Leg length discrepancy is a condition where the length of one leg is different than the other (shorter or longer) because of either or both a functional (muscle/posture) or structural (bone/cartilage) abnormality. In the specific a functional leg length occurs when your legs are the same, but another condition such as pelvic tilt or piriformis shortening creates the appearance of one leg being longer or shorter than the other. A structural leg length inequality it means that there is a true difference. Osteopaths, chiropractors and physiotherapist should be able to determine the degree of leg length inequality using visual inspection and manual tests.
Causes
1.Neuromuscular
- Muscle imbalance causing different pull on pelvis (anterior superior Ilium or posterior inferior ilium).
- Muscle tightness/shortness especially piriformis (which lead to an external rotation of the femur thus shortening of the leg) and QL (raising ipsilateral iliac crest).
- Genu recurvatum, valgus, varus
- Asymmetrical fallen arches or over pronation
- Polio, Cerebral palsy.
2. Trauma
- Fracture
- Injury epiphyseal plate
- Iatrogenic (such as hip or knee surgery)
- Idiopathic
- Hip disorder (such Legg-Perthes-Calve’ or Slipped capital femoral epiphysis).
- Advanced degenerative changes
Signs & Symptoms
The patient/athlete may present with an altered gait (such as limping) and/or scoliosis and/or low back pain.
Lower extremity disorders are possibly associated with LLD, some of these are:
- Increased hip pain and degeneration (especially involving the long leg)
- Increased risk of: knee injury, ITB syndrome, pronation and plantar fascitis, asymmetrical strength in lower extremity.
- increased disc or vertebral degeneration.
- symptoms vary between patients, some patients may complain of just headaches!!!!!
Diagnosis
On standing examination one iliac crest may be higher/lower than the other. However a physiotherapist, osteopath or chiropractor will examine the LLD in prone or supine position and measure it, confirming the diagnosis of structural (or functional) LLD.
–LLD in supine position–
The LLD should be measured using bony fixed points
1. ASIS to medial malleoli
2. ASIS to knee joint line
X-Ray should be taken in a standing position. A full three exposure to a full spine film (divided in 3 sections). The osteopath, physiotherapist or chiropractor will look at:
- Femoral head & acetabulum
- Knee joints
- Ankle joints.
Treatment/Management
Treatment of leg length inequality involves many different approaches, which vary among osteopaths, physiotherapist and chiropractor and whether the LLD is functional or structural. Thus is a combination of:
- Myofascial release (massage) & stretching of shortened muscles.
- Manipulation or mobilization of the spine, sacro-iliac joint (SIJ), hip, knee, foot,
- Orthotics – shoe lift can be used to treat discrepancies from two to six cm (usually up to 1 cm can be inserted in the shoe. For larger leg length inequalities, the shoe must be built up. This needs to be done for every shoe worn, thus limiting the type of shoe that the patient can wear).
- Surgery (epiphysiodesis, epiphyseal stapling,bone resection).
Hints.
Lift height should be built up gradually to allow body time to adapt to changes. Heel lift may reduce low back pain, scoliosis, improve weight distribution.
Athletes require a more precise and dynamic lift.
Orthotics, why do supinated or pronated foot influence leg length? (look at the figure below).
Dott. Emanuele Luciani
Osteopath, physiotherapist, hatha yoga teacher
Osteopath registered with the General Osteopathic Council (GOsC)
(number 8232http://www.osteopathy.org.uk/home/)
"Centro Studi Tre Fontane"
Via Luigi Perna 51, Rome
