Trendelenburg Gait Leg Length Discrepancy

posted on 29 Apr 2015 15:05 by entertainingvoo6
Overview

If one scans the literature it readily becomes obvious that leg length discrepancy/asymmetry is a common finding. This fact has been a very controversial topic within chiropractic, and diagnostic rationales have been built around this very common finding.

The object of this column is to consider some of the causes of this discrepancy that the profession may have ignored or not been aware of.Leg Length Discrepancy

Causes

The causes of LLD are many, including a previous injury, bone infection, bone diseases (dysplasias), inflammation (arthritis) and neurologic conditions. Previously broken bones may cause LLD by healing in a shortened position, especially if the bone was broken in many pieces (comminuted) or if skin and muscle tissue around the bone were severely injured and exposed (open fracture). Broken bones in children sometimes grow faster for several years after healing, causing the injured bone to become longer. Also, a break in a child?s bone through a growth center (located near the ends of the bone) may cause slower growth, resulting in a shorter extremity. Bone infections that occur in children while they are growing may cause a significant LLD, especially during infancy. Bone diseases may cause LLD, as well; examples are neurofibromatosis, multiple hereditary exostoses and Ollier disease. Inflammation of joints during growth may cause unequal extremity length. One example is juvenile rheumatoid arthritis. Osteoarthritis, the joint degeneration that occurs in adults, very rarely causes a significant LLD.

Symptoms

The effects vary from patient to patient, depending on the cause of the discrepancy and the magnitude of the difference. Differences of 3 1/2 to 4 percent of the total length of the lower extremity (4 cm or 1 2/3 inches in an average adult), including the thigh, lower leg and foot, may cause noticeable abnormalities while walking and require more effort to walk. Differences between the lengths of the upper extremities cause few problems unless the difference is so great that it becomes difficult to hold objects or perform chores with both hands. You and your physician can decide what is right for you after discussing the causes, treatment options and risks and benefits of limb lengthening, including no treatment at all. Although an LLD may be detected on a screening examination for curvature of the spine (scoliosis), LLD does not cause scoliosis. There is controversy about the effect of LLD on the spine. Some studies indicate that people with an LLD have a greater incidence of low back pain and an increased susceptibility to injuries, but other studies refute this relationship.

Diagnosis

There are several orthopedic tests that are used, but they are rudimentary and have some degree of error. Even using a tape measure with specific anatomic landmarks has its errors. Most leg length differences can be seen with a well trained eye, but I always recommend what is called a scanagram, or a x-ray bone length study (see picture above). This test will give a precise measurement in millimeters of the length difference.

Non Surgical Treatment

Treatment for an LLD depends on the amount of difference and the cause, if known. The doctor will discuss treatment options carefully with you and your child before any decisions are made. It is important to note that treatment is planned with the child?s final height and leg lengths in mind, not the current leg lengths. Treatment is generally not needed if the child?s final LLD is predicted to be 2 centimeters or less at full height. However, the child should return to an orthopaedic doctor by age 10 for re-evaluation. Treatment is often recommended for LLDs predicted to be more than 2 centimeters at full height. If treatment is done, it usually doesn?t begin until the child starts walking. Possible treatment options include, A ?lift? in one shoe to level the child?s hips. This is often the only treatment needed for small discrepancies.

LLD Shoe Inserts

Surgical Treatment

Surgeries to lengthen a leg are generally only performed when there is a difference in leg length of greater than four centimeters. These types of surgeries can be more difficult and have more complications, such as infections, delayed healing, dislocations, and high blood pressure. In a several step process, bone lengthening surgeries involve cutting a bone in two in order to allow new bone growth to occur. After the bone is cut, a special apparatus is worn with pins that will pull the bone apart at approximately one millimeter per day. This causes osteogenesis, or new bone growth, in between the cut bone segments. A cast or brace may be required for several months after surgery to allow the new bone growth to harden and provide extra support.