Leg Length Discrepancy Symptoms
Overview
Large leg length inequalities can be treated by staged lengthenings or by simultaneous ipsilateral femoral and tibial lengthenings. Additionally, lengthenings can be combined with appropriately timed epiphysiodesis in an effort to produce leg length equality. Staged lengthenings are often used for congenital deficiencies such as fibular hemimelia, in which 15 cm or more may be needed to produce leg length equality. We typically plan for the final lengthening to be completed by age 13 or 14 years, and allow at least 3 years between lengthenings. Lengthening of both the tibia and femur simultaneously requires aggressive therapy and treatment of soft tissue contractures. Curran et al[57] reported the need for surgical release of soft tissue contractures in 3 of 8 patients treated with simultaneous ipsilateral femoral and tibial lengthenings. Lengthening over an IM nail can be done in an effort to decrease the amount of time the fixator needs to be worn and to prevent angular malalignment. This technique requires that the patient be skeletally mature and it carries a higher risk of osteomyelitis (up to 15%). Additionally, if premature consolidation occurs, a repeat corticotomy is more difficult.
Causes
From an anatomical stand point, the LLD could have been from hereditary, broken bones, diseases and joint replacements. Functional LLD can be from over pronating, knee deformities, tight calves and hamstrings, weak IT band, curvature in the spine and many other such muscular/skeletal issues.
Symptoms
In addition to the distinctive walk of a person with leg length discrepancy, over time, other deformities may be noted, which help compensate for the condition. Toe walking on the short side to decrease the swaying during gait. The foot will supinate (high arch) on the shorter side. The foot will pronate (flattening of the arch) on the longer side. Excessive pronation leads to hypermobility and instability, resulting in metatarsus primus varus and associated unilateral juvenile hallux valgus (bunion) deformity.
Diagnosis
The only way to decipher between anatomical and functional leg length inequalities (you can have both) is by a physical measurement and series of biomechanical tests. It is actually a simple process and gets to the true cause of some runner?s chronic foot, knee, hip and back pain. After the muscles are tested and the legs are measured it may be necessary to get a special X-ray that measures both of your thighs (Femurs) and legs (Tibias). The X-ray is read by a medical radiologist who provides a report of the actual difference down to the micrometer leaving zero room for error. Once the difference in leg length is known, the solution becomes clear.
Non Surgical Treatment
The non-surgical intervention is mainly usedfor the functional and environmental types of leg length discrepancies. It is also applied to the mild category of limb length inequality. Non-surgical intervention consists of stretching the muscles of the lower extremity. This is individually different, whereby the M. Tensor Fascia latae, the adductors, the hamstring muscles, M. piriformis and M. Iliopsoas are stretched. In this non-surgical intervention belongs also the use of shoe lifts. These shoe lifts consists of either a shoe insert (up to 10-20mm of correction), or building up the sole of the shoe on the shorter leg (up to 30-60mm of correction). This lift therapy should be implemented gradually in small increments. Several studies have examined the treatment of low back pain patients with LLD with shoe lifts. Gofton obtained good results: the patients experienced major or complete pain relief that lasted upon follow-up ranging from 3 to 11 years. Helliwell also observed patients whereby 44% experienced complete pain relief, and 45% had moderate or substantial pain relief. Friberg found that 157 (of 211) patients with LBP, treated with shoe lifts, were symprom-free after a mean follow-up of 18 months.
shoe lifts for uneven legs
Surgical Treatment
Large leg length inequalities can be treated by staged lengthenings or by simultaneous ipsilateral femoral and tibial lengthenings. Additionally, lengthenings can be combined with appropriately timed epiphysiodesis in an effort to produce leg length equality. Staged lengthenings are often used for congenital deficiencies such as fibular hemimelia, in which 15 cm or more may be needed to produce leg length equality. We typically plan for the final lengthening to be completed by age 13 or 14 years, and allow at least 3 years between lengthenings. Lengthening of both the tibia and femur simultaneously requires aggressive therapy and treatment of soft tissue contractures. Curran et al[57] reported the need for surgical release of soft tissue contractures in 3 of 8 patients treated with simultaneous ipsilateral femoral and tibial lengthenings. Lengthening over an IM nail can be done in an effort to decrease the amount of time the fixator needs to be worn and to prevent angular malalignment. This technique requires that the patient be skeletally mature and it carries a higher risk of osteomyelitis (up to 15%). Additionally, if premature consolidation occurs, a repeat corticotomy is more difficult.
Large leg length inequalities can be treated by staged lengthenings or by simultaneous ipsilateral femoral and tibial lengthenings. Additionally, lengthenings can be combined with appropriately timed epiphysiodesis in an effort to produce leg length equality. Staged lengthenings are often used for congenital deficiencies such as fibular hemimelia, in which 15 cm or more may be needed to produce leg length equality. We typically plan for the final lengthening to be completed by age 13 or 14 years, and allow at least 3 years between lengthenings. Lengthening of both the tibia and femur simultaneously requires aggressive therapy and treatment of soft tissue contractures. Curran et al[57] reported the need for surgical release of soft tissue contractures in 3 of 8 patients treated with simultaneous ipsilateral femoral and tibial lengthenings. Lengthening over an IM nail can be done in an effort to decrease the amount of time the fixator needs to be worn and to prevent angular malalignment. This technique requires that the patient be skeletally mature and it carries a higher risk of osteomyelitis (up to 15%). Additionally, if premature consolidation occurs, a repeat corticotomy is more difficult.
Causes
From an anatomical stand point, the LLD could have been from hereditary, broken bones, diseases and joint replacements. Functional LLD can be from over pronating, knee deformities, tight calves and hamstrings, weak IT band, curvature in the spine and many other such muscular/skeletal issues.
Symptoms
In addition to the distinctive walk of a person with leg length discrepancy, over time, other deformities may be noted, which help compensate for the condition. Toe walking on the short side to decrease the swaying during gait. The foot will supinate (high arch) on the shorter side. The foot will pronate (flattening of the arch) on the longer side. Excessive pronation leads to hypermobility and instability, resulting in metatarsus primus varus and associated unilateral juvenile hallux valgus (bunion) deformity.
Diagnosis
The only way to decipher between anatomical and functional leg length inequalities (you can have both) is by a physical measurement and series of biomechanical tests. It is actually a simple process and gets to the true cause of some runner?s chronic foot, knee, hip and back pain. After the muscles are tested and the legs are measured it may be necessary to get a special X-ray that measures both of your thighs (Femurs) and legs (Tibias). The X-ray is read by a medical radiologist who provides a report of the actual difference down to the micrometer leaving zero room for error. Once the difference in leg length is known, the solution becomes clear.
Non Surgical Treatment
The non-surgical intervention is mainly usedfor the functional and environmental types of leg length discrepancies. It is also applied to the mild category of limb length inequality. Non-surgical intervention consists of stretching the muscles of the lower extremity. This is individually different, whereby the M. Tensor Fascia latae, the adductors, the hamstring muscles, M. piriformis and M. Iliopsoas are stretched. In this non-surgical intervention belongs also the use of shoe lifts. These shoe lifts consists of either a shoe insert (up to 10-20mm of correction), or building up the sole of the shoe on the shorter leg (up to 30-60mm of correction). This lift therapy should be implemented gradually in small increments. Several studies have examined the treatment of low back pain patients with LLD with shoe lifts. Gofton obtained good results: the patients experienced major or complete pain relief that lasted upon follow-up ranging from 3 to 11 years. Helliwell also observed patients whereby 44% experienced complete pain relief, and 45% had moderate or substantial pain relief. Friberg found that 157 (of 211) patients with LBP, treated with shoe lifts, were symprom-free after a mean follow-up of 18 months.
shoe lifts for uneven legs
Surgical Treatment
Large leg length inequalities can be treated by staged lengthenings or by simultaneous ipsilateral femoral and tibial lengthenings. Additionally, lengthenings can be combined with appropriately timed epiphysiodesis in an effort to produce leg length equality. Staged lengthenings are often used for congenital deficiencies such as fibular hemimelia, in which 15 cm or more may be needed to produce leg length equality. We typically plan for the final lengthening to be completed by age 13 or 14 years, and allow at least 3 years between lengthenings. Lengthening of both the tibia and femur simultaneously requires aggressive therapy and treatment of soft tissue contractures. Curran et al[57] reported the need for surgical release of soft tissue contractures in 3 of 8 patients treated with simultaneous ipsilateral femoral and tibial lengthenings. Lengthening over an IM nail can be done in an effort to decrease the amount of time the fixator needs to be worn and to prevent angular malalignment. This technique requires that the patient be skeletally mature and it carries a higher risk of osteomyelitis (up to 15%). Additionally, if premature consolidation occurs, a repeat corticotomy is more difficult.
