Leg length discrepancy (LLD) is when there is a noticeable difference in length of one leg to the other. LLD is common and can be found in 70% of the population (Gurney, 2002). LLD can be structural or functional. Structural LLD is when a long bone in the leg is longer or shorter than the other. Structural LLD is often the result of congenital or boney damage of epiphyseal plate. Functional is when there is an apparent LLD from higher in the chain such as scoliosis. Generally as pelvic floor therapists we are orthopedic based therapists. In physical therapy school we learned that a leg length discrepancy had to be >1 cm to be considered significant, and based off of recent research that is still the case. Research in the last few years has focused on whether LLD has an effect on age related changes with osteoarthritis, posture & gait, and pain. Physiopedia suggests differential diagnosis of sacroiliac dysfunction, scoliosis, low back pain, iliotibial band (ITB) syndrome, stress fractures, and pronation. It can often feel like a chicken or egg question.
In the clinic I typically screen for a leg length discrepancy during my initial evaluation. A LLD may be noticed upon observation of gait assessment, standing posture, or part of the pelvic obliquity screen in standing and then in supine.
During gait, a LLD will create bilaterteral gait impairments. Khamis et al did a systematic review of LLD and gait deviations in 2017. They narrowed the search down to 12 articles and found that LLD >1cm was significantly related to gait deviations. These deviations occurred bilaterally, and while initially compensations occurred in the sagittal plane, as the LLD increased so did the gait deviations, and then affected frontal planes of motion as well. Resende et al (2016) agrees that even mild LLD should not be overlooked. They found that the most likely gait deviations were also in the sagittal planes and consisted of rearfoot and ankle dorsiflexion and inversion, knee flexion and adduction, hip adduction and flexion, and pelvic trendelenburg.
The sagittal, or right/left plane, and frontal, or front/back, plane involvement is consistent with the differential diagnosis of sacroiliac dysfunction, low back pain, and pronation. Really, one could justify why a LLD could contribute to pain and dysfunction in most of the lower body. It is reasonable to think that these compensational moments in gait over a long period create boney changes in the lower extremities which may contribute to low back pain.
Clinically, a leg length discrepancy can be assessed directly with a tape measure or indirectly with a shoe lift. Badii (2014) found a higher interrater reliability with the indirect method of a shoe lift as opposed to measuring with a tape measure.
Rannisto et al (2019) looked at leg length discrepancy among meat cutters with low back pain. All participants had been working for 10 years and were greater than 35 years old. Participants needed to have a LLD of 5mm (5mm is 0.5 cm) or more and complain of low back pain of >2/10 on visual analog scale (VAS). They were all given insoles and randomized into 2 groups; the intervention group were given lifts to correct the LLD about 70%; for example a 10mm LLD was corrected to 3 mm. The LLD was measured with a laser ultrasound technique. Participants were followed for 12 months. The intervention group had improvement in low back pain intensity, sciatica intensity, and took less sick time. Possibly the most amazing part is that for those that wore the heel lift at work the compliance was good.
Leg length discrepancy can often be an underlying component contributing to complaints of pain and dysfunction. It may have more of an effect on the populations who stand or walk for most of their work, and I wonder as more people transition to standing desks if we will see more people come into the clinic with a previously undiagnosed LLD.
My biggest clinical pearls from this research is that:
- Heel lifts can be used to diagnose and then for treatment (yay! One less step of getting the tape measure out)
- The heel lift does not have to be perfect. Clinically, I will try a lift and have the person walk, and then we can make a team decision if this lift is enough and feels better
- The gait compensations are consistently adduction and internal rotation throughout the lower body chain. I will continue to work on the opposing muscle groups; lateral rotators, hip extensors and abductors.
Leg Length Discrepancy can be evaluated using various assessments. To learn orthopedic evaluative techniques for patients, consider joining Lila Abbate in her course Advanced Orthopedic Assessment for the Pelvic Health Therapist.
Maziar Badii, A Nicole Wade, David R Collins, Savvakis Nicolaou, B Jacek Kobza, Jacek A Kopec, Comparison of lifts versus tape measure in determining leg length discrepancy; Journal of Rheumatology 2014, 41 (8): 1689-94
Renan A. Resende, Renata N. Kirkwood, Kevin J. Deluzio, Silvia Cabral, Sérgio T. Fonseca. "Biomechanical strategies implemented to compensate for mild leg length discrepancy during gait" Gait & Posture, Volume 46, 2016; 147-153, https://doi.org/10.1016/j.gaitpost.2016.03.012
Sam Khamis, Eli Carmeli, Relationship and significance of gait deviations associated with limb length discrepancy: A systematic review, Gait & Posture, Volume 57, 2017, 115-123, https://doi.org/10.1016/j.gaitpost.2017.05.028
Burke Gurney, Leg length discrepancy, Gait & Posture, Volume 15, Issue 2, 2002, Pages 195-206, https://doi.org/10.1016/S0966-6362(01)00148-5.
Satu Rannisto, Annaleena Okuloff, Jukka Uitti, et al. Correction of leg-length discrepancy among meat cutters with low back pain: a randomized controlled trial. BMC Musculoskeletal Disorders. 2019;(1):1. doi:10.1186/s12891-019-2478-3.
How does a male sports and orthopedic physical therapist come to teach about pelvic health and wellness? I was fortunate enough to spend ten years in the NHL as the physical therapist and athletic trainer for the Florida Panthers. Ice hockey is one of the sports that has the highest incidence of groin strains among other pelvic related pathologies.1 As a clinician that was responsible for taking care of the world’s best hockey players, I was challenged to understand the interconnected relationships between the lumbopelvic-hip complex very quickly.
In the early years of my career development and the treatment of mostly males with pelvic pathologies, I leaned heavily on pelvic health professionals to help me understand an area of the body I received little training on in school and even less in my clinical care as a sports and orthopedic manual physical therapist. After years of treating hip and pelvic pathologies on my players I became more comfortable in this enigmatic area of the body. A good friend of mine was on faculty with Herman & Wallace and we frequently would communicate and compare notes. She was treating an increasing number of “sports hernias” (now termed athletic pubalgia or core muscle injury) and was relying on me to help her understand this injury and how to treat it. In turn, she helped me understand what went on in the pelvic health profession and what those therapists were trained to treat and how they went about it.
This collaboration eventually led to me joining Herman & Wallace and offering a sports and orthopedic perspective to pelvic floor consideration. I have attended Herman & Wallace’s Pelvic Floor courses to fully understand the training that a pelvic health therapist undergoes. Admittedly, I do not perform internal work because I have found a niche helping clinicians such as myself who understand that the pelvic floor is a key variable in human movement and we need to understand it at a much higher level than what we are exposed to in school, but don’t have the career trajectory of becoming an internal practitioner of the pelvic floor.
I have designed the Athletes and Pelvic Rehabilitation course to reach both the sports and orthopedic clinician as well as the pelvic health practitioner who might be a veteran of pelvic floor education and treatment. Both groups will leave this course with additional tools for their clinical tool box in the realms of manual therapy and exercise.2 Here are some of the objectives for the course:
What do people who have attended courses with Dr. Dischiavi have to say? Janna wrote the following email to Herman & Wallace about Steve's Course:
"Good morning. I wanted to make sure that you knew what a fantastic clinician you have to join your team in Steve Dischiavi. I am a practicing OB and orthopedic therapist and felt this course was fantastic! Usually the main goal is to come away with a couple of clinical "pearls." I felt as though I came away with a full days worth of "pearls." I really liked that the course was not totally pelvic floor based, however was totally relevant to the women's health population, but it will also apply to the majority of my current patient population as well. Thank you for the opportunity to learn from Steve!"
1. Orchard JW. Men at higher risk of groin injuries in elite team sports: a systematic review. Br J Sports Med. 2015;49(12):798-802.
2. Tuttle L. The Role of the Obturator Internus Muscle in Pelvic Floor Function. Journal of Women’s Health Physical Therapy. 2016;40(1):15-19.
Akinesia is a term typically used to describe the movement dysfunction observed in people with Parkinson disease. It is defined as a poverty of movement, an impairment or loss of the power to move, and a slowness in movement initiation. There is an observable loss of facial expression, loss of associated nonverbal communicative movements, loss of arm swing with gait, and overall small amplitude movements throughout all skeletal muscles in the body. The cause of this characteristic profile of movement is due to loss of dopamine production in the brain which causes a lack of cortical stimulation for movement.
If the loss of dopamine production in the brain causes this poverty of movement in all skeletal muscles the body, how does the pelvic floor function in the person with Parkinson disease and what should the pelvic floor rehabilitation professional know about treating the pelvic floor in this population of patients?
Let’s take a closer look referencing a very telling article about Parkinson disease and skeletal muscle function. In the Italian town of L’Aquila, a major devastating 6-point Richter scale earthquake occurred on April 6, 2009. 309 people died and there was destruction and collapse of many historical structures, some greater than 100 years old. The nearby movement disorder clinic had been following 31 Parkinson disease patients in the area, 17 of them higher functioning and the other 14 much lower functioning. In fact, of those 14, 10 of them were affected by severe freezing episodes with severe nighttime akinesia requiring assistance with bed mobility tasks, 1 was completely bedridden and the others with major fluctuations in motor performance. 13 of the 14 patients also had fluctuating cognitive functioning.
This devastating earthquake occurred at 3:30 am. All 14 of these patients were able to escape from their homes during or immediately following the event. Caregivers reported that in the majority of the cases, the person with Parkinson’s disease was the first one to be alerted to the earthquake, the first one to get out of the house, ability to alert relatives to run for safety, physically assisting relatives out of the collapsing buildings, and in some cases independently escaping down 1-2 flights of stairs.
Paradoxical kinesia is thought to be the reason for this all but sudden ability to move normally within the presence of an immediate threat to their life and lives of loved ones. Paradoxical kinesia is defined as “a sudden and brief period of mobility typically seen in response to emotional and physical stress in patient’s with advanced idiopathic Parkinson’s disease.” There are a few mechanisms hypothesized to play a role, such as, adrenaline, dopaminergic reserves activating the flight reaction, and compensatory nearby cerebellar circuitry.
There is no pathological evidence that in Parkinson disease there is any break in the continuity of the motor system. The neurologic pathways are all intact and the ability to produce muscle power is retained however requires a strong base of clinic knowledge of the disease to help these patients activate these intact motor pathways. I look forward to sharing the neurologic basis of these deficits in Parkinson disease and strategies in pelvic floor rehab to do just that!
Erica Vitek, a specialist in treating patients with neurologic dysfunction, is the author and instructor of Neurologic Conditions and Pelvic Floor Rehab, taking place September 14-16, 2018 in Grand Rapids, MI.
Bonanni, L., Thomas, A., Anzellotti, F., Monaco, D., Ciccocioppo, F., Varanese, S., Bifolchetti, S., D’Amico, M.C., Di Iorio, A. & Onofrj, M. (2010). Protracted benefit from paradoxical kinesia in typical and atypical parkinsonisms. Neurological sciences, 31(6), 751-756.
The following is a guest submission from Alysson Striner, PT, DPT, PRPC. Dr. Striner became a Certified Pelvic Rehabilitation Practitioner (PRPC) in May of 2018. She specializes in pelvic rehabilitation, general outpatient orthopedics, and aquatics and treats at Carondelet St Joesph’s Hospital in the Speciality Rehab Clinic located in Tucson, Arizona.
Recently, I had a patient present with Complex Regional Pain Syndrome (CRPS) on his right foot. He stated that the pain had started about 10 days after his prostatectomy when someone had fallen onto his right foot. He reported a bunionectomy on that foot 7 years prior and noted an episode of plantar facilities before his prostatectomy. CRPS is defined as “chronic neurologic condition involving the limbs characterized by severe pain along with sensory, autonomic, motor, and trophic impairments” in a 2017 article "Complex regional pain syndrome; a recent update" by Goh, En Lin. The article goes on to discuss how CRPS can set off a cascade of problems including altered cutaneous innervation, central and peripheral sensitization, altered sympathetic nervous system function, circulating catecholamines, changes in autoimmunity, and neuroplasticity.
A recent persistent pain theory to explain the relationship between pelvic floor and his foot could be overflow or ‘smudging’ in his homunculus. The homunculus is the map of our physical body in our brain where the feet are located next to the genitals. Possibly when one has pain, there can be ‘smudging’ of our mental body map from one area into another. I have heard this explained as though a chalk or charcoal drawing has been swipes their hand through the picture. A recent study by Schrabrun, SM et al “Smudging of the Motor Cortex is Related to the Severity of Low Back Pain” found that people with chronic low back pain had a loss of cortical organization which and that this loss was associated with the severity and location of LBP.
There are many ways to improve the organization of the homunculus and create neuroplasticity. One such way was suggested is with Transcutaneous electrical nerve stimulation (TENS) to the bottom of the foot to affect bladder spasms and pain. In recent study, “Transcutaneous electrical stimulation of somatic afferent nerves of the foot relieved symptoms related to postoperative bladder spasms,". Zhang, C et al. 2017 found that participates that had either a bladder surgery or a prostate surgery had improvement in bladder spasm symptoms and VAS scores on day two and three. Their protocol was to use two electrodes over the bottom of the foot at 5 Hz with 0.2 millisecond pulse width until a muscle twitch was achieved and was increased, but still comfortable for an hour (there is a picture of electrode placement in the article). The authors note that this neuromodulation of the foot sensory nerves may inhibit interactions between the somatic peripheral neuropathway and autonomic micturition reflex to calm the bladder and pain.
No matter what we do to help calm nervous systems from the top down; pain neuroscience education, mindful based relaxation, graded motor imagery, or from the bottom up; de-sensitization, biofeedback, or good old-fashioned TENS. The result is the same; a cortical organization and happier patients.
En Lin Goh†, Swathikan Chidambaram† and Daqing Ma. "Complex regional pain syndrome: a recent update". Burns & Trauma 2017 5:2.https://doi.org/10.1186/s41038-016-0066-4"
Schabrun SM, Elgueta-Cancino EL, Hodges PW. "Smudging of the Motor Cortex Is Related to the Severity of Low Back Pain." Spine (Phila Pa 1976). 2017 Aug 1;42(15):1172-1178. doi: 10.1097/BRS.0000000000000938
Chanjuan Zhang, et al. "Transcutaneous electrical stimulation of somatic afferent nerves in the foot relieved symptoms related to postoperative bladder spasms". BMC Urol. 2017; 17: 58. doi: 10.1186/s12894-017-0248-9