- making the right changes……..so that all parts are in cooperation for the restoration change
2- that you are directing change and not a further body compensattion to the compensation you have forced…….(if it is in fact a forced compensation and not the correction you are hoping for)….. time and re-evals will determine this
3- after restoration and strengthenging you must quickly wean off the lifts from them
4- you are speaking of tibial and femoral short………those are structural short LLDs , make sure you know if you are dealing with functional or structural shortness

Hope that Helps

Ivo and Shawn

Clearing that long leg….

Even MORE on short legs…

We remember from last week, and the week before, there at least SIX common compensations for a short leg.

We recounted them and spoke about leaning to the side of the short leg last time. Here are the others, in case you need a reminder:

•  pronation of the longer side, supination of the shorter
• circumduction of the longer leg around the shorter
•  hip hike on long leg side (seen as contraction of hip abductors, obliques and quadratus  lumborum on short leg side)
• excessive ankle plantar flexion on short side
•  excessive knee bend on the long leg side

Lets look at “circumduction" of the longer extremity. Swinging the longer leg out and around helps to create clearance for the longer leg.  It makes no difference if the leg is functionally or structurally short, the body still needs a strategy to move around the asymmetry. This can sometimes occur with one of the other compensations, but we usually see it by itself.

This compensation often occurs with a pelvic dip on the same side, due to weakness of the gluteus medius complex.

Watch the above video (which we slowed down for you) that we captured on “the Gait Cam” a few times to see what we are talking about. This person has a left short leg and has a pelvic drift during stance phase to that side . We slowed it down so it is easier to see.

Remember here is that what you are seeing is the compensation, not necessarily the problem. When one leg is shorter, something must be done to get the longer leg through swing phase.

Circumduction….Tautological gait…Increasing your gait vocabulary on a daily basis..

Ivo and Shawn.