Functional Leg Length Inequality Research Articles

Scoliosis and Lower Limb Inequality: To Lift or Not to Lift, That Is the Question.

In subjects with scoliotic alterations of the spine, asymmetrical lengths of the lower limbs are frequently observed, a condition commonly referred to as leg length inequality (LLI) or discrepancy (LLD). This asymmetry can induce pelvic misalignments, manifested by an asymmetric height of the iliac crests, and consequently an alteration of the spine's axis. Although correcting this discrepancy might appear to be a straightforward solution, further investigation may reveal other indications. The purpose of this article is to aid clinicians confronted with the decision of whether to compensate for an LLI in individuals with scoliosis, encompassing both adolescents and adults. It presents a literature review on the incidence of LLIs in the general population, distinguishing between structural LLI (sLLI) and functional LLI (fLLI) types of LLIs, and quantifying their magnitude with clinical and instrumental evaluation. Additionally, it links these two types of LLIs to the type of scoliosis (structural or functional). From a clinical perspective, it also examines the compensatory mechanisms employed by the pelvis in the presence of structural or functional LLIs in order to draw useful indications for therapeutic decisions. Moreover, it proposes an additional evaluation parameter in the coronal plane, namely the central sacral vertical line (CSVL), to aid in the decision-making process regarding LLI compensation. Although this parameter has been documented in the literature, it has been little associated with LLIs. The findings indicate that scoliotic discrepancies should be compensated (conservatively or surgically) only when the imbalance of the femoral heads is on the same side as the imbalance of the sacrum and the iliac crests; this corrective action should result in a reduction of the overhang in the coronal plane.

Leg length inequality and its relationship with injuries incidence of young basketball players: an observational study.

Introduction: The leg length inequality (LLI) creates postural changes collaborating with the emergence of functional limitations and musculoskeletal disorders. In a sport like basketball inequality of the lower limbs may be added to the demands of the sport and generate an increase in the incidence of injuries. Objective: The aim of this study was to identify young basketball players from with structural or functional LLI and its influence in injury incidence in a period of 6 months. Methods: 18 players were followed with an average age of 14.50 ± 1.86 of a basketball team from the city of Sorocaba for a period of 6 months. At the beginning and end of that period were applied tests from the Morbidity Survey Report modified for basketball to obtain data such as physical characteristics, training time, incidence of injuries, quantitative and qualitative measurement of the length of the lower limbs. Results: 72.2% of players had LLI and 50% had some kind of injury during this period, among the most common, sprains and muscle strains. Conclusions: There was a high rate of players with LLI and a positive relationship between this inequality with the incidence of injury.

The Effects of Manual Therapy on Lower Extremity Alignment in Pelvic Malalignment

The purpose of this study was to analyze the effects of manual therapy on lower extremity alignment in pelvic malalignment. The subjects were 20 adults with pelvic malalignment. They were divided into two groups: manual therapy group (n=10) and stretching exercise group (n=10). Each group performed the intervention two times per week for 4 weeks. The lower extremity alignment was measured by pelvic deviation, functional leg length inequality, and plantar pressure distribution, which were measured between pre- and post-test. In the result of pelvic deviation, there was a significant difference between the pre- and post-test of the manual therapy group and stretching exercise group. In the result of the functional leg length inequality, there was a significant difference between the pre- and post- test of the manual therapy group. In the result of plantar pressure distribution, there was a significant difference between the pre- and post- test of the manual therapy group. These findings suggest manual therapy improves the pelvic deviation, functional leg length inequality, and plantar pressure distribution in the pelvic malalignment.

Abstract: Hip Asymmetry: Implications in Abdominal Contour Surgery

INTRODUCTION: Asymmetry is a known phenomenon in the human body and has been analyzed in multiple areas including the face, breasts, and trunk.1–3 Nonetheless, asymmetry of the hips and its implication in body contouring procedures has not yet been reported. Hip asymmetry is common in the general population4 and may account for uneven abdominoplasty scar and the apparent discrepancies in volume following liposuction of the hips and flanks. The ASIS or iliac crests are often used as landmarks for incision and umbilicus placement. It is crucial to analyze the area preoperatively for proper operative planning and discuss the presence of asymmetry with patients. The goal of this study was to determine the presence of hip asymmetry in healthy females presenting for abdominal contour surgery. METHODS: Analysis of preoperative standardized photographs of 100 healthy female patients presenting for abdominoplasty was performed by three independent plastic surgeons. They were asked to evaluate for hip asymmetry, and when present, determined which side was higher. Adobe Photoshop CS2 was also used to objectively measure hip asymmetry. Patient demographics were collected. Patients were females with no known history of hip abnormalities. Age range 17–64 (average 43.6). BMI 16–47 (average 23.6). RESULTS: At least 2 plastic surgeons found asymmetries in 90% of patients. The surgeons noted discrepancies in hip height in 93%, 82% and 63% of patients, averaging 79%. The objective data showed that 93% of patients have hip asymmetry, and the left hip was higher in the majority of patients, 58%. CONCLUSION: The results showed that the majority of patients who present for abdominal contour surgery have asymmetric hips. Patients are usually unaware of the unevenness of their own hips, however, they often notice postoperative discrepancies in scar height after abdominoplasty or volume differences after liposuction. Hip asymmetry has become apparent to the senior author, and as a result he utilizes photographic grids as a tool to help identify asymmetries during the preoperative consultation. In the operating room, a crisscross suture technique is used to determine ideal scar placement.5 Evaluation of preoperative asymmetries is a critical part of the consultation and should be adopted by plastic surgeons performing abdominal contour surgeries. Detailed hip analysis aids in the management of patient expectations, helps with umbilicus/scar placement and mitigates medical-legal issues. Reference Citations: 1. Rohrich RJ, Hartley W, Brown S. Incidence of breast and chest wall asymmetry in breast augmentation: a retrospective analysis of 100 patients. Plast Reconstr Surg. 2003 Apr 1;111(4):1513–9; 2. Aston SJ, Smith DM. Taking it on the chin: recognizing and accounting for lower face asymmetry in chin augmentation and genioplasty. Plast Reconstr Surg. 2015 Jun;135(6):1591–5. 3. Rohrich RJ, Sorokin ES, Brown SA, Gibby DL. Is the umbilicus truly midline? Clinical and medicolegal implications. Plast Reconstr Surg. 2003 Jul;112(1):259–63; discussion 264–5. 4. Anatomic and functional leg-length inequality: a review and recommendation for clinical decision-making. Part I, anatomic leg-length inequality: prevalence, magnitude, effects and clinical significance. Knutson GA1. Chiropr Osteopat. 2005 Jul 20;13:11. 5. Matarasso A. Traditional abdominoplasty. Clin Plast Surg. 2010 Jul;37(3):415–37.

Leg length inequality and its relationship with injuries incidence of young basketball players: an observational study

Background: The leg length inequality (LLI) creates postural changes collaborating with the emergence of functional limitations and musculoskeletal disorders. In a sport like basketball inequality of the lower limbs may be added to the demands of the sport and generate an increase in the incidence of injuries. The aim of this study was to identify young basketball players from with structural or functional LLI and its influence in injury incidence in a period of 6 months. Methods: 18 players were followed with an average age of 14.50 ± 1.86 of a basketball team from the city of Sorocaba for a period of 6 months. At the beginning and end of that period were applied tests from the Morbidity Survey Report modified for basketball to obtain data such as physical characteristics, training time, incidence of injuries, quantitative and qualitative measurement of the length of the lower limbs. Results: 72.2% of players had LLI and 50% had some kind of injury during this period, among the most common, sprains and muscle strains. Conclusions: There was a high rate of players with LLI and a positive relationship between this inequality with the incidence of injury.

The influence of pelvic adjustment on vertical jump height in female university students with functional leg length inequality.

[Purpose] This study aimed to investigate the effect of pelvic adjustment on vertical jump height (VJH) in female university students with functional leg length inequality (FLLI). [Subjects] Thirty female university students with FLLI were divided into a pelvic adjustment group (n = 15) and a stretching (control) group (n = 15). [Methods] VJH was measured using an OptoGait. [Results] After the intervention, jump height improved significantly compared with the pre-intervention height only in the pelvic adjustment group, while FLLI showed statistically significant improvement in both groups. [Conclusion] Pelvic adjustment as per the Gonstead method can be applied as a method of reducing FLLI and increasing VJH.

Phemister Epiphysiodesis in Leg Length Inequality Treatment - Evaluative Outcome analysis

The aim of this study was to evaluate the efficacy of Phemister epiphysiodesis for leg length inequality (LLI) treatment in comparison with epiphysiodesis techniques currently in use and to determine factors that may influence outcomes. Nineteen girls and sixteen boys with a mean skeletal age of 12.2 years and a mean functional LLI of 3.8 cm at the time of surgery were enrolled. Data were retrieved from hospital records and bone ages were determined using standard atlases. Mean follow-up duration was 7 years. Good results (final LLI < 1.5 cm) were obtained in 74.3% of patients, fair results (final LLI 1.6-2.0 cm.) were seen in 5.7% and poor results (final LLI > 2 cm) were seen in 20%. A mean clinical LLI of 1.7 cm was the treatment outcome for the entire group. Valgus deformity of 7°, 10° and 13° occurred in three patients. 1. Phemister epiphysiodesis performed for LLI produced the desired correction but was associated with a risk of over- or undercorrection and frontal plane deformity due to inadequate physeal closure. 2. These complications are typical for any kind of epiphysiodesis.

Pilot study of the impact sacroiliac joint manipulation has on walking kinematics using motion analysis technology

ObjectiveThe purpose of this study was to evaluate the feasibility of engaging in a series of larger studies measuring the effect of sacroiliac joint manipulation on walking kinematics using motion analysis technology. MethodsTwelve college students engaged in a baseline 90-second gait analysis at 1.5 mph using infrared VICON cameras. Following this, they underwent a prone heel comparison test for functional leg length inequality. Upon examination, participants were then classified as follows: left short leg, right short leg, or no short leg. Participants in each of the 2 short leg branches of this study were then randomized to receive either chiropractic manipulative therapy to the posterior superior iliac spine on the short limb side or no manipulation. Recruitment was ongoing for this pilot study until 1 participant was recruited in each of the following 5 comparative study groups: left short leg—manipulation, left short leg—no manipulation (control 1), right short leg—manipulation, right short leg—no manipulation (control 2), and no short leg (control 3). All participants then underwent another 90-second gait analysis. Data were then grouped and submitted to a blinded biomechanist to determine if there were any unique biomechanical differences between the groups. ResultsNo statistically significant differences were measured because of this being a pilot study with a small sample size. ConclusionsThe data from this study indicate that a series of larger studies with this design is feasible.

기능적인 하지길이 차이에 따른 족저압 변화가 족부체열에 미치는 영향

Purpose : The purpose of the research was to analyze foot pressure, foot temperature, and correlation between foot pressure and foot temperature to grasp impact on foot pressure and body temperature distribution chart depending on functional difference of leg length. Method : After measuring leg length, put 15 students whose functional difference of leg length was over 10mm to difference group and 15 students whose functional difference of leg length was under 5mm to normal group and categorize soles of foot into 6 sections of hallux head, 1st metatarsal head, 2-4 metatarsal head, 5 metatarsal head, lateral heel, and then measure by foot pressure analyzer to analyze characteristic of pressure distribution and classify into front of the lower leg, back of the lower leg, soles of foot and measure by body temperature analyzer to analyze by checking body temperature. Result : Weight difference depending on foot pressure and body temperature was bigger when functional difference of leg length was bigger, and it could be confirmed that foot pressure and body temperature of short leg side were higher than those of short leg side. Thus, if difference exists in leg length, weight load on short leg side increases which results in higher foot pressure and body temperature, therefore enabling an assumption that mechanical problem will occur in short leg. Conclusion : When functional leg length inequality, weight bearing and pressure was getting high as a result, temperature was getting high in short leg.

A Review of Symptomatic Leg Length Inequality following Total Hip Arthroplasty

Leg length inequality (LLI) following total hip replacement is a complication which features increasingly in the recent literature. The definition of LLI is complicated by lack of consensus regarding radiological measurement, clinical measurement and the incomplete relationship between LLI and associated symptoms. This paper reviews 79 reports relating to LLI post hip replacement, detailing definitions and classification and highlighting patient populations prone to symptomatic LLI. While there is no universal definition of LLI, there is a broad consensus that less than 10 mm of difference on AP view plain radiographs is clinically acceptable. There are few techniques described that consistently produce a postoperative LLI of less than this magnitude. Where postoperative LLI exists, lengthening appears to cause more problems than shortening. In cases of mild LLI, non-surgical management produces adequate outcomes in the majority of cases, with functional LLI cases doing better than those with true LLI. Operative correction is effective in half of cases, even where nerve palsy is present, and remains an important option of last resort. Poor outcomes in patients with LLI may be minimised if individuals at risk are identified and counselled appropriately.

The Influence of Pelvic Adjustment on Functional Leg Length Inequality and Foot Pressure

[Purpose] This study was conducted to evaluate the influence of pelvic adjustment on functional leg length inequality (FLLI) and foot pressure. [Subjects] The study subjects were 40 adults who were healthy but had FLLI of at least 10 mm. Subjects were randomly assigned to two groups, an experimental group (n=20) and a control group (n=20). [Methods] The subjects of the experimental group underwent pelvic adjustment 3 times a week for 4 weeks. A tape- measure was used to measure FLLI, and F-Scan was used to measure the heel pressure difference (HPD) and the 1st metatarsal pressur difference (MPD). For all subjects, the lengths of both legs were measured before the intervention, and at 2 weeks and 4 weeks after the intervention was started. [Results] Pelvic adjustment was effective at reducing FLLI , HPD and 1st MPD. HPD and the 1st MPD were reduced in proportion to the reduction in FLLI . FLLI was effectively reduced after 2 weeks of intervention and the reduction was more remarkable after 4 weeks. [Conclusion] We presume that pelvic adjustment reduces FLLI and foot pressure difference and that foot pressure difference is reduced in proportion to the reduction in FLLI. In conclusion, we consider that pelvic adjustment is suitable for reducing FLLI as well as foot pressure difference.

Mathematical modeling of the socalled Allis test: a field study in orthopedic confusion

BackgroundChiropractors use a variety of supine and prone leg checking procedures. Some, including the Allis test, purport to distinguish anatomic from functional leg length inequality. Although the reliability and to a lesser extent the validity of some leg checking procedures has been assessed, little is known on the Allis test. The present study mathematically models the test under a variety of hypothetical clinical conditions. In our search for historical and clinical information on the Allis test, nomenclatural and procedural issues became apparent.MethodsThe test is performed with the subject carefully positioned in the supine position, with the head, pelvis, and feet centered on the table. After an assessment for anatomic leg length inequality, the knees are flexed to approximately 90°. The examiner then sights the short leg side knee sequentially from both the foot and side of the table, noting its relative locations: both its height from the table and Y axis position. The traditional interpretation of the Allis test is that a low knee identifies a short tibia and a cephalad knee a short femur. Assuming arbitrary lengths and a tibio/femoral ratio of 1/1.26, and a hip to foot distance that placed the knee near 90°, we trigonometrically calculated changes in the location of the right knee that would result from hypothetical reductions in tibial and femoral length. We also modeled changes in the tibio/femoral ratio that did not change overall leg length, and also a change in hip location.ResultsThe knee altitude diminishes with either femoral or tibial length reduction. The knee shifts cephalad when the femoral length is reduced, and caudally when the tibial length is reduced. Changes in the femur/tibia ratio also influence knee position, as does cephalad shifting of the hip.ConclusionThe original Allis (aka Galeazzi) test was developed to identify gross hip deformity in pediatric patients. The extension of this test to adults suspected of having anatomical leg length inequality is problematic, and needs refinement at the least. Our modeling questions whether this test can accurately identify aLLI, let alone distinguish a short tibia from a short femur.

Anatomic and functional leg-length inequality: A review and recommendation for clinical decision-making. Part II, the functional or unloaded leg-length asymmetry

BackgroundPart II of this review examines the functional "short leg" or unloaded leg length alignment asymmetry, including the relationship between an anatomic and functional leg-length inequality. Based on the reviewed evidence, an outline for clinical decision making regarding functional and anatomic leg-length inequality will be provided.MethodsOnline databases: Medline, CINAHL and Mantis. Plus library searches for the time frame of 1970–2005 were done using the term "leg-length inequality".Results and DiscussionThe evidence suggests that an unloaded leg-length asymmetry is a different phenomenon than an anatomic leg-length inequality, and may be due to suprapelvic muscle hypertonicity. Anatomic leg-length inequality and unloaded functional or leg-length alignment asymmetry may interact in a loaded (standing) posture, but not in an unloaded (prone/supine) posture.ConclusionThe unloaded, functional leg-length alignment asymmetry is a likely phenomenon, although more research regarding reliability of the measurement procedure and validity relative to spinal dysfunction is needed. Functional leg-length alignment asymmetry should be eliminated before any necessary treatment of anatomic LLI.

Anatomic and functional leg-length inequality: A review and recommendation for clinical decision-making. Part I, anatomic leg-length inequality: prevalence, magnitude, effects and clinical significance

BackgroundLeg-length inequality is most often divided into two groups: anatomic and functional. Part I of this review analyses data collected on anatomic leg-length inequality relative to prevalence, magnitude, effects and clinical significance. Part II examines the functional "short leg" including anatomic-functional relationships, and provides an outline for clinical decision-making.MethodsOnline database – Medline, CINAHL and MANTIS – and library searches for the time frame of 1970–2005 were done using the term "leg-length inequality".Results and DiscussionUsing data on leg-length inequality obtained by accurate and reliable x-ray methods, the prevalence of anatomic inequality was found to be 90%, the mean magnitude of anatomic inequality was 5.2 mm (SD 4.1). The evidence suggests that, for most people, anatomic leg-length inequality does not appear to be clinically significant until the magnitude reaches ~ 20 mm (~3/4").ConclusionAnatomic leg-length inequality is near universal, but the average magnitude is small and not likely to be clinically significant.

Reliability and validity of rigid lift and pelvic leveling device method in assessing functional leg length inequality.

Clinicians commonly include an assessment of leg length inequality (LLI) as a component of a musculoskeletal examination. Little research is available, however, documenting reliability and validity of clinical methods for assessing LLI. The purpose of this study was to determine the reliability and validity of assessing functional LLI using a pelvic leveling device. Subjects were 19 women and 13 men between the ages of 18 and 55 who reported having a diagnosed or suspected LLI. Clinical determination of LLI was made by placing rigid lifts under the suspected shorter lower extremity until the leveling device indicated that the iliac crests were level. This measurement was made twice by one investigator and once by a second investigator. Standing radiographic measurements of LLI using rigid lifts were used to establish validity of the clinical method. Intraclass correlation coefficients [ICC(2,1)] and absolute difference values were computed to assess reliability and validity. The mean absolute difference between the two clinical measurements of LLI by the same investigator was 0.29 cm (+/- 0.52), with an ICC = 0.84. The mean absolute difference between clinical measurements of LLI by the two investigators was 0.49 cm (+/- 0.46), with an ICC = 0.77. The ICC and mean absolute difference reflecting agreement between radiographic measurements and clinical measurements of LLI was 0.64 and 0.58 cm (+/- 0.58), respectively, for one investigator and 0.76 and 0.55 cm (+/- 0.37), respectively, for the second investigator. The intratester reliability, intertester reliability, and validity assessments included instances in which paired observations disagreed regarding which lower extremity was the shorter lower extremity. Factors that may be associated with the unacceptable reliability and validity of the clinical assessment method include asymmetric positioning of the ilia, body composition of the patient, and design of the clinical instrument. The authors discuss clinical implications related to assessment of LLI.

Functional Leg Length Inequality Following THA

Functional Leg Length Inequality Following THA

Functional leg-length inequality following total hip arthroplasty

A consecutive series of 100 patients undergoing primary total hip arthroplasty were assessed for functional leg-length inequality (FLLI). In addition, the medical records of all patients treated for FLLI by the senior author (C.S.R.) in the past 15 years was reviewed. A questionnaire was distributed to the members of The Hip Society specifically to query the prevalence, etiology, and management of FLLI. Fourteen percent of patients were noted to have pelvic obliquity and FLLI 1 month after surgery. All had resolution of the symptoms by 6 months after surgery. Nine patients have been identified over the past 15 years with persistent FLLI. Among the causes suggested by respondents to the questionnaire are tightness of periarticular soft tissues with resultant pelvic obliquity and degenerative conditions of the spine with contracture. Methods of treatment and prevention are discussed.

Methodology for restoring functional leg length in revision total hip arthroplasty

Functional leg length was measured in 30 patients before and after revision total hip arthroplasty. The authors emphasize the importance of preoperative planning, and determination of adjustment of the leg length should be aimed at a balanced attitude of the entire pelvis and lower back. In order to correct the length inequality, the leg was lengthened in the revision in 25 cases, left unchanged in 2 cases, and shortened in 3 cases. The mean functional leg-length inequality was 13 mm before operation and 4 mm after operation. The mean radiographic inequality between the upper surfaces of the iliac crests was 13 mm before operation and 9 mm after operation. The side operated was more often functionally shorter than the other side before operation, and longer than the other side after operation. The authors emphasize the importance of functional leg length in revision hip arthroplasty. The functional length discrepancy can be corrected in revision, but there appears to be a risk of overlengthening.