LIMB LENGTH DISCREPANCY
Types of limb length discrepancy
1. True limb length discrepancy
Caused by anatomical or structural change in the lower leg resulting from
congenital maldevelopment (congenital hip dysplacia) or trauma (fracture).
2. Functional/Apparent limb length discrepancy
Results from a compensation for a change that may have occured because of
positioning rather than structure.
This LLD is assessed to determine whether leg length differences are due to some
type of pelvic obliquity, sacroiliac dysfunction, foot pronation or supination or
postural abnormality (spinal scoliosis).
This test is done after it has been determined that a true limb length discrepancy
does not exist.
Observation of limb length discrepancy
The presence of LLD can be observed in standing:
Hip and knee fixed on long side
Ankle plantar flexed on the short side
Asymmetric lower gluteal crease
Pelvic tilt/obliquity
Shoulder tilt to one side
Foot supinated on short side and pronated on long side
Pelvic tilting can be due to limb shortening, hip abduction/adduction or spinal
deformity
Observing LLD during gait
Unequal arm swing
Marked limp during gait
Measurement of True Limb Length
Squaring of the pelvis
True limb length can be measured only after squaring the pelvis and measuring
each leg in the same identical position
The legs should be 15-20 cm (4-8 inches) apart and parallel to each other
The distance between the umbilicus and the left ASIS should be equal to the
distance between the umbilicus and the right ASIS
Both ASIS should be in a straight line parallel to the couch
1. Tape measurement
From ASIS (distal aspect) to medial malleolus (distal aspect)
However these values are influenced by muscle wasting or obesity. Hence an alternative
method is to measure from the ASIS (distal aspect) to the lateral malleolus (distal aspect).
Disadvantages of measurements limited till the medial malleolus
Measuring to only the medial malleoli disregards the potential for LLD arising from
asymmetry in the foot distal to the tibiotalar joints calcaneal fracture, developmental
abnormalities, degenerative arthritis, Charcot foot (collapsed medial longitudinal arch).
Some other potential sources of error of the tape measure method include deviation of
the tape measure owing to differences in the circumferences of the legs or unilateral
deviations along the long axis of the leg (eg, because of genu valgum)
2. Segmental measurement
Femoral length: Greater trochanter to lateral knee joint line.
Tibial length: Medial knee to medial malleolus
3. Iliac Crest Block Method
A common alternative method is to palpate the iliac crests of the standing subject and to
estimate the extent of the asymmetry.
Iliac crest palpation with blocks (ICPBL) technique, in which 5-mm blocks are placed
under the short limb to level the iliac crest heights.
This method takes into account the disparity in foot height between the two limbs. Using
varying heights of the block helps to establish the additional length required for the
patient to feel level
4. Determining shortening above the Great Trochanter
Measurement from the GT to the lateral joint line will give an indication of the
femoral shaft length.
Nelaton's Line : Imaginary line drawn from the ischial tuberosity of pelvis to ASIS
on the same side. If the Greater Trochanter of femur palpated well above the line
it is an indication of a dislocation of hip or coxa vara. Both the sides should be
compared
Bryant's Triangle : Patient lying in supine, examiner drops an imaginary
perpendicular line from ASIS of pelvis to the examining table. Second imaginary
line is from tip of the Greater Trochanter of femur to meet first line at right angle.
Second line is measured and compared with the opposite side. Differences may
indicate conditions like coxa vara or C.D.H (Congenital dislocation of hip). This
measurement can be done with radiographs.
5. Weber- Barstow maneuver
Visual method
Patient in supine lying with hips and knees flexed.
The therapist stands the patient's feet and palpates the distal end of the medial
malleolus
The patient then lifts the pelvis from the examining table and returns it to the
starting position
The therapist passively extends the patients legs and compares the position of the
malleoli using the borders of the thumbs
Different levels indicate asymmetry
6. Galleazzi Sign (Allis sign)
The knees are flexed to 90 degrees with hip and ankle at 45 degrees.
Note the height of the knees and the parallelism of the femur and the tibia
If the knees are at different height and the femur are parallel, the discrepancy is in
the femur. (The longer femur will cause the ipsilateral knee to project more
distally)
If the knees are at different height and the tibia are parallel, the discrepancy is in
the tibia. ( The longer tibia will cause the knee to lie more proximal than the
opposite side)
7. Relative length of tibia
Patient in prone lying. The examiner places the thumbs transversely across the
soles of the feet just in front of the heels. The knees are flexed to 90 degrees and
the relative height of the thumbs are noted.
The legs should be perpendicular to the examining table
8. Relative length of the femur
Patient in spine lying. Hip and knees flexed to 90 degrees. If one femur is longer
than the other, its height will be longer.
If the limb length discrepancy is more than 2cm shoe lift will be given for short leg
Functional/Apparent Limb Length
1. Xiphisternum to medical malleolus keeping the body and the legs parallel to the
couch and not making any attempt to square the pelvis
2. Umbilicus to the medical malleolus
3. Supine to Sitting method
Patient is in supine lying with straight legs
Therapist examines if the medical malleoli are level
Patient is asked to sit up
The therapist observes whether one leg moves proximally farther up than the
other. If one leg moves farther up than the other, it is a functional LLD arising
from pelvic rotation. It may be also because of lumbar pathology.
4. Observation method
Patient stand in normal relaxed standing position
The therapist palpates the ASIS and PSIS and notes any differences
The therapist then positions the patient so that the subtalar joints are in
neutral position while weight bearing. The patient maintains this position
with toes straight ahead and knees straight
The therapist re-palpate the ASIS and PSIS
If the previously noted differences disappear, a functional LLD arising from
pelvis, hip, knee, ankle and foot problems should be suspected.
Upper Limb Length Discrepancy
Patient position: Standing erect or supine
Length of whole arm: Acromion to tip of middle finger
Humerus length: Acromion to the lateral epicondyle
Ulnar length: Olecranon process to the ulnar styloid process
Hand length: Distal crease at wrist to tip of middle finger
Limb Girth Measurement
Measurement of circumference of the limb
Indicators:
Generalized Oedema
Local Swelling
Joint Effusion
Atrophy/Disuse atrophy
Method of girth measurement
Ankle figure of eight (Pg no. 937) -
Measurement of hand swelling (Pg no. 478-479) -
Lower limb girth measurement (Pg. no848) -
1) 6 inches below the Apex of Patella
2) Apex of Patella or joint line
3) 2 inches above Base of Patella
4) 4 inches above base of Patella
5) 6 inches above base of Patella
6) 9 inches above Base of Patella
The other method of limb girth measurement
Take the segmental length and divide into 3 parts. Measure at each point.
Compare with the opposite side
