We have talked about the gait signs and osteopathic measurements for limb length discrepancy, so today let us talk about treatment. Like most biomechanical topics, there are wide variety of approaches available. I can only summarize my approach, as I only want to discuss the topics I have experience with.
This is Part 4 of our discussion on limb length discrepancy and I have been recently inspired by Drs Clifton Bradeley, Lucy Best, and Daryl Phillips. I think my practice of limb length discrepancy evaluation and treatment was good, but really only scratched the surface if I was to specialize in it.
What are some of the general rules used in limb length treatment that we can discuss here. They include:
- The basic mantra of "Start Low and Go Slow"
- The Orthopedic Rule of "Do Not Treat under 1/2 inch" is Just Wrong
- There is a corelation between demands in activity and the amount of lift needed
- Full Length Lifts are preferred for athletes due to the time spent on the ball of their feet
- Heel Lifts (and full length lifts) should be a separate entity to custom orthotic devices
- If you are dealing with complex biomechanics, make one change at a time
- Lifts over 1/4 inch should be lessened as they go distal
- See if your lift applied corrects for gait changes you were blaming on the short leg syndrome
- Maintain forefoot flexibility with full length lifts with cross striations
- Full Length lifts can be cut off at the sulcus for less digital pressure
- Lifts can be added (by certain companies) to the midsole of athletic shoes
- Lifts are added to outsoles by local cobblers
- Lifts of any sort can be helped by power lacing and/or tongue padding
So, you can see, with 13 general rules, we have alot to talk about. I will do 6 of these rules today and 7 more next week. I need to announce now that I will be unable to answer questions October 11th due to heart surgery until December 13th. There will be precordered posts each Tuesday during that time, but a leave of absense is required so I can begin to heal. Thanks for any good thoughts.
1. The Basic Mantra of "Start Low and Go Slow"
The utilization of lift therapy to help your patients is a very powerful biomechanical modality. It is a primary direct stabilizer of the low back with leveling of the sacral base, and it is an indirect stabilizer on the pelvis, upper spine, shoulders, and of course lower extremity. This powerful intervention will adjust aspects of the whole body and needs to be started slowly. When measuring a limb length discrepancy, the typical "Start Low" starting point is 1/8 inch correction even if the actual difference is 3/8 or 7/8. The "Go Slow" means that you add additional lifts biweekly or on a month basis. If I was to see a patient with 1/2 inch difference in a month for followup, I would start them at 1/8 and have them add another 1/8 in 2 weeks. This of course is always tied to the patient's symptoms, with lowering the lift height if the inch increased any symptoms.
2. The Orthopedic Rule of "Do Not Treat Under 1/2 Inch" is Just Wrong
I have had such great success correcting 1/8 to 3/8 inch limb length discrepancies that I can not imagine using 1/2 inch discrepancy as your protocol. For sports, where small changes of anything can be very beneficial, even 1/16 inch difference can be important.
3. There is a correlation between the demands of activity and the amount of lift needed
If you are hardly walking and standing, lifts may be not that important. The opposite of that is definitely true as slight mechanical faults can wreck havoc on the body as your exercise at high levels. Since you typically do one thing at a time with olympic level or professional level athletes, you are given the opportunity to see how incredible 1/16 or 1/8 inch lift on the short side benefits the lower extremity, back, and upper extremity.
4. Full Length Lifts are preferred for athletes due to the time that they spend on the balls of their feet.
Most that treat limb length discrepancies are emotionally stuck on heel lifts. If symptoms are related to prolonged standing, heel lifts are fine to balance the spine. However, if the patient has symptoms with movement, please experiment with full length lifts over heel lifts. I just readily go to a full length lift (typically these are sulcus length with the toe area cut out). I was trained to use heel lifts, but when patients did not respond, I would change them to full length lifts and get better symptom response.
5. Heel Lifts (and Full Length Lifts) should be a separate entity to custom foot orthotic devices.
I love to discover the importance of my treatments. When you take the average patient coming into my office with mechanical issues, I like to decide if their issues are limb length related, pronation or supination related, weak or tight muscle related, pure overuse related, etc. Patients will come in with combinations of factors routinely. Due to this, you will routinely use orthotic devices and lifts on the same patient. Any modality helps symptoms and can stir up symptoms. The best way I have found is to keep modalities separate as best you can. You definitely want to tell your patient that the lift is causing or helping this and the orthotic device is causing or help that. This helps you make adjustments.
6. If you are dealing with complex biomechanics, make one change at a time.
I can not say this enough, but I will still break this rule due to the pressures of time. So, as best you can, follow this rule so you understand what you did and how it worked. I would place treatment of limb length discrepancy into the complex biomechanics folder. It is always coupled with shoe changes due to volume issues, effects on the orthotic devices that are placed under, how you lace the shoe, how you follow the patient to get them future lifts, etc. But, this is a world that can be so beneficial for your patients.
Next week I will talk about the remaining general rules. Thanks for hanging in there with me.
