LLD

[ericparker]

Have someone coming in who was reffered by Scholls as they apparently measured from his knee to his heel (not conventional?) and found that there was an inch discrepancy! I'll wait and see before I pass judgement on that one! Generally what height is max for a heel lift on an orthotic before you switch attention to the shoe?

regards

Eric

[robertisaacs]

Hey eric. Welcome to the forum. Excellant first question.

An inch below the knee? Sounds dodge to me!! But as you say we'll wait and see. People do get excited about LLDs, osteopaths especially. If i had a quid for every time someone said "they were 2 inches different but he's corrected it now so its only 5mm" i'd have... well a fiver at least.

Measuring LLD BK is not so unusual. I like to do it if only to see where the LLD is. I suspect its a good deal more repeatable as well (based on personal observations) since the bony markers are easier to find and have less soft tissue.

To answer your question, it depends on the shoe. Some are better than others at accomodating lifts. As a general rule i rarely put more than 6mm of solid raise in a shoe (or 10mm soft).

TOP TIP. Don't neglect to look at the OTHER shoe. Some shoes have really thick linings or heel wedges which can be removed. That can buy you a few more MMs. Or sometimes you can just grind some of the heel down. Theres more than one way to skin a homeopath.

Regards
Robert

[ronm]

personally i don't measure LLD. i test by getting pt to cop hold of couch armrests, push up and slide posterior into apex of chair and evaluate relative positions of medial malleolii (and repeat 3x)

scope for inaccuracies certainly, but no more so i believe than with using a tape measure between boney prominancies.

[dtt]

Hi All

As far as I am aware the only accurate way of assessing an LLD is via a single sweep CT scan ??

But back to the real world

I have found in unnecessary (unworkable) to post more than half the measurement of the total LLD on an orthotic.

Unnecessary , because by posting half the shortening ,that usually alleviates any symptoms.

Unworkable , because to post more on an inch shortening via an orthotic would I believe compromise the fit of normal footwear so my logic dictated "if you have to change the shoes anyway get the heel raise fitted to the new pair or to the existing pair" and save the pt the expense of new shoes.

Just my thoughts on that one

Happy New Year to ALL BTW ;D

Cheers

Derek

[robertisaacs]

I have found in unnecessary (unworkable) to post more than half the measurement of the total LLD on an orthotic.
Unnecessary , because by posting half the shortening ,that usually alleviates any symptoms.

Unworkable , because to post more on an inch shortening via an orthotic would I believe compromise the fit of normal footwear so my logic dictated "if you have to change the shoes anyway get the heel raise fitted to the new pair or to the existing pair" and save the pt the expense of new shoes.

Just my thoughts on that one

Half is about iso9000 standard.

My thoughts on how much and whether to do it are predictably ambivilant.

We know that the movement of the STJ produces around 10mm worth of variation in Leg length (don't ask me for the reference but i remember the study.)

We know that a good amount of the "rest" can be made up with the knee remaining flexed longer.

We cheerfully chuck a pair of insoles in which will (alledgedly) limit pronation and thus remove one of the mechanisms by which the body compensates for an LLD... then we stick a 3mm heel raise on with great fanfare and expect it to make a difference!

Consider the well known and oft lamented inconsistancy in measurement for LLD and the potential problems with aligning a spine which may have been settled into its misaligned position for years with associated bony and soft tissue change (davis law).

Consider also the fact that it is damn hard to assess to what degree the patient is already compensating for the difference during gait (assuming they are not a hairdresser or a buck house guard).

Should we be using heel raises at all in patients with anything but gross LLDs?

Personally the primary factor for me when deciding to use a heel raise (or not) is generally the gait analysis rather than the static assessment. If the static shows anything under 10mm but the gait looks symetrical from the hips north i tend not to bother. If they measure right but the gait is significantly asymmetrical i will often use a raise regardless of the static measurement.

And when i do use them it tends to be based on the formula of "a bit", "some", "a chunk" or "loads" rather than all or half of what i measure!

But what do i know?
Regards
Robert

[dtt]

Morning Robert

Having a bad one already ?? ;D

The question was

Generally what height is max for a heel lift on an orthotic before you switch attention to the shoe?

I just expressed an opinion on that question.

I personally do not post on asymptomatic LLD because

Consider the well known and oft lamented inconsistancy in measurement for LLD and the potential problems with aligning a spine which may have been settled into its misaligned position for years with associated bony and soft tissue change (davis law).

On the rare occasions that I do

the formula of "a bit", "some", "a chunk" or "loads"

is the one I use.

I have found that to post no more than half the total LLD is all that is required to alleviate symptoms.

Again just my thoughts.

Robert the empty room awaits for your next row !! ;D ;D

Cheers
Derek

[robertisaacs]

Having a bad one already ??

Don't know what you mean!

Your thoughts were good. I LIKED your thoughts. I was just adding mine .

Although i am vaguely hoping somebody will disagree with me. Thats always fun. I'm in danger of having to do another of my supporting an unsupportable statement threads.

Its all love
Robert

[ianl]

Hi

Just a quickie

Some research being done at Lancashire uni is confirming that placing a raise to half the actual difference is enough to equalise pelvic function bilaterally. From this couls we The imply that this could be regarded as a maximum?!. Whether you place this on the orthosis or on the shoe is another question.

Back to my little cupboard under the stairs now with my Davy Lamp and Canary.

Ian

[robertisaacs]

Some research being done at Lancashire uni is confirming that placing a raise to half the actual difference is enough to equalise pelvic function bilaterally. From this couls we The imply that this could be regarded as a maximum?!. Whether you place this on the orthosis or on the shoe is another question.

I'd love to see that research.

A lot would depend on the methodology. Static or mobile? How are they assessing pelvic function? With or without the "arch support"?

Regards
Robert

[ianl]

Hi Robert
Prof Jim Richard's is the guy who has been leading it. Started of as a curiosity project in that many pods seem to use heel rises and so they began looking at it in more depth. He, I think, is a bioengineer rather than a pod and some info is available here:

www.djo.eu/en_US/eNews_June_2007_An_interview_with_Jim_Richards.html?taxonomyId=19498

They have looked at the raise issue both static and dynamic. Don't know about the arch support side of it. He has just published a book on biomechanics (along with a an interactive educational website for those using the book) in which some of the results are mentioned.

Cheers
Ian

[rothbart]

The first question that needs to be answered, in my opinion, is: are you dealing with a functional LLD or an anatomical (structural) LLD. In my experience, most LLD are functional, in which case, you would NOT use a heel left (actually you should never use a heel lift, but rather lift the whole foot using a heel to toe platform. Using just a heel lift will throw the innominate forward on that side and can actually unlevel the pelvis).

Many functional LLD are due to Asymmetrical pronation patterns. An excellent paper (again my opinion) was written on that subject in the December 2006 issue of the Journal of the American Podiatric Medical Association. I treat functional LLD by stabilizing the abnormal asymmetrical pronation patterns (FLLD are really a symptom of an unleveled pelvis). When the FLLD is due to an ascending pattern, stabilizing the foot will stabilize (level) the pelvis. And when the pelvis is level, the heels are level (FLLD is resolved without using any type of lift underneath the foot).

Hope this helps.

Prof B

[TimVS]

Today, Oi am mainly agreeing with..... Robert and Ian!

(Jesse's podiatry)

Anyway. I tend to use heel lifts where there is back pain or sometimes shoulder pain accompanying an LLD. Can help I find. Also useful with tight post compartment, PF, and Severs.

Problem with LLDs is it's all a bit subjective, so tends to be clinical rather than EBM. Nothing wrong with that IMO, but it does rather bring it down to suck it and see. I mean, take a pelvis that isn't level. Often cited. But why isn't it level? Pronated foot, lig laxity at knee joint, tight hamstring pulling pelvis downwards, tight QL pulling pelvis up? Glutes? Spinal curvature? SIJ? Some of those might not actually be helped with a heel lift, but better treated with soft tissue work, manipulation, etc. So it really comes back to a) trial and error and b) looking at the whole person rather than just the lwr limb, something us pods aren't always very good at

BTW I don't think ther are quite enough question marks in that post, so here's a few more for you ?

Right, I'll get me coat (must stop watching Fast Show repeats)

[robertisaacs]

Problem with LLDs is it's all a bit subjective, so tends to be clinical rather than EBM. Nothing wrong with that IMO, but it does rather bring it down to suck it and see. I mean, take a pelvis that isn't level. Often cited. But why isn't it level? Pronated foot, lig laxity at knee joint, tight hamstring pulling pelvis downwards, tight QL pulling pelvis up? Glutes? Spinal curvature? SIJ? Some of those might not actually be helped with a heel lift, but better treated with soft tissue work, manipulation, etc. So it really comes back to a) trial and error and b) looking at the whole person rather than just the lwr limb, something us pods aren't always very good at

This week i are been mostly... giving you karma for talking so much sense.

[TimVS]

;D

[rothbart]

When treating patients with an unlevel pelvis (e.g., a FLLD), you must treat the whole person. Otherwise your results will be less then optimal. A FLLD can come from the feet, but it can also come from the occlusion (ascending vs descending distortional patterns respectively). For more information, log on to my research website at www.rothbartsfooot.info. There is a great deal of information dealing with Ascending vs Descending Patterns (This is not a promotion, my research website is just that, set up to provide total body biomechanics).

Prof B