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Leg Length Discrepancy And Shoe Lifts

Overview

Leg length discrepancies are differences between the lengths of your legs. Not only can the actual difference vary from person to person but also how much it affects daily life. Small discrepancies often go unnoticed and do not need to be treated. Larger differences may affect posture or cause a limp during walking. The discrepancy may be from the upper leg bone (femur) or the lower leg bone (tibia).Leg Length Discrepancy

Causes

The causes of LLD are many, including a previous injury, bone infection, bone diseases (dysplasias), inflammation (arthritis) and neurologic conditions. Previously broken bones may cause LLD by healing in a shortened position, especially if the bone was broken in many pieces (comminuted) or if skin and muscle tissue around the bone were severely injured and exposed (open fracture). Broken bones in children sometimes grow faster for several years after healing, causing the injured bone to become longer. Also, a break in a child?s bone through a growth center (located near the ends of the bone) may cause slower growth, resulting in a shorter extremity. Bone infections that occur in children while they are growing may cause a significant LLD, especially during infancy. Bone diseases may cause LLD, as well; examples are neurofibromatosis, multiple hereditary exostoses and Ollier disease. Inflammation of joints during growth may cause unequal extremity length. One example is juvenile rheumatoid arthritis. Osteoarthritis, the joint degeneration that occurs in adults, very rarely causes a significant LLD.

Symptoms

The effects of limb length discrepancy vary from patient to patient, depending on the cause and size of the difference. Differences of 3 1/2 percent to 4 percent of the total length of the leg (about 4 cm or 1 2/3 inches in an average adult) may cause noticeable abnormalities when walking. These differences may require the patient to exert more effort to walk. There is controversy about the effect of limb length discrepancy on back pain. Some studies show that people with a limb length discrepancy have a greater incidence of low back pain and an increased susceptibility to injuries. Other studies do not support this finding.

Diagnosis

There are several orthopedic tests that are used, but they are rudimentary and have some degree of error. Even using a tape measure with specific anatomic landmarks has its errors. Most leg length differences can be seen with a well trained eye, but I always recommend what is called a scanagram, or a x-ray bone length study (see picture above). This test will give a precise measurement in millimeters of the length difference.

Non Surgical Treatment

The way in which we would treat a LLD would depend on whether we have an anatomical or functional difference. To determine which one is causing the LLD you will need to get your legs measured. This is the easiest way to determine if it is anatomical or functional. With a functional LLD we must first determine the cause and treat the cause. Should the cause be one that is not correctable then we may need to treat the LLD as if it were an anatomical or may have to treat the opposite leg to improve one's gait. As for the anatomical LLD, we may start off with a heel lift only in the shoe and follow up to see if we will need to put the lift full sole on the bottom of the shoe. This is determined by the affects that a heel lift in one shoe may have on that knee. Should the LLD be more than 1/4 inch we usually recommend starting between 1/8 inch to 1/4 inch less than the actual amount and let the body adjust to the change and then raise up to the measured amount later.

Leg Length Discrepancy Insoles

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Surgical Treatment

Surgical treatments vary in complexity. Sometimes the goal of surgery is to stop the growth of the longer limb. Other times, surgeons work to lengthen the shorter limb. Orthopedic surgeons may treat children who have limb-length conditions with one or a combination of these surgical techniques. Bone resection. An operation to remove a section of bone, evening out the limbs in teens or adults who are no longer growing. Epiphyseal stapling. An operation to slow the rate of growth of the longer limb by inserting staples into the growth plate, then removing them when the desired result is achieved. Epiphysiodesis. An operation to slow the rate of growth of the longer limb by creating a permanent bony ridge near the growth plate. Limb lengthening. A procedure (also called distraction osteogenesis or the Ilizarov procedure) that involves attaching an internal or external fixator to a limb and gradually pulling apart bone segments to grow new bone between them. There are several ways your doctor can predict the final LLD, and thus the timing of the surgery. The easiest way is the so-called Australian method, popularised by Dr. Malcolm Menelaus, an Australian orthopedic surgeon. According to this method, growth in girls is estimated to stop at age 14, and in boys at age 16 years. The femur grows at the rate of 10 mm. a year, and the upper tibia at the rate of 6 mm. a year. Using simple arithmetic, one can get a fairly good prediction of future growth. This of course, is an average, and the patient may be an average. To cut down the risk of this, the doctor usually measures leg length using special X-ray technique (called a Scanogram) on three occasions over at least one year duration to estimate growth per year. He may also do an X-ray of the left hand to estimate the bone age (which in some cases may differ from chronological age) by comparing it with an atlas of bone age. In most cases, however, the bone age and chronological age are quite close. Another method of predicting final LLD is by using Anderson and Green?s remaining growth charts. This is a very cumbersome method, but was till the 1970?s, the only method of predicting remaining growth. More recently, however, a much more convenient method of predicting LLD was discovered by Dr. Colin Moseley from Montreal. His technique of using straight line graphs to plot growth of leg lengths is now the most widely used method of predicting leg length discrepancy. Whatever method your doctor uses, over a period of one or two years, once he has a good idea of the final LLD, he can then formulate a plan to equalize leg lengths. Epiphyseodesis is usually done in the last 2 to 3 years of growth, giving a maximum correction of about 5 cm. Leg lengthening can be done at any age, and can give corrections of 5 to10 cm., or more.
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