In daily clinical practice, we can utilize leg length checks on just about every patient presenting with lower extremity, spinal and upper extremity complaints. In our Foot Levelers community, we understand the role the feet play in many ailments that patients present with, and we know that foot function has a powerful influence on the entire body. The exposure that we have had with leg length discrepancy (LLD) beginning in chiropractic college and then expanding out into the seminars and classes we have taken during our years of practice offers solid support for how important LLD is in everyday patient care.
LLD and Why It Matters:
Recall that there are essentially two types of LLD: anatomical and functional. Anatomical LLD is a difference in the size and/or length of the femur or tibia. This is most often caused by inherited or genetic growth asymmetry, fracture, surgery or pathologies. Functional LLD is a difference in the alignment of the supporting structures between the ground and the femur head. This is most often caused by excessive foot pronation that affects the alignment of the ankles, knees, hips and pelvis.
In my practice, I check for LLD on my patients as a part of my initial exam. Even if someone presents with headaches, TMJ disorders or neck and shoulder pain, I check to see how level their feet are in the prone (position one and two) and supine positions, just like we learned in Thompson, Activator, SOT and other techniques. What do the feet and leg length have anything to do with those areas? The feet are the foundation of our human house, and they have a significant influence on the forces that start at the heel and move their way through the bones and joints up the legs, pelvis, hips and spine.
This also goes for children as well as adults. The three arches of the plantar vault begin forming at age four and they finish forming by ages six or seven. In my practice, I find overpronation can lead to LLD in children ages five and up, so I always make sure I look at their feet.
The Crooked Person Diagram Provides a Roadmap to Understanding:
In reviewing the role the feet play in influencing the stability of the hips, pelvis, spine and the rest of the body, recall that most patients walking through the doors of our clinic have some degree of overpronation. This includes children so I use the same considerations for kids as I do for adults. The diagram of the Crooked Person always serves as a way of fostering concise and consistent understanding of the effects that overpronation has on the body.
As we discuss the diagram, keep in mind that the foot with the worst excessive pronation is on the left. The effects of the flatter left foot are denoted by the arrows. I consistently find that the side of the worse pronated foot is the side of the shorter leg length discrepancy.
Notice in the diagram that as the three arches of the left foot fall and collapse to the floor, the entire foot drops medially and inferior. The distal tibia rotates inwards causing increased stress on the medial ankle region. The proximal tibia has also rotated inwards causing the femur to follow suit. These actions will then cause the left pelvis to tilt downwards, rotate forward and create the left functional short leg.
Patients are Hungry for an Explanation:
Of interesting note is how many patients present to us having been told they have a “short leg” but have no clarification or means of comprehending what that actually means. The medical practitioners that diagnose the short leg do so because it is often quite easy to see when observing the patient in a prone or supine position. But most of the time, the “short leg” is presumed to be anatomical when it is usually functional.
Furthermore, many practitioners do not know the difference and end up putting a heel lift in the patient’s shoe because that seems to be the right thing to do. How many times have you taken OUT a heel lift because the patient had a functional short leg, and the lift was causing more problems or simply is not necessary? Since patients often do not know the difference between the two types of LLD, it is up to you to make the distinction and educate them on what is going on with their bodies.
Quite a few of my patients have been told by another healthcare professional that they have an anatomic short leg but in actuality they do not. Often, I will take their camera phone and snap pictures of their leg length in the prone position before I adjust them and after I adjust them to show them how their legs even up. This can help provide that “Light Bulb Moment”. For some of you, showing your tape measurements or X-ray markings will serve the same purpose.
Exam and Treatment Suggestions:
On the initial visit, have the patient get their feet digitally scanned by you or your staff. This helps to evaluate and identify the arch deficiencies whose effects move up the Kinetic Chain to the hips and pelvis leading to the short leg. The scanner helps you do this easily and efficiently. Having every patient get scanned as part of your protocol helps establish the critical role the feet play in setting up an LLD. Proceed through the rest of your exam and chiropractic procedures making sure at some point you check the patient prone and supine and observe the LLD.
You may also choose to incorporate weight bearing X-rays, or specific measurements utilizing a tape measure to help to further distinguish anatomic vs. functional LLD. You will be performing whatever physiotherapy modalities you utilize and then adjust the 26 bones of the feet, the tibia, fibula, femur, pelvis and lower back utilizing the patterns found on the Crooked Person diagram. Remember that just because patients are young, that does not mean they have perfect feet. Children will show excessive foot pronation and LLD just as much as adults so make sure you keep a lookout for it.
Custom Orthotics and the Functional Short Leg:
Get the patient custom, three-arch, flexible orthotics as soon as possible so that their plantar vault and the rest of the body can be properly supported. By leveling the feet, you level the Crooked Person and the knees, hips, pelvis and spine even balance out. Patients who wear their custom orthotics consistently will appear more level on their prone and supine leg checks during routine evaluation and follow ups to your office.
Check the shoes they are wearing and ensure that patients are wearing custom orthotics in the home as well as during work, sports and leisure activities. What’s important is that they maintain healthy stabilization around the clock. Foot Levelers has many custom orthotics styles to accommodate all their footwear.
Heel Lifts and the Anatomic Short Leg:
Begin by doing exactly what you did for someone with the functional LLD. Once you get to the post-adjustment check, someone with an anatomical LLD is going to still show one leg shorter than the other. An anatomical short leg is physically shorter than the other in some manner. Here is a suggested protocol of what to do:
- Begin with prescribing a pair of custom orthotics for the patient and have them wear them for two weeks. After you follow up, see how the patient’s symptoms, presentation and life are going for them. Most of the time, I never need to use a heel lift of any kind. The Foot Levelers orthotics provide support to all the three arches and the body can right itself enough for the patient to feel great. If the patient indicates that they still feel “off” or you are noticing symptoms or patterns in the body that you still want to improve, go to step two.
- After the initial two weeks has passed and you feel the patient needs more correction, begin with a three mm heel lift under the short leg. Let the patient go another one to two weeks and re-evaluate them and see how they progress. Use your judgment to see if they are good now or they need to go to step 3.
- After one to two weeks with the three mm lift, if you feel they need even more correction, proceed to the five mm lift. Observe for another one to two weeks and then re-evaluate. If you feel the five mm lift is not sufficient, then move to step 4.
- After one to two weeks with the five mm lift, if you feel they need even more correction, proceed to a seven mm lift. Again, evaluate after one to two weeks and see how the patient is doing.
- Any correction over seven mm must be physically done to the outside of the shoe. A shoemaker or shoe repair technician will have to build material on the bottom of the shoe to raise up that side.
In my practice, I rarely use any lift above five mm. The higher you get, the more serious the condition and the more biomechanical implications follow. Just be confident about putting in a heel lift and explain to the patient why they may or may not be important.
The patient can always take away a heel lift if it is too high for them and go back to the previous lift or no lift based upon their comfort. That may be part of the clinical treatment plan. The patient feedback will tell us what feels right.
Bring it all home with the custom, three-arch, flexible Foot Levelers Custom Orthotics:
My monthly blog posts are written to help you communicate information more effectively and concisely with your patients. We are all busy and have schedules to keep but we NEVER cut corners and give our patients less than 100%. The information I have provided helps us to convey knowledge about the LLD phenomenon so patients can understand and apply it.
Your inclusion of the custom orthotics in your treatment plan is critical. Nothing will help stabilize the entire body like a pair of custom orthotics to support your ongoing, expert chiropractic care.
So get creative and make recommendations based on your knowledge of the patient and their lifestyle. Our patients respond well to these products and they make such a difference for their symptoms and overall balance of their body. Plus, they appreciate you and your expertise partnering with them to maintain an active, healthy lifestyle.
Dr. Kevin M. Wong, DC is a graduate of the University of California, Davis, and a 1996 Summa Cum Laude graduate of Palmer College of Chiropractic West. He has been in practice for over 25 years and is the owner of Orinda Chiropractic & Laser Center in Orinda, CA.
As a member of Foot Levelers Speakers Bureau since 2004, Dr. Wong travels the country speaking on extremity and spinal adjusting. See upcoming events with Dr. Wong and other Foot Levelers speakers at footlevelers.com/seminars. Check out his monthly blogs with proven practice tips to help you achieve optimal patient outcomes.