Are Your Legs a Different Length?
Do you have a Pelvic Tilt?
“More common than you may think and without correction this postural imbalance will eventually cause terrible wear in your spine.”
-By Tim Errington, DC
Leg-length inequality is surprisingly common and can go undetected for many years. Usually there will eventually be some varying symptoms which can be from mild to extreme. So, if leg-length inequality is suspected, then a focused examination by a qualified structural chiropractor is the best course of action. He will determine the amount of difference and establish whether or not it is impacting on the patient’s spine and/or gait.
The chiropractor should determine the source of the inequality, and establish whether or not a correction should be made. Finally, he should determine, by evaluation, whether the treatment has sufficiently addressed the problem.
Examination should be in a standing position
The patient should be examined in a standing, weight-bearing position. Measurements of leg-length discrepancy obtained prone or lying down in non-weight-bearing positions are unreliable as muscle imbalance will affect the results. If there is a pelvic tilt due to a possible leg length difference, then an X-ray is always the best course of action as it is vitally important to be accurate. Correction without a standing X-ray should only be done with young children and even then parents could be wise to request one.
The spinal degeneration that results from leg length discrepancies can be absolutely devastating to a person’s health, and it is therefore vital that an accurate clinical evaluation is made. There can be no guessing here; there is too much at stake. Once an accurate determination is made, then effective chiropractic care can proceed. Since the legs provide support for the pelvis both during standing and walking, it is of no surprise that an inequality can have a far reaching effect on both pelvic and spinal alignment.
The X-ray above shows a 40 year old woman from the front. We see a leg length inequality of only 5mm (on the left), which is tilting the pelvis and causing a lumbar curvature. If you look at the spine from the side (on the right) we can see that already the lower disc space is thinning with degeneration.
Here we see a 60 year old man whose inequality was never recognized. The result was massive degeneration and he used a walking stick just to get around. When he came to our clinic he had already suffered 25 years of terrible pain. This could all quite easily have been avoided if only he had found the right chiropractor!
If one leg is shorter than the other then it follows that the pelvis becomes un-level and it tips the spine to one side. This can then cause an abnormal lumbar curvature or even a scoliosis. Walking patterns are altered subconsciously in compensation. This can lead to uneven wear and eventually hip or knee replacement surgery. A leg-length difference of 5mm or over statistically results in a higher incidence of low back pain. Athletes, on the other hand, and those who spend a lot of time on their feet may develop chronic symptoms with just 3 mm of discrepancy.
Anatomical or Functional?
There are two classifications of a short leg based on structure and cause. Each needs identifying and will require different treatment. An anatomical short leg is caused by a difference in the length of the actual leg. This can happen after a fracture or perhaps a hip replacement, but is most often the result of asymmetrical growth. A functional short leg isn’t actually a short leg at all; it just seems that way. The most common cause is excessive pronation of a foot (flat foot) on one side, and another possibility that we see often here in Singapore is excessive valgus (bow legs). If one leg is bent more than the other then this may also be a cause.
Correction – Orthotic or Lift?
When we know that there is a pelvic tilt due to a Leg Length Inequality, providing support to improve symmetry is the most effective treatment. When an anatomical difference in leg length affects the alignment of the pelvis and spine, chiropractic care should include the recommendation of an appropriate amount of heel-lift to raise the pelvis on the low side. The body can tolerate a small discrepancy and generally it is accepted that anything under 3mm difference is OK. The exception may be athletes (such as long distance runners), who spend many hours a day exercising and competing on their feet.
If the cause is partly or entirely a functional one due to foot pronation, then the use of orthotics to stabilize the feet must be incorporated into the correction.Only the standing postural exam, with careful evaluation of lower extremity alignment, permits this determination.
For most patients, a slight under correction (to within about 3 mm) is generally the best way to achieve good results while avoiding any negative reactions. If the amount of lift needed exceeds 6 mm (i.e.the difference measured at the femur heads is more than 9 mm), then usually the additional lift must be built onto the shoe, since a lift in excess of 6 mm will push the foot out of most shoes. This is done by adding half of the heel lift amount to the sole of the shoe.
Why are X-Rays so important?
When the chiropractor is considering making a correction for Leg Length Inequality this absolutely MUST be done by referring to a radiographic study (X-ray). At times the spine is such that a correction of the leg length will push the spine further away from normal alignment and this can have disastrous results. So, the correct weight bearing X-rays with the right interpretation is a must!
How long does the correction take?
Usually patients that present with a Leg Length Inequality are suffering symptoms and this is why they sought chiropractic care. If a pelvic tilt is left untreated long enough this will usually result in serious damage to the spine and especially the lower intervertebral disc. If this is the case then the treatment may take some weeks or months as the functional changes required to evoke change and healing must be done gradually.
At Total Health Chiropractic we will not introduce all the changes in one go as, if there is a provocation of symptoms, then we want to know what is causing it. We will usually loosen the pelvis and the spine with adjustments before gradually introducing corrective lifts. The heel lift may be introduced from about the sixth adjustment, depending on the particular case. The lift will be introduced 3mm at a time with at least 4-8 weeks between to allow the body to gradually adapt. Obviously the more degeneration there is in the spine, the slower will be the changes. It’s usually better to be over conservative rather than over aggressive with the correction.