10/13/2010

 Optimal Requirements:

◦ Center of Gravity Control

Kathy J. Siesel, DPM
Ohio College of Podiatric Medicine
 Requires good alignment and function of the spine,
innominate bones and lower limbs
 Asymmetrical alignment at any level can alter the
center of gravity
◦ Minimal Energy Expenditure
 Differences in size or length of lower limbs or lower
limb girdles will change the amount of energy required
for movement

 Produces  Anatomical/Structural
◦ Abnormal control of center of gravity ◦ Due to difference in actual length of one or more
 Center of gravity is slightly different position relative segments
to each lower limb  Functional
◦ Imbalanced foot placement ◦ Due to abnormal function of one or more segments
 Shorter versus longer stride lengths on one side
◦ Compensations to maintain balance
 Combined
 Long side shortens and short side lengthens
◦ Part anatomic and part functional
◦ Increased work and stress
 All together requires more energy for movement  Environmental
◦ Created by surfaces and movement
= common cause of running injury

 1 lower limb is structurally shorter

 Short boney segment
 Any level of the limb including foot/ankle
 Compensation types
◦ Uncompensated
Shorter
◦ Partially Compensated segment
Shorter
◦ (Fully) Compensated Limb
Shorter
◦ Over Compensated segment
Shorter
segment
Ground

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 Lower limbs are of equal boney length

 Mechanical shortening of one or both limbs Structural/Anatomical Limb Length Difference
at any level due to:
◦ Spasm of muscle
◦ Contracture of muscle or tendon
◦ Abnormal foot function +
 Muscle
M l iimbalance
b l may b
be a result
l or the
h
etiology Functional Limb Length Difference
 Flexibility problems can arise due to
abnormal function

= Unilateral Pronation Combined LLD

Crested Road

 Limbs of equal structural length

o Uphill limb hits sooner
 Forced to function asymmetrically due to
acts like a long limb
environmental
e o e ta factors
acto s
◦ i.e.
shortens
h (pronates)
( )
 Uneven road surface o Downhill limb hits later
 Banked track acts like a short limb
 Asymmetrical shoe wear
 Shoe manufacture problem, ie: heel counter not set
lengthens (supinates) Uphill
Side
correctly
Downhill
Side

 Banked Track
 Banked Track ◦ Run too slow for track
◦ At optimal speed, • Runner is too vertical
body is perpendicular on banked track
to the track when running • Uphill
U hill limb
li b = llong li
limb
b
• Downhill limb = short limb

Pronates
Supinates

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 Definition
 Banked Track
◦ Run too fast for track ◦ The change in structure, position or function of one
 Runner is too horizontal on track part to neutralize the effect of or in response to an
 Uphill side = short side abnormal structure, position or function of another
 Downhill side = long side part

◦ Limb length differences create an abnormal

position and/or function of the joints

Supinates Pronates

 MTJ Pronation (closed kinetic chain)

 Depend on:
 STJ Pronation (closed kinetic chain)
◦ Amount of available motion in the compensating
joint/joints
 These can be proximal or distal joints or both  Knee Flexion
◦ Energy expenditure (tends to occur in direction of
least energy expenditure)
 Hip Internal Rotation
 Generally, pronation requires much less energy than
supination.
 Back/Spine Flexion/Functional Scoliosis

 STJ Supination (closed kinetic chain)

 Simple Curve
◦ Long Side
 Ankle Equinus  Spine Concavity
 Shoulder Tilt (Drop)
 Knee
K Varum
V  Iliac Crest Higher
◦ Short Side
 Spine Convexity
 Hip Valgum (genu varum position)  Higher Shoulder
 Pelvic Tilt (Iliac Crest Lower)
 Spine/Back Functional Scoliosis ◦ Head
 Appears tipped toward
short side

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 Unilateral Complaints
 Complex Curve
◦ Any level from foot to spine
◦ Long Side
 Convex thoracic spine  Paradoxical Symptoms
 Concave lumbar spine ◦ Pronatory versus Supinatory
◦ Shoulders level  Back Pain or Spasm
◦ Arms even ◦ Sciatica type possible
◦ Head perpendicular  Knee Complaints
◦ Any side, capsular, ligamentous, joint, tendinous
Iliac Crest height is  Foot Complaints
best indicator ◦ Any side, capsular, tendinous, ligamentous, joint

 Most commonly occur on the long limb side

 Reasons
◦ Longer stance phase (shortened swing phase) due
to earlier heel strike
◦ Increased stresses (shock absorption lessened due
to pronation)
◦ Pronatory compensations (plantar fasciitis, Achilles
tendinitis, tibialis posterior tendinitis, 1st MPJ pain,
shin splints, patellar tendinitis, anserine bursitis,
tight hamstrings, sciatica, SI joint pain, low back
pain)
 Asymmetrical function
◦ At any or multiple levels
 Unilateral or paradoxical diagnosis
◦ Symptoms may be only on one side or symptoms
on each side that may not seem to go together
 Asymmetrical shoe wear
◦ Shoe wear (outsole or upper) different on each side
due to difference in function

 Direct Assessment  Radiographic

◦ Radiographic
 Non-weight bearing
 Weight bearing
 Indirect Assessment
◦ Tape Measurements
 Non-weight bearing
 Weight bearing
 STJ neutral or relaxed
◦ Trial Lifts
 Of known thicknesses
Correlate with: ◦ Best is standing AP view lumbosacral level with feet
6 inches apart and beam perpendicular to iliac crest
oGait Analysis ◦ Measure limb length
oShoe Wear  Draw a line that connects the top of the femoral heads,
then measure the length of a line perpendicular to this
oSymptoms line from the top of the femoral heads to the floor (or
to the edge of the film to determine the difference)
Before and ◦ Measure the sacral base plane
after lift  Draw a line that connects the posterior part of the
addition sacral promontory and draw a line perpendicular to the
top center of the femoral heads that intersects the
sacral promontory line and measure the difference

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 True Limb Length  True Limb Length

◦ Measured from ASIS to Medial Malleolus
 Apparent Limb Length ◦ Pt. lying supine on exam table
 O.K. for screening or maybe for non-athletes
 difference may be inferior to medial malleolus
 Standing Limb Lengths
◦ in NCSP and RCSP
 Apparent Limb Length
◦ From ASIS to ground ◦ Measured from Umbilicus to Medial Malleolus
◦ From PSIS to ground ◦ Pt. lying supine on exam table
◦ Questionable value of measurement
 Umbilicus is midline structure
 Large difference required to be apparent

Standing Limb Lengths

 Standing Limb Lengths
◦ Measure from ASIS and/or PSIS to floor in both  If equal in NCSP Not Structural LLD
NCSP and RCSP
 Note differences
 Takes into consideration the structures below the  If not equall in
i NCSP S l
Structural
malleoli Component to LLD
 Considers compensations, if measure in both RCSP and
NCSP
 Can place thumbs horizontal at ASIS/PSIS and note
 If not equal in NCSP and structurally shorter
levelness of pelvis in both RCSP and NCSP (may be side is even shorter in RCSP Combined LLD
useful as a screening for athletes) (structural + functional components)

ASIS to Ground Right Left Difference ASIS to Ground Right Left Difference

In NCSP 97 95 2 cm In NCSP 97 95 2 cm

In RCSP 96 94 2 cm In RCSP 95 95 0 cm

 The difference is the same amount and direction in  The difference noted in NCSP is leveled out in RCSP
both RCSP and NCSP so there is no compensation. so there is full compensation.
 Will use a lift on the short side, heel lift to a full  Will likely need to control pronation of long side
length lift depending on amount and shoe gear and add some amount of lift on short side

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ASIS to Ground Right Left Difference ASIS to Ground Right Left Difference

In NCSP 97 95 2 cm In NCSP 97 95 2 cm

In RCSP 95.5 94 1.5 cm In RCSP 94 93.5 -1.5 cm

 The difference noted in NCSP is lessened in RCSP,
and the same side is short so there is partial
compensation.
 Usually need to control pronation and may also need to
use a lift
 The longer side in NCSP becomes the shorter side
in RCSP so there is over compensation of the limb
length difference.
 Usually need to control the pronation and may also
need a lift

ASIS to Ground Right Left Difference ASIS to Ground Right Left Difference

In NCSP 97 97 0 cm In NCSP 97 95 2 cm

In RCSP 96 95 1 cm In RCSP 96 93 3 cm

 There is no difference in NCSP and there is a
difference in RCSP so this is a functional limb
length difference as there was no structural
difference. You may also see the pronation only on
one side.
 Need to control the pronation.
 The difference in NCSP is the structural component.
The difference in RCSP is greater; this is the
functional component. Structural + Functional =
Combined
 Need to control the pronation and stretch the tight
structure(s)

 Sitting in chair with feet on floor  Head ? Tilted; toward long or short
◦ One knee higher Structural problem below knee
 Lying supine with knees flexed and heels  Shoulders ? Tilted; toward long or short
against gluteal region (Galleazzi/Allis test)
◦ Note knee heights Lower knee = Shorter limb
 Arm Swing ? Increased; on long or short
 “Wedge Test”: Pt. seated on exam table
squarely in center, grasp ankles press toward
table then pull gently and compare medial  Back ? Scoliosis (? Functional)
malleoli Concave – long, Convex – short
Complex curve
 Segmental measurements
?Reducible
◦ ASIS to Knee, Knee to Medial Malleolus, Medial
Malleolus to floor Sit or stand and bend over

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 Hip Unilateral movement on frontal or  Compare ASIS to PSIS

transverse plane
Lower on short side ◦ Both low on same side Structural LLD
◦ One low, one high on same side
Functional Pelvic Rotation; around the SI Joint
 Knee Excess midstance flexion  M
May need d to refer
f to chiropractor
hi or osteopath
h to have
h
Genu recurvatum repositioned
◦ Sacroiliac Joint Dysfunction
 Posterior Innominate
 Foot Unilateral pronation  ASIS low and PSIS high on one side
Increased angle of gait on long side  Anterior Innominate
 ASIS high and PSIS low on one side
Increased base of gait on long side

 General Guidelines  Heel Lifts in Shoe (athletic)

◦ Start small and work up to the point where you have
symptomatic relief
◦ Generally start with no more than ½ correction
◦ If change by ¼” or more, Pt. may have muscular
back pain for a few days
◦ Longer lifts (more toward the toes) maintain more
normal function of foot and ankle (less equinus)
◦ Shoe gear determines amount of lift and length of
lift (running shoe versus soccer cleat)
◦ May end up at a totally corrected level
◦ Up to ¼ inch can add under heel only
 May need to extend more distal if it is uncomfortable
◦ ¼ to ½ inch need to extend more distal to distal
arch, metatarsal heads or sulcus
◦ > ½ inch in shoe is full length to toes = sole lift
 still must taper it to fit into shoe under met heads
◦ If using orthotic and < ¼ inch may be able to
decrease thickness of orthotic on long side (debulk
heel)
◦ If have an ankle equinus on long limb side, then will
need to add equinus lift on both sides.

 Sole Modifications
◦ > ¼ to ½ inch lifts need to be added to the sole  If biomechanical problem
 Write prescription and send to shoe repair or
pedorthist for lift to be added use functional orthotic
◦ Problems with sole lifts
 Awkward If muscular
 l problem
bl
 Add weight (can consider hollow lift or cork lift)
 If added improperly, changes function of shoe
correct muscle imbalance
◦ Can consider removing the height from the other ◦ Stretching
shoe ◦ Strengthening
 From the midsole material outside shoe ◦ Surgical lengthening/shortening
 From the inside of shoe

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 All options available

◦ Lifts
◦ Orthotic device
◦ Correct imbalance
 Stretching
 Strengthening
 Surgical

 What to start with first?

 May require any or all of these.