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leg length question
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leg length question - February 15, 2006 4:06:00 PM
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tf8560
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A patient I evaluated demonstrated an asymmetrical pelvis higher on the right in standing yet when I had him supine and aligned properly, the right leg measured shorter from the asis to the medial maleolus and the umbilicus to the medial maleolus. Barring any error on my part, what are some potential reasons why this may be?
Thank you for your help
Tom Fletcher
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Re: leg length question - February 15, 2006 11:57:00 PM
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Randy Dixon
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It could be many things, not least of which measurements aren't that reliable. To be more helpful I can give an example, if the apparent leg length difference is a matter of a rotated pelvis then you might measure the anterior leg as being longer, yet when lying the pelvis is less rotated and you might get the opposite measurement.
did you measure in sitting, both the legs in log sitting and looking at pelvis when sitting on the table?
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Re: leg length question - February 16, 2006 1:44:00 AM
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PTupdate.com
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I'd say more pelvic obliquity than leg length discrepency.
What crest is lower, and which ASIS is lower versus the other, and which PSIS is lower, again in relation to the other?
John Duffy, PT OCS
[URL=http://www.PTUpdate.com]www.PTUpdate.com[/URL]
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John M. Duffy, PT
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Re: leg length question - February 16, 2006 3:10:00 AM
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JLS_PT_OCS
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An even better question would be whether any of this assymetry is related to pain.
I would say that there is quite a bit of evidence to indicate it is not.
I don't measure such things as pelvic landmarks in my patients any more than I note their eye color.
If all else fails, I might consider addressing some of these issues, but it should be way down the list...
J
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: leg length question - February 16, 2006 3:43:00 AM
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truthseeker
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With all due respect, I find that LLD is the root cause of many of my patient's pain. And Jason, I have found more evidence for than against LLD as being contributory.
What Randy said is true. The clinical tests are unreliable. However, if you do a sort of meta-analysis you may get a better indication.
When I look at leg length, I look at 10-11 factors.
1. iliac crest height in stance with both knees fully extended
2. ASIS position in supine
3. shoe wear pattern (more pronation on the long side)
4. ability to pronate in stance (pronate more on the long side)
5. Apparent leg length in supine after ASIS position is normalized through unilateral LE traction or inferior glide mobilization of the elevated pelvis
6. hooklying tibial length (bend their knees, put their feet together and see which tibial tubercle is higher)
7. hooklying femoral length (bend their knees put their feet together and see which tibial tubercle is farther away from their head)
8. Do they have chronic pain on one side (especially if it is more than one joint)
9. ASIS to medial malleolus length (least reliable in my opinion)
10. "towel test" place a folded towel under one foot and have the patient shift their weight from side to side and sense the amount of lopsidedness. Then switch the towel. If one side feels more lopsided then it indicates the longer leg.
11. Hip hike test - have the patient stand with both knees extended and hike one foot as high as they can, measure that distance, then do the same on the other side. The side that they can lift the highest is the SHORT side.
Even better is a scanogram or standing AP pelvis Xray with both feet in subtalar neutral and both knees in full extension.
You may, as Duffy said, have obliquity, but that does not necessarily mean that you don't have a LLD. Often, the malleoli will be even even if there is LLD because the long leg with cause the pelvis to move superiorly and the ilium to rotate posteriorly. That is why in my screening that Many of the tests can be done only after the ASISs are level. Pelvic obliquity confounds the already semi-unreliable tests.
Hope that helps
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Re: leg length question - February 16, 2006 1:20:00 PM
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PJM
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Tom Fletcher,
What problem did the patient present with?
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Re: leg length question - February 16, 2006 1:49:00 PM
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tf8560
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From: miami
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Patient is a 67 y/o retired male he is a guest at a wellness spa that I as a PT consult at. He has had some past issues with hip bursitis intermittantly, had a tear/repair of the L Achilles in 1975, and the 4/5 toes on L have decreased sensation when he walks the treadmill (which he does 30-40 mins 5X/wk)
He presents to me for a biomechanical assessment. Not formal PT but more of "why could this be happening and what can I do about it?"
Essentially, when observing his posture ther is a glaring pelvic obliquity higher on the R with a spinal shift to the Left. His R leg has increased genu valgus somewhat.
The PSIS ,Iliac crest and ASIS on the R are all higher on the R.
There are pronated feet bilaterally caused by a rearfoot varus on the R and a rearfoot and forefoot varus on the L.
So, in checking leg lengths, he measures 94.7 cm on L and 93.7 cm on R. (tested supine)
During gait, there is seemingly alot of biomechanical stress to thelateral R hip and low back.
I was just curious as to why seemingly in standing everything is elevated on the R but in supine, the R leg measures shorter.
Of course I have considered that my measurements could be off or my palpation skills are not that great.
But lets say everything on my end was OK My question is...what could be causing this to happen/...Is it a pelvic rotation, femoral anteversion...just want to pick some brains as to what could cause something like this?
Hope this helps
Tom Fletcher,PT
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Re: leg length question - February 16, 2006 5:36:00 PM
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Geert Jeuring
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Hello Tom, as far as I can see your patient uptil now has no problem accept for the decreased sensation. I would be very happy with 67 to have only this kind of trouble and still be able to wald the treadmill as often as he does. If he doesn´t have problem don´t give him one!
Geert
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Re: leg length question - February 16, 2006 6:15:00 PM
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Synergy
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Tom,
Have you tried Deerfield's or the long sitting tests? Are there any restrictions noted with sacral or lumbar AP springing/mobility testing? I imagine if Barrett were here, he would ask how the limb in question appears when he is relaxed in supine. Is this patient in any pain?
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Chris Adams, PT, MPT
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Re: leg length question - February 16, 2006 9:27:00 PM
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Randy Dixon
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Jason,
I thought you used the lumbar manipulation CPR?
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Re: leg length question - February 16, 2006 11:04:00 PM
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nari
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I'm with Geert and Jason on this one. There is no mention of pain,or is that a wrong assumption?
Apart from the academic interest in how the pelvis/Lx spine got like that, which is fair enough, I would leave him alone. There are plenty of people around with marked asymmetry in the lower limbs and they do just fine.
Nari
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Re: leg length question - February 17, 2006 1:38:00 AM
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certMDT
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Randy -
The 3/4 pelvic landmarks are not the standard for the lumbar manipulation anymore. I believe the tests are the 4/5 subjective/objective questions used in the prediction rule in Annals of Internal Medicine. No pelvic landmark palpation there.
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Charles Sheets PT OCS Dip MDT
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Re: leg length question - February 17, 2006 2:53:00 AM
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truthseeker
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Evidently the man thought something was up or he wouldn't have asked. Reduced sensation and hip bursitis must bother him. Who are we to determine what is acceptable dysfunction. It is the patient that decides what is acceptable.
We offer what advice we can and tell the patient whether or not we can reasonably affect it. I have a 64 year old elite track athlete that I treat from time to time. By some of your comments, he should just be happy that he doesn't use a walker.
Tom, the discrepancy between apparent LLD and ASIS to medial malleolus measurements could simply be that the Right pelvis is posteriorly rotated, that confounds the asis to med. mal. measurement
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Re: leg length question - February 17, 2006 5:00:00 AM
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Alex Brenner PT MPT OCS
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[QUOTE]And Jason, I have found more evidence for than against LLD as being contributory.[/QUOTE]Tom Reeves,
Is your evidence anecdotal or are you referring to what you have read in the literature?
From what research I have read on LLI (leg length inequality)I have found that it is all over the place. Some authors say that 5mm difference side to side can lead to biomechanical problems and lower extremity pain, while others say that it takes 10-15mm differences from side to side before symptoms occur. Just curious as to what you have found.
Alex
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Alex Brenner, PT, MPT, OCS
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Re: leg length question - February 17, 2006 6:38:00 AM
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JLS_PT_OCS
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Agree with Charlie and Alex.
Tom, what evidence do you have showing leg length inequality to be a risk factor for any musculoskeletal problems?
I agree, this can theoretically be a problem, but since it does not develop suddenly, I wonder if/how it's related to pain and if so how a heel lift might help.
I used to try correcting this sort of thing all the time (as Tim Flynn says, "I'm a recovering biomechanist."), but found that messing with leg length caused more people to be worse (or new pain in different areas) than better.
I have seen several large trials attempting to correlate physical findings with injury rate. Leg length never seems to come up.
Discrepancies in balance, flexibility, or strength sometimes does. So I guess that's what I'd be more interested in, from a treatment perspective.
If all else fails, then I might try a heel lift or something, what the heck it's biologically plausible. But it's about dead last on my list of things to try.
I think we should be encouraging Tom F to look elsewhere for a solution for this gentleman. Certainly a review of the literature would seem to indicate that, anyway.
J
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Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: leg length question - February 17, 2006 6:45:00 AM
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JLS_PT_OCS
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I found an old conversation I had a while back on the NSCA discussion forum about this, here's an excerpt:
There's really no way to know if these supposed "imbalances" have anything to do with anyone's symptoms. Leg length has never been shown to be the cause of anything in particular. In fact, several studies of back and leg pain that included leg length show it to be an incidental finding. My concern is that we can really convince people they have a problem by "medicalizing" what are essentially normal variants.
Even for such things as shin splints, which you would think would be directly related to overpronation of the 'long' leg, it is not a factor:
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15273181&query_hl=14
Even for those who claim that leg length causes/is related to back pain, it is found to be unrelated:
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15611489&query_hl=20
Even those who try REALLY hard to find such "posture/alignment = pain" evidence have a difficult time, indeed.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15537798&query_hl=22
Pelvic assymetry seems to be found quite often in a random sample of patients (not just musculoskeletal patients, but a somewhat random sample):
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12811280&query_hl=22
I think it's time we put to rest the imbalance=pain myth, it has plagued our profession for far too long as it is...
J
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: leg length question - February 17, 2006 7:55:00 AM
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truthseeker
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I disagree Jason, I have found just as many, if not more that support a relationship between LLD and a multitude of musculoskeletal -itises. I don't have time now to reference them but I will sometime this weekend.
This is a subject that I wrote my final project on for my t-DPT program so be prepared for a boatload of references.
Have a nice weekend
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Re: leg length question - February 17, 2006 7:59:00 AM
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truthseeker
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regarding your first post, sorry, i jumped to the last one, LLD is one of the first things I look at with unilateral symptoms. Why would someone develop assymetrical symptoms? arguably they take just as many steps with the R as they do the L.
If what you say is true, then PT is simply a waste of money. If strength, proprioception, and flexibility are irrelevant, then so are we.
I refuse to believe that the things that I use effectively are not valid. I am not speaking of dogma, I don't recall ever having LLD being pounded into my brain in school or at any course, I have just found it to be incredibly pervasive and usually very consistent with the plausible biomechanical theory that you refer to.
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Re: leg length question - February 17, 2006 8:08:00 AM
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truthseeker
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Alex,
The most powerful evidence that I have come across was a study done by Friberg (Clinical symptoms and Biomechanics of Lumbar Spine and Hip Joint in Leg Length Inequality, Spine, Vol. 8, No. 6, 643-651, 1983)
To summarize, a study of 653 patients with chronic LBP and 359 symptom free conscript soldiers. The study found that beginning at a 5mm LLD, people were much more likely to be in the symptomatic group than the asymptomatic group.
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Re: leg length question - February 17, 2006 4:11:00 PM
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tf8560
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Thanks for all the response. My interest is purely academic. I see this every now and then and just wondering what any possible explanation could be. I want to continouosly improve my clinical skills but frankly after 20 years of orthopedics you realize the more you know, the less you know. A few years out of school you think you know everything, then you realize you dont know sh*t. Ive done 180's on my thinking so many times Im dizzy.
One thing about biomechanics... It seems like no matter what approach you may take in evaluation and treatment ie Mckenzie, maitland, Norwegian etc...to me it all seems like it comes back to anatomy and functional biomechanics.
Sometimes a frustration that I have when I read on these forums are statements like "the research doesnt support this or that" I agree with Tom Reeves and think "then what are we doing? Why is there even a need for our services?" Our patient's want to get better and heck if we help them and they tell their friends and doctors then they're happy, I'm happy , my kid likes his new Ipod, my wife enjoys our nice house and family vacations while the researchers develop back pain from prolonged sitting although there is no scientific evidence to support increrased risk of back pain from prolonged sitting.
Sorry for the rambling, its been a long week. I appreciate all your input and points of view. You guys are my go to guys. Have a great weekend everybody.
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