Short Leg Syndrome: Email Advice

Hi Dr. Blake

I came across your blog and have found it really helpful, thank you for posting there. I hope you don't mind but I was hoping for some basic advice.

I have been suffering from low back pain and right anterior hip for about 3-4 years and have seen a variety of medical professionals (physios, chiros, orthos etc) with limited success. I have been getting contradictory advice from different medical professions so hoped you could help. 

A physiotherapist told me 1 year ago I had a true LLD (Limb Length Discrepancy) of approx 1 cm (measured by looking at my ankle bones with me lying down) and I got an orthotic made with 0.5cm (~50% of my LLD) heel lift in my short right leg. This didn't really help with my symptoms after wearing it for about half a year. 6 months ago a chiropractor told me based on x-rays I had a 1.6cm true LLD so advised me to up my heel lift to 1.5cm. Again this extra lift hasn't really helped with my symptoms after wearing it for 4-5months and I found it caused some foot pain as it was a very high heel lift.

Recently I have been working another physiotherapist who believes a lot LLD are functional so has been giving me a correct exercise programme aimed at addressing this. 

I am very confused about whether I have a true or functional LLD. My chiro x-rays were taken standing in my bare feet so I thought this proved it a true LLD as it measures the tops of the femurs being off by 1.6cms (see pics below).

Any advice you could offer would be much appreciated.

Thank you in advance

Kind Regards

Before Lifts

After Lifts

Dr. Blake's comment: Thank you so very much. It is so hard to know all the causes of your problem and being a podiatrist, I am very limited in the advice I could give you. First of all, when you put in the lifts, the spine looked so much better with the hip and sacral base still low. Also, it looks like some of the most compression of the spine without the lift is around L1 and L2. This can give both anterior hip and low back pain easily. Please have a Nerve Conduction Study with EMG to see what is involved. Also, have an MRI of the Low Back and see if L1 and L2 are injured. Then decisions can be made. 

     From my viewpoint, I would use around 15 mm for 3 months under the left as close to full length and see what symptoms change. Of course, if there is increasing pain, blame the lifts, and remove. If no untoward effects, I hope after 3 months you can go up to 20 mm. You have some scoliosis and need to be put on a program of back strengthening and stretching that is appropriate for your curves. Typically, the concave side of the curve gets tighter, and the convex side looser, so you stretch the concave side and strengthen the convex side.  

     To do this correctly you have to have several shoes with the full-length built up on the outside of the shoe that you can stay with for the 3-month experiment. You have to have some full-length lifts of 1/8 th inch to put in your right side if you need to lessen the overall lift for a while.  Hope this helps some. Rich

The Patient then Responded:

Thanks so much for your reply. 

I had 2 questions if you could find the time

1. You advise I use a shoe with a lift on the outside of the shoe as opposed to a heel lift or orthotic with heel lift in the short leg? Using a heel lift is obviously easier to manage as it can be moved from shoe to shoe as opposed to being tied to shoes that have to be built up. A heel lift is a bad idea for an LLD of what I have (1.6cm)? Dr. Blake's comment: I think heel lifts can produce more instability at the heel over a full-length lift. You can limit your shoe wearing with full length lifts tapered at the toes, although there is so much crowding at this amount that it may make it hard. So much of this process is experimentation to see how you feel. All I am suggesting is that you try one or two pairs of shoes built up to see the difference. It is a $50 experiment per shoe and can be removed if it does not work. So many patients feel so much more stable, actually lifted more than shoe inserts, and so much better shoe fit overall. It becomes an individual decision, but so many of my patients prefer it. Try it on one pair of shoes. Nothing to lose but time. Here is my video playlist on short leg syndrome:                  https://www.youtube.com/playlist?list=PLuAexfdWrwEy9uugpAxol_quLWzKPf9Jl
2. You suggest I go up to 2cm even though my x-ray shows my LLD is 1.6cm and wondered why 2cm? Dr. Blake's comment: If I have labeled the image entitled "after lifts" correctly in the images above, you are still not level completely at the hips, and probably most importantly base of the spine. We call it Sacral Base Unevenness and it is more important to a lot of patients that this be level than leg length correction at the hips. If you look at how L5 sits on top of the sacrum, you can see that the sacrum still falls to the left. Once you have the lifts in, taking this one xray called AP Pelvic Standing with 20 mm lift under the left side should be done. You can send me the image. 

Thanks again

Kind Regards

Treatment for Short Leg Syndrome in Child: Email Advice

Hello Dr. Blake,

My son has seen you several times for orthotics.  He was diagnosed with cerebral palsy, has bilaerally pronated feet, and mild scoliosis.

It's the scoliosis that I am trying to assess.  We have been to many doctors and chiropractors.  One doctor cited a shorter leg length as a reason for the scoliosis, but other professionals don't agree.  My son's spine when sitting is straighter than when he stands, so something in weight bearing changes his posture.  Also, if he tends to lean to one side in standing posture, I am wondering if that also affects the results seen in the x-rays.

I don't like to x-ray him often to reduce his exposure.  I want to get an accurate x-ray that eliminates other factors that might be impacting what is seen on the x-rays such as standing posture, pronated feet etc., in the hopes that I can see how much of it is his spine and how much comes from these other factors.  I hope that in this way, we can try to address these other factors individually and their impact on the spine, of course with the goal of correcting his scoliosis.

I hope that makes sense.

You are very good at evaluating gait and biomechanics and I was hoping you might provide some suggestions or referrals to professionals who you'd recommend that can help with what I'm trying to assess.

Sincerely,

Dr Blake's response: 

     Thank you for the email. I agree to be mindful of x ray exposure, but you also have to have accurate information to treat your son. Typically, once the orthotics are where I like them, I have the patient take an AP Standing Pelvic Xray with orthotics on but no lifts. I coach the patient to stand as straight as possible daring the xray to show a short leg. The xray gets the leg length difference, any pelvic rotations, any unevenness of the base of the spine, and also the lumbar part of the scoliosis. Since it is weight bearing, it has a true bearing on how he walks. After I review the xray, I will make recommendations on lifts, physical therapy, etc. I love sending patients who have pelvic or sacral base unevenness to Dr Irene Minkowsky here in San Francisco. She typically knows what profession can help the most. Hope this makes sense. Rich

Top 100 Biomechanical Guidelines #23: Sacral Base Crucial Measurement for Short Leg Syndrome

Right SideLeft Side

The Sacral Base is at the base of the spine where the 5th Lumbar Vertebrae meets the sacrum. In the photo above, the sacrum rests below L5 and is slanted downward towards the right. This xray is called a Standing AP Pelvic Xray. To measure the sacral base difference, you draw a line along the sacral base until that line hits the ilium on the right and left sides at an equal spot. Then you drop a line down from these spots to the bottom of the xray plate. The sacral base measurement, also called sacral base unleveling, is the difference in heights between the two sides with one side higher. Of course, the base of the spine should be level with the ground. When treating leg length difference, xrays are taken when the initial treatment is not successful, or in chronic pain syndromes when you want to be as exact as possible. Comparing the hip height difference with the sacral base unleveling may help in deciding how much leg length difference should be initially corrected. In many cases, I will take these standing xrays after I am satisfied with my overall orthotic and lift therapies to see how far off I still am. The xrays should be taken in this case with shoes, orthotics, and lifts on and the patient standing in normal stance with the knees straight.