Kymberly Matarese

Solving Feet Conditions

Leg Length Discrepancy And Running

Overview

Some people have an ?apparent? LLD which may make the affected leg seem longer than the other leg. There are several factors that can contribute to this feeling. Most commonly, contractures or shortening of the muscles surrounding the hip joint and pelvis make the involved leg feel longer, even when both legs are really the same length. Additionally, contractures of the muscles around the lower back from spinal disorders (i.e. arthritis, spinal stenosis), curvatures of the spine from scoliosis, and deformities of the knee or ankle joint can make one leg seem longer or shorter. In the general public, some people have an ?apparent LLD? as long as one half inch but usually don?t notice it because the LLD occurs over time. A ?true? LLD is where one leg is actually longer than the other. Patients can have unequal leg lengths of 1/4? to 1/2? and never feel it too! You can also have combinations of ?True? and ?Apparent? LLDs. During total hip replacement surgery, the surgeon may ?lengthen? the involved leg by stretching the muscles and ligaments that were contracted, as well as by restoring the joint space that had become narrowed from the arthritis. This is usually a necessary part of the surgery because it also provides stability to the new hip joint. Your surgeon takes measurements of your leg lengths on x-ray prior to surgery. Your surgeon always aims for equal leg lengths if at all possible and measures the length of your legs before and during surgery in order to achieve this goal. Occasionally, surgeons may need to lengthen the operable leg to help improve stability and prevent dislocations as well improve the muscle function around the hip.Leg Length Discrepancy

Causes

A number of causes may lead to leg length discrepancy in children. Differences in leg length frequently follow fractures in the lower extremities in children due to over or under stimulation of the growth plates in the broken leg. Leg length discrepancy may also be caused by a congenital abnormality associated with a condition called hemihypertrophy. Or it may result from neuromuscular diseases such as polio and cerebral palsy. Many times, no cause can be identified. A small leg length discrepancy of a quarter of an inch or less is quite common in the general population and of no clinical significance. Larger leg length discrepancies become more significant. The long-term consequences of a short leg may include knee pain, back pain, and abnormal gait or limp.

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

Asymmetry is a clue that a LLD is present. The center of gravity will shift to the short limb side and patients will try to compensate, displaying indications such as pelvic tilt, lumbar scoliosis, knee flexion, or unilateral foot pronation. Asking simple questions such as, "Do you favor one leg over the other?" or, "Do you find it uncomfortable to stand?" may also provide some valuable information. Performing a gait analysis will yield some clues as to how the patient compensates during ambulation. Using plantar pressure plates can indicate load pressure differences between the feet. It is helpful if the gait analysis can be video-recorded and played back in slow motion to catch the subtle aspects of movement.

Non Surgical Treatment

Internal heel lifts: Putting a simple heel lift inside the shoe or onto a foot orthotic has the advantage of being transferable to many pairs of shoes. It is also aesthetically more pleasing as the lift remains hidden from view. However, there is a limit as to how high the lift can be before affecting shoe fit. Dress shoes will usually only accommodate small lifts (1/8"1/4") before the heel starts to piston out of the shoe. Sneakers and workboots may allow higher lifts, e.g., up to 1/2", before heel slippage problems arise. External heel lifts: If a lift of greater than 1/2" is required, you should consider adding to the outsole of the shoe. In this way, the shoe fit remains good. Although some patients may worry about the cosmetics of the shoe, it does ensure better overall function. Nowadays with the development of synthetic foams and crepes, such lifts do not have to be as heavy as the cork buildups of the past. External buildups are not transferable and they will wear down over time, so the patient will need to be vigilant in having them repaired. On ladies' high-heel shoes, it may be possible to lower one heel and thereby correct the imbalance.

LLL Shoe Insoles

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Surgical Treatment

Surgical operations to equalize leg lengths include the following. Shortening the longer leg. This is usually done if growth is already complete, and the patient is tall enough that losing an inch is not a problem. Slowing or stopping the growth of the longer leg. Growth of the lower limbs take place mainly in the epiphyseal plates (growth plates) of the lower femur and upper tibia and fibula. Stapling the growth plates in a child for a few years theoretically will stop growth for the period, and when the staples were removed, growth was supposed to resume. This procedure was quite popular till it was found that the amount of growth retarded was not certain, and when the staples where removed, the bone failed to resume its growth. Hence epiphyseal stapling has now been abandoned for the more reliable Epiphyseodesis. By use of modern fluoroscopic equipment, the surgeon can visualize the growth plate, and by making small incisions and using multiple drillings, the growth plate of the lower femur and/or upper tibia and fibula can be ablated. Since growth is stopped permanently by this procedure, the timing of the operation is crucial. This is probably the most commonly done procedure for correcting leg length discrepancy. But there is one limitation. The maximum amount of discrepancy that can be corrected by Epiphyseodesis is 5 cm. Lengthening the short leg. Various procedures have been done over the years to effect this result. External fixation devices are usually needed to hold the bone that is being lengthened. In the past, the bone to be lengthened was cut, and using the external fixation device, the leg was stretched out gradually over weeks. A gap in the bone was thus created, and a second operation was needed to place a bone block in the gap for stability and induce healing as a graft. More recently, a new technique called callotasis is being use. The bone to be lengthened is not cut completely, only partially and called a corticotomy. The bone is then distracted over an external device (usually an Ilizarov or Orthofix apparatus) very slowly so that bone healing is proceeding as the lengthening is being done. This avoids the need for a second procedure to insert bone graft. The procedure involved in leg lengthening is complicated, and fraught with risks. Theoretically, there is no limit to how much lengthening one can obtain, although the more ambitious one is, the higher the complication rate.
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