Some people have an ?apparent? LLD which may make the affected leg seem longer than the other leg. There are several factors that can contribute to this feeling. Most commonly, contractures or shortening of the muscles surrounding the hip joint and pelvis make the involved leg feel longer, even when both legs are really the same length. Additionally, contractures of the muscles around the lower back from spinal disorders (i.e. arthritis, spinal stenosis), curvatures of the spine from scoliosis, and deformities of the knee or ankle joint can make one leg seem longer or shorter. In the general public, some people have an ?apparent LLD? as long as one half inch but usually don?t notice it because the LLD occurs over time. A ?true? LLD is where one leg is actually longer than the other. Patients can have unequal leg lengths of 1/4? to 1/2? and never feel it too! You can also have combinations of ?True? and ?Apparent? LLDs. During total hip replacement surgery, the surgeon may ?lengthen? the involved leg by stretching the muscles and ligaments that were contracted, as well as by restoring the joint space that had become narrowed from the arthritis. This is usually a necessary part of the surgery because it also provides stability to the new hip joint. Your surgeon takes measurements of your leg lengths on x-ray prior to surgery. Your surgeon always aims for equal leg lengths if at all possible and measures the length of your legs before and during surgery in order to achieve this goal. Occasionally, surgeons may need to lengthen the operable leg to help improve stability and prevent dislocations as well improve the muscle function around the hip.
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.
The patient/athlete may present with an altered gait (such as limping) and/or scoliosis and/or low back pain. Lower extremity disorders are possibly associated with LLD, some of these are increased hip pain and degeneration (especially involving the long leg). Increased risk of: knee injury, ITB syndrome, pronation and plantar fascitis, asymmetrical strength in lower extremity. Increased disc or vertebral degeneration. Symptoms vary between patients, some patients may complain of just headaches.
A doctor will generally take a detailed medical history of both the patient and family, including asking about recent injuries or illnesses. He or she will carefully examine the patient, observing how he or she moves and stands. If necessary, an orthopedic surgeon will order X-ray, bone age determinations and computed tomography (CT) scans or magnetic resonance imaging (MRI).
Non Surgical Treatment
Treatment of leg length inequality involves many different approaches, such as orthotics, epiphysiodesis, shortening, and lengthening, which can be used alone or combined in an effort to achieve equalization of leg lengths. Leg length inequality of 2 cm or less is usually not a functional problem. Often, leg length can be equalized with a shoe lift, which usually corrects about two thirds of the leg length inequality. Up to 1 cm can be inserted in the shoe. For larger leg length inequalities, the shoe must be built up. This needs to be done for every shoe worn, thus limiting the type of shoe that the patient can wear. Leg length inequalities beyond 5 cm are difficult to treat with a shoe lift. The shoe looks unsightly, and often the patient complains of instability with such a large lift. A foot-in-foot prosthesis can be used for larger leg length inequalities. This is often done as a temporizing measure for young children with significant leg length inequalities. The prosthesis is bulky, and a fixed equinus contracture may result.
Many people undergo surgery for various reasons – arthritis, knee replacement, hip replacement, even back surgery. However, the underlying cause of leg length inequality still remains. So after expensive and painful surgery, follow by time-consuming and painful rehab, the true culprit still remains. Resuming normal activities only continues to place undue stress on the already overloaded side. Sadly so, years down the road more surgeries are recommended for other joints that now endure the excessive forces.