True Vs. Functional Leg Length Discrepancy
Overview
Surgery is another option. In some cases the longer extremity can be shortened, but a major shortening may weaken the muscles of the extremity. In growing children, lower extremities can also be equalized by a surgical procedure that stops the growth at one or two sites of the longer extremity, while leaving the remaining growth undisturbed. Your physician can tell you how much equalization can be attained by surgically halting one or more growth centers. The procedure is performed under X-ray control through very small incisions in the knee area. This procedure will not cause an immediate correction in length. Instead, the LLD will gradually decrease as the opposite extremity continues to grow and "catch up." Timing of the procedure is critical; the goal is to attain equal length of the extremities at skeletal maturity, usually in the mid- to late teens. Disadvantages of this option include the possibility of slight over-correction or under-correction of the LLD and the patient?s adult height will be less than if the shorter extremity had been lengthened. Correction of significant LLDs by this method may make a patient?s body look slightly disproportionate because of the shorter legs.
Causes
Some causes of leg length discrepancy (other than anatomical). Dysfunction of the hip joint itself leading to compensatory alterations by the joint and muscles that impact on the joint. Muscle mass itself, i.e., the vastus lateralis muscle, pushes the iliotibial band laterally, causing femoral compensations to maintain a line of progression during the gait cycle. This is often misdiagnosed as I-T band syndrome and subsequently treated incorrectly. The internal rotators of the lower limb are being chronically short or in a state of contracture. According to Cunningham's Manual of Practical Anatomy these are muscles whose insertion is lateral to the long axis of the femur. The external rotators of the hip joint are evidenced in the hip rotation test. The iliosacral joint displays joint fixations on the superior or inferior transverse, or the sagittal axes. This may result from many causes including joint, muscle, osseous or compensatory considerations. Short hamstring muscles, i.e., the long head of the biceps femoris muscle. In the closed kinetic chain an inability of the fibula to drop inferior will result in sacrotuberous ligament loading failure. The sacroiliac joint dysfunctions along its right or left oblique axis. Failure or incorrect loading of the Back Force Transmission System (the longitudinal-muscle-tendon-fascia sling and the oblique dorsal muscle-fascia-tendon sling). See the proceedings of the first and second Interdisciplinary World Congress on Low Back Pain. Sacral dysfunction (nutation or counternutation) on the respiratory axis. When we consider the above mentioned, and other causes, it should be obvious that unless we look at all of the causes of leg length discrepancy/asymmetry then we will most assuredly reach a diagnosis based on historical dogma or ritual rather than applying the rules of current differential diagnosis.
Symptoms
The symptoms of limb deformity can range from a mild difference in the appearance of a leg or arm to major loss of function of the use of an extremity. For instance, you may notice that your child has a significant limp. If there is deformity in the extremity, the patient may develop arthritis as he or she gets older, especially if the lower extremities are involved. Patients often present due to the appearance of the extremity (it looks different from the other side).
Diagnosis
On standing examination one iliac crest may be higher/lower than the other. However a physiotherapist, osteopath or chiropractor will examine the LLD in prone or supine position and measure it, confirming the diagnosis of structural (or functional) LLD. The LLD should be measured using bony fixed points. X-Ray should be taken in a standing position. The osteopath, physiotherapist or chiropractor will look at femoral head & acetabulum, knee joints, ankle joints.
Non Surgical Treatment
In some circumstances, the physician will recommend a non-surgical form of treatment. Non-surgical treatments include orthotics and prosthetics. Orthotics are a special type of lift placed in or on a shoe that can be used in the treatment of leg length discrepancies between two and six centimeters. In pediatric patients who have large discrepancies and are not good candidates for other treatment forms, prosthetics can be helpful.
shoe lifts for men's shoes
Surgical Treatment
Surgeries for LLD are designed to do one of three general things ? shorten the long leg, stop or slow the growth of the longer or more rapidly growing leg, or lengthen the short leg. Stopping the growth of the longer leg is the most commonly utilized of the three approaches and involves an operation known as an epiphysiodesis , in which the growth plate of either the lower femur or upper tibia is visualized in the operating room using fluoroscopy (a type of real-time radiographic imaging) and ablated , which involves drilling into the region several times, such that the tissue is no longer capable of bone growth. Because the epiphyseal growth capabilities cannot be restored following the surgery, proper timing is crucial. Usually the operation is planned for the last 2 to 3 years of growth and has excellent results, with children leaving the hospital within a few days with good mobility. However, it is only appropriate for LLD of under 5cm.
Surgery is another option. In some cases the longer extremity can be shortened, but a major shortening may weaken the muscles of the extremity. In growing children, lower extremities can also be equalized by a surgical procedure that stops the growth at one or two sites of the longer extremity, while leaving the remaining growth undisturbed. Your physician can tell you how much equalization can be attained by surgically halting one or more growth centers. The procedure is performed under X-ray control through very small incisions in the knee area. This procedure will not cause an immediate correction in length. Instead, the LLD will gradually decrease as the opposite extremity continues to grow and "catch up." Timing of the procedure is critical; the goal is to attain equal length of the extremities at skeletal maturity, usually in the mid- to late teens. Disadvantages of this option include the possibility of slight over-correction or under-correction of the LLD and the patient?s adult height will be less than if the shorter extremity had been lengthened. Correction of significant LLDs by this method may make a patient?s body look slightly disproportionate because of the shorter legs.
Causes
Some causes of leg length discrepancy (other than anatomical). Dysfunction of the hip joint itself leading to compensatory alterations by the joint and muscles that impact on the joint. Muscle mass itself, i.e., the vastus lateralis muscle, pushes the iliotibial band laterally, causing femoral compensations to maintain a line of progression during the gait cycle. This is often misdiagnosed as I-T band syndrome and subsequently treated incorrectly. The internal rotators of the lower limb are being chronically short or in a state of contracture. According to Cunningham's Manual of Practical Anatomy these are muscles whose insertion is lateral to the long axis of the femur. The external rotators of the hip joint are evidenced in the hip rotation test. The iliosacral joint displays joint fixations on the superior or inferior transverse, or the sagittal axes. This may result from many causes including joint, muscle, osseous or compensatory considerations. Short hamstring muscles, i.e., the long head of the biceps femoris muscle. In the closed kinetic chain an inability of the fibula to drop inferior will result in sacrotuberous ligament loading failure. The sacroiliac joint dysfunctions along its right or left oblique axis. Failure or incorrect loading of the Back Force Transmission System (the longitudinal-muscle-tendon-fascia sling and the oblique dorsal muscle-fascia-tendon sling). See the proceedings of the first and second Interdisciplinary World Congress on Low Back Pain. Sacral dysfunction (nutation or counternutation) on the respiratory axis. When we consider the above mentioned, and other causes, it should be obvious that unless we look at all of the causes of leg length discrepancy/asymmetry then we will most assuredly reach a diagnosis based on historical dogma or ritual rather than applying the rules of current differential diagnosis.
Symptoms
The symptoms of limb deformity can range from a mild difference in the appearance of a leg or arm to major loss of function of the use of an extremity. For instance, you may notice that your child has a significant limp. If there is deformity in the extremity, the patient may develop arthritis as he or she gets older, especially if the lower extremities are involved. Patients often present due to the appearance of the extremity (it looks different from the other side).
Diagnosis
On standing examination one iliac crest may be higher/lower than the other. However a physiotherapist, osteopath or chiropractor will examine the LLD in prone or supine position and measure it, confirming the diagnosis of structural (or functional) LLD. The LLD should be measured using bony fixed points. X-Ray should be taken in a standing position. The osteopath, physiotherapist or chiropractor will look at femoral head & acetabulum, knee joints, ankle joints.
Non Surgical Treatment
In some circumstances, the physician will recommend a non-surgical form of treatment. Non-surgical treatments include orthotics and prosthetics. Orthotics are a special type of lift placed in or on a shoe that can be used in the treatment of leg length discrepancies between two and six centimeters. In pediatric patients who have large discrepancies and are not good candidates for other treatment forms, prosthetics can be helpful.
shoe lifts for men's shoes
Surgical Treatment
Surgeries for LLD are designed to do one of three general things ? shorten the long leg, stop or slow the growth of the longer or more rapidly growing leg, or lengthen the short leg. Stopping the growth of the longer leg is the most commonly utilized of the three approaches and involves an operation known as an epiphysiodesis , in which the growth plate of either the lower femur or upper tibia is visualized in the operating room using fluoroscopy (a type of real-time radiographic imaging) and ablated , which involves drilling into the region several times, such that the tissue is no longer capable of bone growth. Because the epiphyseal growth capabilities cannot be restored following the surgery, proper timing is crucial. Usually the operation is planned for the last 2 to 3 years of growth and has excellent results, with children leaving the hospital within a few days with good mobility. However, it is only appropriate for LLD of under 5cm.
