Leg Length

Replies to This Discussion

Permalink Reply by Walt Fritz, PT on September 30, 2010 at 6:17pm

I don't mean to butt in before Joe, but I use a supine measurement. With legs in midline, I traction then rest the legs on the table. Thumbs nestled under each medial malleoli and compare sides. Chiros often do this in prone, but I find it easier in supine.

I have already done a standing pelvic evaluation to check for rotation/upslip. If the standing and supine findings agree, I seldom look farther. If they differ, I may measure using a tape measure. I measure from greater trochanter to malleolus. To me, measuring as I was taught in PT school (ASIS to malleolus) means very little.

Walt Fritz, PT

Permalink Reply by Robert Downes on October 1, 2010 at 6:05am

Tanks Walt! What do you mean by "With legs in midline"? Also, how do you check for the rotation/upslip?

Thanks,
Bob D

Permalink Reply by Walt Fritz, PT on October 1, 2010 at 6:25am

Robert,

"Legs in midline" just refers to assuring that the leg, when measured in supine, are in a neutral alignment and not shift off to one side.

Rotation is checks by palpating and comparing each ASIS and PSIS. Low ASIS indicates anterior rotation while high ASIS indicates a posterior rotatioin. High PSIS indicates anterior rotation while low PSIS indicates a posterior rotation. Measuring the levelness of the lateral pelvic crests gives you an indication of relative upslip/downslip. A pure pelvic rotation reads, for example, right ASIS low, right PSIS high (in standing) and right leg long in supine = pure right anterior rotation, as the anteriorly rotated side will have a "lengthened" leg. Add into the mix an upslip in the right and the legs may measure as equal in supine, despite the obvious pelvic rotation.

Permalink Reply by Robert Downes on October 5, 2010 at 12:23pm

Thanks, Walt. Here's another question: How do you measure tibial rotation versus forefoot abduction/adduction. That is, if you see externally rotated feet how do you know if it is coming from the forefoot versus coming from tibial external rotation?

Thanks,
Bob D

Permalink Reply by Walt Fritz, PT on October 5, 2010 at 5:31pm

I would back up to the hips first. Get them prone and measure internal vs external rotation. Int Rot should be 35 degrees, external 45 degrees. Limitations in one direction or another will give you an indication as to whether the hips has tightness (from what ever source). As I said previous, anterior pelvic rotation of one side tends to internally rotate that femur. This rotation will get translated down the foreleg, usually creating a pronation of the foot.

I typically pay little attention to specific forefoot rotation, unless there appears to be some sort of deformity. I find it will follow the femur.

Permalink Reply by Robert Downes on October 6, 2010 at 12:46pm

Thanks Walt, this is great information! I am trying to differentiate forefoot external rotation (abduction) from tibial external rotation because I just took an orthotic seminar that makes a distinction betwwen the two in their algorithm. If the tibia is externally rotated then you have to view the foot external rotation amount by looking in the plane that the tibia is rotated.

Thanks,
Bob D

Permalink Reply by Peter Lelean on October 6, 2010 at 4:21pm

Hey guys . . interesting post on a critically important topic. Walt, as usual, is in my view right on the money. A few more things to consider; how is it all put back together i.e. misalignments, fascial migration around the pelvis, issues with pubic symph alignment etc. Perhaps looking at tibial torsion is also an issue in some cases of forefoot rotation. Walt's comment on anterior pelvic rotation invites consideration of tight iliopsoas . . anterolisthesis . . kyphosis . . are we on track here Erik D? Following this post with interest, as I am hoping to provide some novel strategies for all of these issues in future workshops in USA. The protocols have been written already. Peace to all. Cheers P

Permalink Reply by Joseph E. Muscolino on October 27, 2010 at 1:10pm

Hi Folks,

Sorry to be so absent. I have been extremely busy in the office, and working on a neck treatment book. It should come out in 2011.

I will throw in a few cents on this topic.

Being a DC, I learned to measure limb length with the patient prone, so I am comfortable with that position. Having said this, I do not put that much importance on limb length, at least not as much as many DCs do. I certainly use it to double check by standing postural evaluation for discrepancies that might cause a low iliac crest height and therefore a compensatory scoliosis, but I do not ascribe the myriad of things to limb length discrepancy that so many DCs do.

I will just throw in a thought about the rotation of the lower extremity, causing the foot to "flare" out. It can come from a number of sources, right? The thigh at the hip joint can be rotated laterally, the knee joint can allow some rotation, at least if the patient's knee joint is flexed. The tibia itself can have torsion in the transverse plane (and usually does), and the tibia can also have a varus bending that alters the position of the foot. And the subtalar (and transverse tarsal) joint can be abducted (I have started calling this lateral rotation because I feel it is more intuitive for students to see), which occurs with pronation. AND, there is the interdependence... e.g., if the hip joint is laterally rotated, then the patient walks over the medial side of the foot, which can cause excessive loss of arch, i,.e, excessive pronation, thus abducting (laterally rotating) the foot...

very complicated...