Leg length discrepancy

[YoungM]

Hi all,

I know we had this discussion in another thread, but just wanted to share my experience and find out if anyone can relate to this, as I'm a bit nervous now.

I am 4.5 weeks out from surgery -had a RTHR on 3/17/09. At this stage, I am walking with the cane, but still have a limp. The limp is minimal with the cane (since I apply a lot of pressure to the cane to avoid it), and is very noticeable when I try walking with no assistance.

My right (operated) leg feels and actually is longer than my left. I looked at my legs in the mirror and my operated right knee falls lower than the left. Also, if I bend my knees up in bed, the right knee pops up higher than the left. The discrepancy is definitely there.

Prior to my surgery, I always shifted my weight to my left hip and stood with all my weight on one side; however, I never felt like my leg was longer than the other, now I do.

The PT took a look at it last week and told me that there definitely is a discrepancy. I don't see my OS until 1.5 weeks. I also don't have outpatient therapy until after I see the OS. Is there anything I can do, or just be patient and continue with walking and exercising?

My other question is -did others have this, and did you find it evened out in time? If so, how long? I realize that I may have a permanent limp -but I'm really hoping this is not the case. I know we talked about the point of the surgery is to remove joint pain, not a limp -but I never had a limp prior, so it upsets me.

Thoughts? Thanks as always

 

[Jamie]

Melissa, try not to worry too much about it at this point. You are still early in your recovery and these things many times will work themselves out. If the feeling of length discrepancy and your limp are still there when you see your surgeon next, talk with him about it and see what he thinks. I would continue using the cane because it is always better for your body to walk properly and not limp. Bless your heart....I can understand why this would be upsetting to you. I hope some of the other hippies who have been through this write soon to help ease your fears.

 

[Josephine]

I can understand your concern - it's one of those "help - am I stuck with this now?" things, isn't it? But as Jamie says, things can change and do. If it's only a few days before you see your chap, then try not to focus too much on this until you see him.

Does your other hip have replacement anywhere in the future?

 

[prairienut]

Melissa, I understand your concern. I am only 2 weeks out and have noticed that my operated leg is slightly shorter than the other, using the same methods you did. I had my staples removed yesterday and asked the PA about it. She said do nothing at this point -- often (usually?) small discrepancies are compensated for by the tilt of the pelvis. Even before the surgery, my operated leg was shorter than the other due to the osteoarthritis and didn't cause me to limp (when it pain-free). You will know better as time goes by how well your body compensates for any difference. I am still using a cane at all times, so I don't know yet what will happen when I try to ditch the cane. I have heard that larger discrepancies may require a shoe lift on the short side. I think we just have to be patient and do our best at the PT.
Gail

 

[Troweltalk]

This is actually a little more common than most people think. In sopme cases, the leg discrepency is significant and in others negligable. In the latter I have heard of it being adjusted with a shoe insert, in your case I guess it would be on your good side to lengthening it to the operated side.

As Jo asked, if your other hip is suffering from a condition that one day will warrant its replacement, that is an opportunity to level the legs out. Your discrpency may actually be from either a slight miss on the cut and placement of the stem or that your good leg has taken such a toll that it needs time to adjust to having a full partner in teh support system again. At first, I could have sworn my operated leg was longer too, but after 5 or 6 weeks of therapy and walking things out, I can't detect any difference anymore and the doctor swears there isn't any.

Good luck!

 

[YoungM]

Thanks everyone. My X-rays show that my left hip is just fine and no signs of arthritis or AVN at all. I will give it some time and discuss with my OS on 4/27. I will also ensure the PT is aware of my issue.

Mud -I'm really hoping it was not a placement issue -I know my OS uses computer assisted technology to ensure exact placement. Hopefully it's a matter of completing my healing.

I'll keep you posted!

 

[Troweltalk]

Thanks everyone. My X-rays show that my left hip is just fine and no signs of arthritis or AVN at all. I will give it some time and discuss with my OS on 4/27. I will also ensure the PT is aware of my issue.

Mud -I'm really hoping it was not a placement issue -I know my OS uses computer assisted technology to ensure exact placement. Hopefully it's a matter of completing my healing.

I'll keep you posted!

Melissa, I may have worded that comment badly; I didn't mean to suggest a mistake may have occured. From what i read, there is a very delicate balance to know just how far the stem will settle into the femar even if the cut is perfect. I believe that issue is the primary cause of leg discrepency.

 

[YoungM]

Ah, gotcha Mud. That makes perfect sense. Thanks for clarifying.

 

[nickji]

Hi Melissa,

Firstly, don't worry - easy to say I know, I worry way too much !!! But in this case from everything I've read on this forum and elsewhere, many many people feel that their leg length is different, when in fact it's almost always the same. But, for your peace of mind, you should check it, and you can. . .

Now, to details, which will take a bit of time, I'm afraid. Maybe you already know all of this, but maybe you don't, so here goes....

Looking at your legs can never accurately measure length. And unless your PT has x-ray eyes, however good s(he) may be (s)he also cannot tell leg length by looking. There is only one way to know, and that is by measurement. If your PT did measure, then maybe they're different, but if s(he) only looked, then quite honestly I'd get another PT.

The reason for this is very simple; there are two ways to measure leg length, apparent and actual. Apparent leg length is affected by many things including your muscles and the way you're 'holding' your hip - and if there's a difference it's quite easy to fix. Actual leg length is the true length of the boney structure, and, as I say, can only be assessed by measuring.

There are many ways to measure actual leg length; one of which you can do yourself, with someone to help you. No qualification or experience is required. You just get a tape measure and measure from a point at the front of the hip called the ASIS (I'll show you where that is in a moment) to the inner ankle bone. You simply lie flat on your back, hold one end of the tape to your ASIS and have your friend stretch it down to your inner ankle bone. Check the length and repeat, holding the tape to the ASIS on the other side. That's it. If the lengths are the same (and most likely they will be), then no matter what it looks like, your leg lengths are equal.

So, where is the ASIS? It's here:

Anterior Superior Iliac Spine. Just put your thumb on the top of your hip bone at your side (where it says 'iliac crest' on the diagram) and move it forward along the bone, and suddenly you'll reach a point where the bone goes vertically downward - that's the ASIS.

and the inner ankle bone, which of course you know, is here:

(the medial malleolus)

Just grab a tape measure and a friend and set your mind at rest. Make sure you're lying flat on a firm surface, with minimal clothing so cloth doesn't affect the measurement.

Enjoy it all,

Nick

 

[YoungM]

Thanks so much, Nick. I will try this. I am done with my inpatient PT. The therapist said it was too early in the game to tell (since it was only 2 weeks at the time) and he only looked at it without measuring. When I go to outpatient therapy, I'll be sure they do this technique to check too.

 

[HopAlong]

Melissa,

My leg length diff is ever so slight.....maybe 1/4" at max, but my limp is still bad too. Did your PT say how much difference?

Its all about PT. Don't worry just yet because one thing I learned is that the more they increase the intensity of my PT workout, the straighter I begin to walk. It's all about gaining full control of your muscles again.
Each time the PT's ask me if I am ready to step it up.....I always say YES! Graduating to the lifecycle made a huge difference too. Now I found myself naturally alternating legs going up the stairs at home, without trying!

One of my PT's (I call him Stretch Armstrong), stretches me so well, that when I leave there I feel invincible! It hurts during the stretches, but as a pilates woman, you already know "no pain, no gain".

Hang in there. I think you will be walking straight soon, since I am getting straighter tooo over time.

Hop

 

[Judles]

Melissa,,,,,,I chime in with what everyone has said here! Please don't be disheartened as your still in the very early stages of recovery! I have friends that have leg discrepancies and have been fitted with orthotics and that has helped them with their gait! My PT suggested he would always want me walking as straight as possible WITH the cane, then to limp without it,! Right now, use all your enegy to HEAL! At least your not in that horrible pain anymore! When the time comes, your OS will reassure you! Stay calm and think positive!

 

[Josephine]

Excellent explanation, Nick.

 

[HopAlong]

Nick,

Your measuring is an interesting concept.....but, most people have a differential if measuring both hips and calves going around. Most people claim that their right thigh or calf is an inch or two larger than their left----or vice versa. So I am wondering how to account for that extra little bulge on one side when measuring straight up and down?

When I asked my PT to tell me which leg was longer, he had me lay on a table and pulled my legs long, then made a few adjustments to make sure I was perfectly straight, then pulled again, while aligning both legs to the middle of the table.......one foot was perfectly aligned with the edge of the table, and the other foot came over the edge about 1/4" or so. That was his method.

 

[Josephine]

The fact is, Hop, that the distance between the Anterior Superior Iliac Spine and the medial malleolus is fixed on the bone and cannot be adjusted or changed in any way. That's why it is accurate. What you PT did was not so accurate.

I'm also not quite sure what you mean by accounting for that 'little extra bulge on one side when measuring straight up and down'. Perhaps you could expand on that for me.

 

[HopAlong]

I see what you are saying Jo...... If the tape measure has a straight and clear way to meet from point A to point B without the need to conform to any body contours to get there, that makes sense. Maybe using a straight stick measure, not a pliable tape measure.
But if your body contours get in the way of the measuring, it won't be 100% accurate.

 

[nickji]

I see what you are saying Jo...... If the tape measure has a straight and clear way to meet from point A to point B without the need to conform to any body contours to get there, that makes sense. Maybe using a straight stick measure, not a pliable tape measure.
But if your body contours get in the way of the measuring, it won't be 100% accurate.

Hop, you're absolutely right. But, the inaccuracy is not great. Studies indicate that the ASIS/ankle measurement is accurate to +/- .85cm, (less than half an inch) in the vast majority of cases. To be more accurate, x-rays or scans would be needed, and x-rays of course are not entirely safe.

There is another method, when the client is standing and the hips are levelled by putting blocks beneath the shorter leg, but this involves a pelvic levelling device, which only specialists have.

For all practical purposes, and within a half inch or less accuracy, the ASIS/Malleolus method is very effective.

I'm going to put in a second post now, with some more technical details for those interested.

Enjoy it all,
Nick

 

[nickji]

Hi Everyone,

Leg Length Discrepancy (LLD) is so important that I'd like to add a little more to the subject. (about 20% of THR patients have a LLD of over 1cm too long - which was the limit that Sir John Charnley said was acceptable)

There are a few more points. One is that any-one who claims they can re-adjust actual leg length discrepancy by manipulation should be shown the door. It's impossible to change the length of the femur and tibia through manipulation. They are osseous structures - Bones !!!. If you do have an actual LLD it's very important for your spine that you level off with a lift in the shoe.

Another point is that awareness of leg length is heightened after hip surgery, and it could sometimes be a pre-existing condition. My approach in LLD cases is always to suspect the spine, and especially the sacro-iliac joint (SI). I use the Stork Test (google it if you're interested), and then if that is positive, manipulation can improve things considerably by working on the spine, especially the SI. (not too be too detailed here, but an apparent LLD can be caused by a rotation in the SI joint - basically a twist in the pelvis.) I mention this because if necessary you can check it with your PT, as not all therapists are aware of it.

Finally, if the leg length difference is apparent, then there is a simple way that one can adjust the hips at home. I've used it with dozens of clients, almost always successfully. If anyone has apparent LLD and would like to know how to correct it themselves, they're welcome to private message me and I'll send details (it's too long to go into a post) so long as that's ok with Jo and Jamie.

Apparent LLD is caused by something like this:

broken link removed: https://tinypics.us/show.php/45321_APARENTLYLONGLEG2.jpg.html

The muscles around the operated right hip have contracted, pulling the pelvis towards the leg, which makes the left leg feel shorter. The contraction can become almost impossible to overcome unless these muscles (especially the gluetus and tensor fasciae muscles) are stretched during physiotherapy not too long after the operation.

Enjoy it all,

Nick

 

[nickji]

Hi Again,

This diagram makes the measurement of actual leg length clearer - they call the ASIS the Spina Iliaca, but it's the same point. As you'll see, as Hop said it doesn't take the moulding of the flesh into account, but it's pretty accurate:

broken link removed: https://tinypics.us/show.php/45322_MEASURLEGLENGTH.jpg.html

As Jo mentioned on another post, apparent LLD is measured from the navel.

Goodnight (it's 02:30)


Nick

 

[JudyS]

Melissa
I am sure by now you have used Nick's method and measured your legs.
My doc took x-rays in the OR when all was done. So when you seee your doc maybe he did the same and you will have an accurate answer.
As far as limping, I seriiously doubt you will be when healed. It is still pretty darn early. My doc did tell me to stay on pain meds as I told him when I was on them I did not have a limp, but did when off pain meds. So do whatever it takes, using a cane or meds to keep the limp to a minimum or away.

I am sure you will be just fine and limp free .
judy