Lifts for Short Leg Syndrome

Short Leg: Heel Lifts vs Full Length Lifts

 

The 8 common biomechanical categories used in the treatment of injuries are:

1.             Short Leg Syndrome (discussed here)

2.             Poor Shock Absorption

3.             Excessive Pronation

4.             Excessive Supination

5.             Tight Muscles

6.             Weak Muscles

7.             Miscellaneous Gait Abnormalities (ie Drop Foot, Polio, etc)

8.             Combinations of the Above

 

Since we are going to talk about lifts I thought I would give your spirit a lift first. I wish to express my gratitude to photographer/artist Robert Stallard for this breathe-taking view of San Francisco Golden Gate Bridge near sunset on one of our cold, foggy San Franciscan summer days.

 

 

 

The heel lift is the main method used in treatment of short legs and their problems. But, heel lifts are inherently unstable, and easy for patients to compensate for by simply bending the knee on that side. Once you bend the knee on the side you are trying to lift, you have lost the correction. Heel lifts, therefore, can make the foot/ankle more unstable by lifting up in the shoe more, and they can make the knee more unstable by producing greater knee bend/flexion.

Doctors are always placing the lift onto an orthotic device. This is not advisable. First of all, it makes it hard to decide what symptoms are related to the lift, and what symptoms are related to the orthotic device, when pain increases with orthotic devices. Secondly, because of the instability mentioned above, the heel lift may negate the added stability produced by the orthotic device. Golden Rule of Foot: Keep orthotic devices and lifts for short legs totally separate.

 

 

 

 

Full length lifts in the treatment of short leg syndrome are much more stable and produce better symptom relief. Full length lifts need to lift the heel and forefoot (metatarsal area), normally equally when 1/4 inch or less, then taper at the toes. This full length lift above, designed around a shoe insert template for W9 (women's size 9), is actually cut off at the toes to give room in the toe box area. Imagine all of the athletes who run up on the ball of their feet, but need a lift for their short leg. How could a heel lift do anything positive for their biomechanics and symptoms? At least 50% of the time most athletes are on the ball of the foot while exercising, so a full length lift seems ideal for the athletic population. Now athletes on the other hand would love the lift to be only under the heel for convenience and shoe fit, but it is so much better to have it full length for their biomechanics.

 

 

 

If you use full length lifts, make sure you make cuts into the material by the ball of the foot to help with smooth push off. This is especially true as you get up over 1/4 inch in lift. Material under the ball of the foot can make it hard to move through, so cutting to increase bend, along with beveling and thinning slightly can all help. You can also see that the front edge of the full length lift is bevelled or skived to make a smoother transition forward. When I am using full length lifts, I always try to get feedback from the athletes on how easy it is to move through their foot. In podiatry talk, I am trying to avoid Sagittal Plane Blockade.

 

 

You can see the cuts do not go through the sides to help with its durability, but they do go completely through from top to bottom.

 

 

Not really demonstrated well, but these cuts do improve the bend of the foot making it easier to move gently through to the toes. When you use lifts over 1/4 inch, it is common to use a greater transition from heel to toe. Typically for 3/8 inch lifts I will use 3/8 inch in the heel, 1/4 inch in the forefoot/metatarsals, again tapered to the toes as one example of this progression. 

Short Leg Syndrome: Heel Lifts vs Full Length Lifts

Here are some of the comments on my You Tube channel on the Negative Impact of Heel Lifts Alone for treating a short leg. Make sure you are stable and feeling better functionally and symptomatically in whatever the type of lift you have. The goal of this post is to not have you blindly put a lift in if the provider tells you, but listen to how your body reacts to it. 

Comment #1

Never ever take advice off the Internet,such as this.

See an expert and get advice.

Heel lifts worked like s miracle for my short leg and the pain it caused,one leg was only a tiny fraction shorter,does that mean it isn't reason enough to be considered a rare case?

Always seek a good expert.

Comment #2

I have to agree with the other post about not being an expert in their field. Heel lifts WHEN used properly have reduced chronic pain. 1) That heel lift is way too much for that person. 2) If you bend your knee to offset the heel lift........IT'S THE WRONG SIZE This is some of the misinformation that is out there....be careful and do your homework folks. 3) Plus she has Morton's toe from the looks of her feet...that's why she's unstable when trying to stand.

Comment #3

mine was 5mm and it almost killed me.

Comment #4

I've worn a lift in my left shoe for nearly 30 years. Personally, I prefer the full-foot lift as opposed to the heel-only lift. The heel-only lift causes additional pressure on my toes and the ball of my foot. I still use heel-only lifts when a full-foot lift isn't available for the specific shoe that I'm wearing.

Lifts for Short Leg

Dr. Blake-

I saw your posting regarding athletes and how if they have a leg length discrepency they should consider a full length foot lift as opposed to a heel lift.  I would like to know where I can buy a full length foot lift that is as flexible as the one you show in your pictures.  I have recently purchased one of the Clearly Adjustable full length lifts, but find it to be extremely ridgid.  I think a more fleixble lift would be more practical for being on my feet a lot.  I used to enjoy working several times a week until a recent possible hip injury.  I was diagnosed with a leg length difference of at least 6mm and have used a heel lift for several years.  I am hoping that trying a full length lift will possibly even out an imbalances in my hips and weight bearing on my feet.  Any help from you on sources to purchase these items would be great!  Thanks!

Jeanne (name changed to protect)

Dear Jeanne, Thanks for your email and sorry for my delay. The material I use is call grinding rubber and you can purchase several 1/8th inch sheets from www.jmsplastics.com. The trickiest part is to skive the leading edge, but try angling the scissors. You can also use 1/8th inch spenco flat insoles and cut out the toes to give more room. Use one pair and you can make a 1/4th inch lift for one side (almost 6 mm). These can be purchased all over. Sure hope this helps you. 

Here the black side of a Spenco insole with the toe part cut out is being compared to a typical heel lift.

Here Grinding Rubber from JMS Plastics is being formed into a full length lift and a heel lift.

Here a Spenco insole is being used as a lift of the short left side and an accommodation for a painful big toe joint. 

Hip Function with Lifts for Short Leg Syndrome

Dr. Blake, 

When one has a lower leg length inequality, have you measured the effects it has on the hips when one goes into 

a heal lift verses a whole foot lift? I am curious to see what you observation is. 

Tim

Hey Tim, Thanks so very much for leaving a comment on the blog post entitled "Heel Lifts vs Full Length Lifts for Short Leg Syndrome". The schematic below is normal hip function in green and various motions or positions considered abnormal in purple. I see that there is a misprint which should read Hip Motion Asymmetry indicating different motion on the right and left. Over the years I have observed more Hip Hike with heel lifts vs full length lifts and more difficulty in general stablizing the hip height difference originally seen. For athletes who spend a lot or a bunch of time (just to irritate my high school English teacher) on the balls of their feet, the role of a heel lift is lessened in effecting change at the hip level and the base of the spine. 

Normal and Abnormal Motions/Positions of the Hip Area

     All this been said, experimentation with each patient is important. Every doctor/therapist that uses lifts goes off some general rules initially. There has to be a starting place. I like to start with full length lifts (normally stop just before the toes). As I watch a patient walk with lifts, I want to see easy, fluid hip motion, a lessening or elimination of limb dominance (lean of the body to one side), no hip hike (jerk upward), no knee instability which could be a sign of hip instability hiding under the clothes, and for the patient to tell me that they feel more stable and centered. Compromises have to be made when there are toe fit issues, or when stability is not being obtained.

     Another doctor/therapist may want to start with heel lifts. As they treat the patient, they should evaluate in every shoe that the patient uses the lifts whether there is hip stability, hip evenness, elimination of limb dominance and no hip hike at heel contact. There are so many shoe styles, that patients often find that the same lift in one shoe that was working well, has some issues with another shoe. In general, the nuances can be worked out, but most just do not wear the lift in those shoes it does not seem to work with.

    So, to answer your basic question, I normally see smoother, more equal, less jerky motion at the hip and knee with full length lifts than heel lifts. But, if I was starting with heel lifts in a non-athlete that was not on the ball of their foot a lot, I probably could find some shoes out there that worked well for the patient in terms of these issues. I hope I was able to answer your question.

Short Leg Treatment: Shoe Lifts

Most patients have a short leg, either structurally or functionally. A structural short leg is true length difference of the bones, where a functional short leg may be caused by many factors including one arch lower than the other side. As long as one arch collapses more than the other side, the short leg syndrome exists.

Most people have one foot longer than the other, but the long foot may or may not be on the long leg. Remember you are taught to buy shoes always for the longer side (longer foot). If you wear out one shoe more than the other, either by observing the heel of the outersole or the footbed within the shoe, you can tell that one leg may be shorter. Orthopedists normally do not recommend treatment unless over 1/2". Podiatrists have observed that as little as 1/8" difference in leg lengths can cause symptoms. By treating these small differences, and having patients report positive outcomes, leg length discrepancies are a vital part of care.

Treatment of leg length discrepancies is with various types of lifts under the short leg. The photo above shows a shoe with a full length external or outersole lift of 3/8". Due to the swelling in his foot, this patient could not tolerate any lifts within the shoe. Full length lifts, whether within the shoe or on the outer sole, are normally so much more stable than just heel lifts. Heel lifts alone can create a high heel effect with more instability. Also, a heel lift alone can be compensated for with mere bending of the knee negating the desired lift height. So, I love full length lifts and try to always start with these in my treatment. A future post will explore this treatment in detail.

Most athletic shoes can accommodate up to 3/8" lifts. All patients should have a trial of lift therapy with shoe inserts with positive results before external shoe lifts are utilized. Most shoe repair shops can put on external lifts, but there may be one in your area that specializes. Ask around for referrals from local orthopedic or podiatry offices. The external lift must be tapered at the toes, and somewhat flexible at the ball of the foot, to allow the patient to walk smoothly from heel to toe.

The Golden Rule of Foot with lift therapy: Start Low, Go Slow. Normally, if the difference is 3/8" total, 1/8" lift is given for 2weeks, then another 1/8" lift for 2 more weeks, then finally the full 3/8". As you go up in lift therapy, blame any new symptoms on the added lift, take out the additional lift until the new symptoms subside, then try again. Some patients are stuck for one reason or another at one level of lift. Their bodies will reject the higher amounts.

There seems to be more stress on the body when the exact same lift is placed on the outersole as was originally used as an insert. It probably weighs slightly more, or effects the motion around heel strike more. To lessen this change, which may cause symptoms itself, place 1/2 of the overall lift in the opposite shoe as an insert initially. Two weeks later, take 1/2 of that away, then finally 2 weeks later take it all away so you are left with just the desired outersole lift. This eases the process dramatically, allowing the body to relax more in making this big change. Good luck!!