Limb Length Inequality: Clinical

Implications for Assessment and

Intervention
Rebecca J. Brady, PT 1
John B. Dean, PT, ATC 2
T. Marc Skinner, PT, ATC 3
Michael T. Gross, PT, PhD 4

CLINICAL
The purpose of this paper is to review relevant literature concerning limb length inequalities in inequality that is considered clini-
adults and to make recommendations for assessment and intervention based on the literature and cally significant, prevalence rates,
our own clinical experience. Literature searches were conducted in the MEDLINE, PubMed, and and the reliability and validity of
CINAHL databases. Limb length inequality and common classification criteria are defined and assessment methods.
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etiological factors are presented. Common methods of detecting limb length inequality include Lower limb asymmetry has been
direct (tape measure methods), indirect (pelvic leveling), and radiological techniques. Interventions
identified and investigated by nu-
include shoe inserts or external shoe lift therapy for mild cases. Surgery may be appropriate in

COMMENTARY
severe cases. Little agreement exists regarding the prevalence of limb length inequality, the degree
merous authors over the past half
of limb length inequality that is considered clinically significant, and the reliability and validity of century. Several terms have been
assessment methods. Based on correlational studies, the relationship between limb length used in the literature to refer to
Copyright 2003 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

inequality and orthopaedic pathologies is questionable. Stronger support for the link between low limb length inequality. Leg length
back pain (LBP) and limb length inequality is provided by intervention studies. Methods involving inequality, leg length discrepancy,
palpation of pelvic landmarks with block correction have the most support for clinical assessment and limb length disparity are all
of limb length inequality. Standing radiographs are suggested when clinical assessment methods examples of terms that refer to the
are unsatisfactory. Clinicians should exercise caution when undertaking intervention strategies for same cluster of conditions. We
limb length inequality of less than 5 mm when limb length inequality has been identified with have elected to use the term limb
clinical techniques. Recommendations are provided regarding intervention strategies. J Orthop length inequality because we be-
Sports Phys Ther. 2003;33:221234.
lieve this term more appropriately
Key Words: assessment, leg length discrepancy, leg length inequality, includes the entire lower extrem-
Journal of Orthopaedic & Sports Physical Therapy

treatment, unequal leg lengths ity. Leg length, as technically de-

fined by anatomists, refers to the
lower extremity segment from the
knee joint to the ankle mortise.

O
ver the past several decades, limb length inequality has
been the topic of a great deal of disagreement among
clinical investigators and researchers. The existence of CLASSIFICATION OF LIMB
limb length inequality is not in doubt. Little agreement LENGTH INEQUALITY
exists, however, regarding the degree of limb length
Several classification systems or
categories of limb length inequal-
1
Physical Therapist, HealthCare Partners Medical Group, Torrance, CA. ity have been proposed. The most
2
Athletic Trainer, Physical Therapist, University of Southern California, Los Angeles, CA.
3
Physical Therapist, Athletic Trainer, Meadowview Regional Medical Center, Maysville, KY. common classification scheme for
4
Professor, Division of Physical Therapy, Program in Human Movement Science, University of North limb length inequality identifies 2
Carolina at Chapel Hill, Chapel Hill, NC. types: anatomical and func-
Ms. Brady, Mr. Dean, and Mr. Skinner were enrolled in the Masters in Physical Therapy Program at the
University of North Carolina at Chapel Hill at the time this work was drafted. The authors of this paper tional.4,9,37,39,48,51,53,58 Anatomical
have no financial affiliation or involvement with any commercial organization that has a direct financial limb length inequality, which has
interest in any matter included in this manuscript and that no other conflict of interest is associated with also been referenced as true or
this work.
Send correspondence to Michael T. Gross, CB #7135, University of North Carolina at Chapel Hill, structural limb length inequality,
Chapel Hill, NC 27599-7135. E-mail: mtgross@med.unc.edu occurs when a physical shortening

Journal of Orthopaedic & Sports Physical Therapy 221

 of a unilateral lower limb exists between the head of
the femur and the ankle mortise.
Functional, or apparent, limb length inequality can
be described as a unilateral asymmetry of the lower
extremity without any concomitant shortening of the
osseous components of the lower limb. A functional
inequality may occur at any portion of the lower
extremity from the most superior aspect of the ilium
to the most inferior aspect of the foot. Sources of
functional limb length inequality include foot me-
chanics,4 adaptive shortening of soft tissues,4,5,39,40
joint contractures,4,40,53 ligamentous laxity,39 and
axial malalignments, including innominate subluxa-
tion and rotation.4,9,37,39,40,48,53
Environmental limb length inequality has been
identified in the podiatry literature.2,5,40 An example
of environmental limb length inequality occurs when
a distance runner consistently trains on 1 side of a
crowned road. This purportedly induces a limb
length inequality over time through the accumulation
of forces during running. Due to the specific nature
of its development, environmental limb length in-
equality may be a significant issue for a small number
of high-level athletes or a specialized workforce popu-
lation. Examples of recommended treatment for envi-
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ronmental limb length inequality are asking a patient
to run on different surfaces (eg, road or grass) or to
run the same course in alternating directions, and
correcting asymmetries in workplace ground surfaces.
Because the development of an environmental limb
length inequality may be an adaptive shortening of
Copyright 2003 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
the limb unilaterally without osseous shortening,
environmental limb length inequality may be consid-
ered as simply another example of a functional limb
length inequality. In this respect, we consider envi-
ronment to be an etiological factor and not a
separate classification of limb length inequality.
Finally, Reid and Smith46 proposed a measurement
classification system to categorize limb length inequal-
ity in which a 0- to 30-mm discrepancy is considered
Journal of Orthopaedic & Sports Physical Therapy
mild, a 30- to 60-mm discrepancy is considered
moderate, and 60 mm or more of lower limb length
discrepancy is considered severe. Subsequent content
in this paper, however, will indicate that many authors
consider limb length inequalities of less than 25 mm
as clinically significant.
PREVALENCE
The reported prevalence of limb length inequality
is perhaps one of the most convoluted and confusing
issues associated with the study of limb length in-
equality. Because little agreement exists as to what
constitutes a significant limb length inequality, almost
as many figures regarding prevalence have been
reported as there have been papers published on the
topic. Prevalence values range from as low as 4% to
8%6 to as high as 90% to 95%.45 Friberg et al18 have
used 5 mm as the criterion for clinical significance,
222
while Blustein and DAmico5 stated that a limb length
inequality of less than 11 mm is insignificant and
patients can easily compensate for this magnitude of
limb length inequality. Gibson et al19 reported that
correction of a 15-mm limb length inequality may be
necessary to reduce a functional scoliosis. Table 1
demonstrates the inconsistency among authors re-
garding the magnitude of limb length inequality that
is considered clinically significant. Intuitively, a large
portion of the population is likely to have a minor
difference in limb lengths, while only a small percent-
age of the population is likely to have a large limb
length inequality. This prevalence trend is evident in
the summary presented in Table 2.
One difficulty in determining the accuracy of
reported prevalence rates is the lack of attention
given to methodological details. For example, Pappas
and Nehme45 cite an unpublished report written by
Anderson, who studied 376 healthy subjects in the
Growth Study at Childrens Hospital in Boston.
Andersons data suggested that the normal difference
in limb lengths for 95% of the general population
would be less than 4 mm at 1 year of age, increasing
to 11 mm for skeletally mature individuals. Unfortu-
TABLE 1. Magnitude of limb length inequality considered clini-
cally significant.
Limb
Length
Inequality
(mm) Notes on Position Taken
3 56
Subotnick suggests that a limb length inequality
greater than 3 mm may require intervention for
runners
5 Friberg et al18 have used 5 mm of limb length
discrepancy as an operational definition for the
condition
6 Holmes et al31 have considered 6 mm of limb
length discrepancy as a clinically significant
magnitude
9 Giles and Taylor20 consider 9 mm of limb length
inequality sufficient to produce low back pain
10 ten Brinke et al57 consider 10 mm of limb length
inequality significant in women with lumbar disk
herniation
11 Blustein and DAmico5 suggest that limb length
inequalities less than 11 mm can be tolerated
through compensations within the body
15 Gibson et al19 suggest that correction of limb
length inequality greater than 15 mm is neces-
sary to reduce functional scoliosis
20 Helliwell29 suggests that limb length inequality
less than 20 mm is subject to significant mea-
surement error when the limb length inequality
has been determined using clinical measurement
methods
Lampe et al35 suggest that impairment is induced
with limb length inequality of 20 mm
22 Papaioannou et al44 indicate that this magnitude
of limb length inequality can be associated with
scoliosis
J Orthop Sports Phys Ther Volume 33 Number 5 May 2003
 evidence of the high prevalence of limb length
TABLE 2. Prevalence rates for limb length inequality based on inequality.4,5,8,9,57
operational definition used by the investigators.
Limb ETIOLOGICAL FACTORS
Length
Inequality Authors have identified numerous etiological fac-
Prevalence (%) (mm) Comments
tors for anatomical limb length inequality. Some
4.08.0 12.5 Summary of previous estimates common etiologic factors are idiopathic developmen-
for normal population6 tal abnormalities,4,5,41,55 fracture,5,20,39,41,49,55 and
7.0 12.5 69 of 1007 control subjects had
a limb length inequality of 12.5 trauma to the epiphyseal growth plate prior to
mm or more42 skeletal maturity.4,5,20,39,41,49,55 Examples of less com-
7.2 10.0 18 of 247 subjects with a his- mon etiologies include degenerative disor-
tory of recurrent back pain13 ders,5,20,39,41,49,55 Legg-Calve-Perthes disease,4,5,20,49
7.7 10.0 38 of 494 subjects with pain of cancer or other neoplastic changes,39,41,49 and infec-
spinal origin13
8.0 10.0 4 of 50 asymptomatic control tions.20,39,49,55 A comprehensive examination of the
subjects20 various conditions which may predispose or cause a
18.3 10.0 217 of 1186 patients with limb length inequality is beyond the scope of this
chronic low back pain20 paper. For a more comprehensive analysis, Blustein
21.9 10.0 27 of 123 patients with acute and DAmico5 have described specific examples of
LBP20
40.0 3.0 Suspected prevalence rate in etiological factors related to anatomical limb length
inequality, and Stanitski55 has examined possible

athletic population56
50.0 5.0 50% of the total population
thought to have a limb length
inequality of 5 mm or more18
See comments 4.011.0 376 normal subjects indicate
that normal difference in limb
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CLINICAL
congenital causes of anatomical or true limb length
inequality.
A functional limb length inequality may result from
adaptive shortening of soft tissues, joint contractures,

lengths for 95% of the general ligamentous laxity, or axial malalignments.4,8 Blake
population would be less than 4 and Ferguson4 have suggested that functional limb
mm at 1 year of age, increasing length inequality can be caused by foot mechanics,

to 11 mm for skeletally mature
individuals45
Copyright 2003 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
COMMENTARY
such as excessive asymmetric pronation. They suggest
that foot pronation is accompanied by decreased
longitudinal arch height compared to the

contralateral foot, resulting in a functionally shorter

nately, no information is available regarding the
methodology used to arrive at this conclusion. Simi-
larly, Subotnick57 has reported that the prevalence of
limb length inequality is as high as 40% in the
athletic population based on his anecdotal observa-
tions. And most recently, ten Brinke et al57 cited Giles
and Taylor20 and Grundy and Roberts27 in suggesting
Journal of Orthopaedic & Sports Physical Therapy
limb ipsilaterally. Blake and Ferguson4 propose that
foot orthotics may be used to limit excessive asymmet-
ric foot pronation, thereby decreasing the magnitude
of the functional limb length inequality. Blustein and
DAmico5 have suggested that a variety of pathologi-
cal conditions alter lower limb mechanics. A function-
ally longer limb may result from the altered limb
mechanics, which then may precipitate compensatory

that the prevalence of limb length inequality is 20%

to 30% in most populations. Giles and Taylor,20
however, actually reported a prevalence rate of 18.3%
in 217 of 1186 patients with chronic low back pain
(LBP), a 21.9% prevalence of limb length inequality
in 27 of 123 patients with acute LBP, and a 8%
prevalence of limb length inequality in 50
asymptomatic control subjects. Grundy and Roberts27
reported a 30% prevalence rate in their control
group, and a 25% prevalence rate in subjects with
LBP. Prevalence rates for limb length inequality may
not only be affected by the magnitude of limb
discrepancy considered clinically significant, but also
the experience of the examiner, demographics of the
subjects who are examined, methods used to recruit
subjects, and methods used to detect limb length
inequality. Despite the lack of information regarding
how authors have arrived at prevalence rate values,
their work has been cited by other authors as
subtalar joint pronation to minimize the magnitude
of the functional limb length inequality.
PATHOLOGIES RELATED TO LIMB LENGTH
INEQUALITY
Numerous investigations have explored possible
relationships between limb length inequality and
orthopaedic pathologies. LBP and scoliosis, as well as
hip, knee, and foot pathologies, have all been ex-
plored for possible associations with limb length
inequality.
The relationship between limb length inequality
and scoliosis has been studied by several au-
thors.5,9,14,19,22,30,44 The type of scoliosis commonly
observed in subjects with limb length inequality has
been referenced as functional scoliosis as opposed to
idiopathic scoliosis. A functional scoliosis is apparent

J Orthop Sports Phys Ther Volume 33 Number 5 May 2003 223

 in standing, but diminishes in sitting, supine, or
prone. The greater the limb length inequality, the
more pronounced the functional scoliosis may be.
Most authors have reported that the lumbar convexity
occurs toward the short limb side.5,9,14,19,44 Hoikka et
al,30 however, reported that lumbar convexity, accom-
panied by pelvic tilt, may occur on the side of the
longer limb.
Giles and Taylor20 examined the effect of a limb
length inequality correction on spinal alignment
using radiographs before and after the correction.
The investigators separated subjects into 3 age
groups: young adults, middle-aged adults, and older
adults. In the 2 groups of younger patients (less than
53 years old), the functional scoliosis was completely
corrected or nearly corrected immediately with board
lifts and remained corrected following 4 months of
shoe lift intervention. In the older patient group, the
correction of spinal alignment was much less and was
not affected at all in many instances with shoe lift
correction. Gibson et al19 and Papaioannou et al44
have reported similar results.
A number of authors have investigated the link
between limb length inequality and LBP,1214,16,
20,22,27,29,30,45,54,57
but no association has been sup-
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ported unequivocally. Giles and Taylor20 observed
that a limb length inequality of 10 mm or more is
more common in patients with LBP, while investiga-
tions by Fisk and Baigent13 and Soukka et al54 did
not find such a correlation. Soukka et al54 reported
Copyright 2003 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
that a group of symptom-free subjects and a subject
group with a history of LBP had similar distributions
of limb length inequality up to 10 mm. They suggest
that a mild limb length inequality of 5 mm or less
may be unrelated to LBP. Even though a limb length
inequality may have a significant influence on spine
position, some patients with a significant limb length
inequality may be able to accommodate it without
experiencing LBP.44 Pain in the lower back may
Journal of Orthopaedic & Sports Physical Therapy
result from a number of causes and often occurs in
the absence of limb length inequality.37
Hip pathologies have also been studied in relation
to limb length inequality. Fisk and Baigent13 identi-
fied hip osteoarthritis, and Gofton and Trueman21
identified hip arthrosis, as common problems in the
hip joint of the longer limb. This finding was
supported by both Friberg14 and Rothenberg.49
Friberg14 suggests that the hip joint in the longer
limb would likely be in a varus position, which
decreases the load-bearing surface of the femoral
head. Increased pressure at the articular surface may
then effect chondral damage. Rothenberg49 also has
suggested that sciatica is more likely to occur on the
longer-limb side, while trochanteric bursitis may oc-
cur more often on the shorter-limb side.
Limb length inequality has also been associated
with a number of knee problems. Holmes et al31
reported that 7 of 61 cyclists with knee pain associ-
224
ated with iliotibial band syndrome also had a limb
length inequality of 6 to 9 mm as documented by
scanogram. Subotnick56 also noted that iliotibial band
strain tends to manifest itself on the shorter limb
side. These 2 reports31,56 provide only limited support
for a relationship between limb length inequality and
iliotibial band syndrome.
Several authors have noted the presence of exces-
sive foot pronation in the longer limb, which effec-
tively shortens the limb and reduces the magnitude
of an anatomical limb length inequality.4,26,40 Exces-
sive foot pronation during gait is accompanied by
internal rotation of the tibia resulting in increased
valgus stress at the knee.26 Injuries related to tensile
forces at the medial knee are a logical
sequela,9,13,22,34,40 while degenerative conditions re-
sulting from increased compressive stress at the
lateral knee may also occur.26 Kujala et al34 reported
that a group of athletes with a limb length inequality
greater than 5 mm had a statistically significant
increase in overuse knee injuries compared to a
control group with no limb length inequality.
As previously mentioned, foot pronation may be
evident on the side of the longer limb in individuals
with limb length inequality.4 Excessive pronation may
also be the cause of a functional limb length inequal-
ity, effectively shortening a limb.8 According to
Resseque and Volpe,47 severe pronation can lead to
ankle joint pathology. DAmico et al8 used the
Electrodynogram system to demonstrate increased
pronation and weight-bearing force at the medial side
of the foot on the longer limb side. Donatelli11 has
suggested that this excessive pronation can lead to
plantar fasciitis, a flat foot, ligamentous laxity, a tight
Achilles tendon, forefoot varus, calcaneovalgus, ankle
joint equinus, or hallux valgus.11 We would like to
note, however, that we have not consistently observed
excessive asymmetric foot pronation either on the
side of the longer limb or on the side of the shorter
limb in patients with anatomical limb length inequal-
ity.
Leppilahti et al36 explored limb length inequality
as a possible factor in Achilles tendon rupture. These
investigators studied 48 patients with a limb length
inequality greater than 5 mm, and reported that the
prevalence of injury to the Achilles tendon was
relatively equal between the shorter limb and the
longer limb. Limb length inequality, therefore, does
not appear to be related to Achilles tendon rupture.
In a study of 371 Finnish Army conscripts,
Friberg15 reported that limb length inequality may
have a predisposing role in causing stress fractures in
either the femur, tibia, fibula, or metatarsals. Friberg
reported a positive correlation between limb length
inequality and stress fractures, but did not provide
statistical measures or methods to support this state-
ment.
J Orthop Sports Phys Ther Volume 33 Number 5 May 2003
 ASSESSMENT OF LIMB LENGTH INEQUALITY
The literature concerning clinical assessment and
diagnosis of limb length inequality is controversial
and inconsistent. Several clinical investigators have
attempted to identify a method that is both valid and
reliable across a variety of populations without being
prohibitively expensive. A number of different assess-
ment tools and methods are proposed, with variable
outcomes.
Radiography
The accepted standard for assessing limb length
inequality in patients has been radiographic evidence.
Radiography has been used extensively as the crite-
rion reference for assessing the validity of various
clinical assessment methods and tools.1,36,1315,
1720,22,24,25,28,29,3436,39,40,4345,4850,54,55,58
We identi-
fied 4 types of radiographic methods that have been
used to determine limb length inequality: telero-
entgenography, orthoroentgenography, scanography,
and computed tomography.
A teleroentgenogram is a single exposure of the
standing subject, imaging the entire lower extremities
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using a long film and an X-ray source-to-image
distance of 2 m. A ruler is placed in the center of the
film cassette to assist measurement and to act as a
magnification marker of known size.39,55 Stanitski55
suggests that the advantages of teleroentgenography
Copyright 2003 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
are the ability to demonstrate axial deformities,
frontal-plane deformities, and limb length inequality
all on 1 film. Limitations of teleroentgenography are
an inherent inaccuracy in patients with a hip or knee
flexion contracture and that the technique is subject
to a magnification error.39,55 Stanitski55 reports an
average magnification error of approximately 6%,
which is easily corrected by placing a magnification
marker of known dimensions on the film. Mannello
Journal of Orthopaedic & Sports Physical Therapy
has suggested that teleroentgenography is adequate
for children but impractical for adults due to the size
of the films required and the distortion of the beam
related to the source-to-image distance.39
Orthoroentgenography attempts to avoid the mag-
nification error experienced with teleroentgenograms
by using separate exposures at the hips, knees, and
ankles on the same long film. A ruler is again placed
on the film cassette to aid in measurement.
Orthoroentgenography is subject to the same limita-
tions regarding patients with fixed joint contractures.
Patients can unintentionally introduce error into the
readings by moving between exposures.55 Friberg14
devised a novel method of ascertaining limb length
inequality radiographically that reduced radiation ex-
posure. He exposed only the hip joints and surround-
ing structures with subjects in standing. Limb length
inequality was determined by the difference in femo-
ral head heights as compared to a true horizontal
J Orthop Sports Phys Ther Volume 33 Number 5 May 2003
reference included in the visual field. Two research
reports14,36 indicate low mean error with repeated
measures using this method.
Scanography uses the same procedure as
orthoroentgenography, but the film size is decreased
by moving the cassette beneath the patient between
exposures.55 Scanography, therefore, has the same
benefits and limitations as orthoradiography.
A major benefit of computed tomography is de-
creased radiation exposure. Computed tomography
has not been more accurate than standard radiogra-
phy in the detection of limb length inequality except
in the case of patients with hip or knee flexion
contractures.55 The increased cost for the computed
tomagraphy scan, therefore, may not be justified
unless a contracture has been identified or radiation
exposure must be minimized.
Radiography has been determined as accurate to
within 3 mm6,13,34 for both anatomical limb length
inequality and limb length inequality induced by iliac
CLINICAL
rotation. Nevertheless, radiography does have internal
sources of error. Clarke6 studied the effect of varying
the tube focal (source-to-image) distance and position
of the tube focal point on radiographic findings. He
used a human skeleton that was adjusted for known
unilateral discrepancies at the iliac crest and femoral
head for a combined difference of 20 mm, and iliac
COMMENTARY
rotations of 15. Radiographs were taken from a
distance of 100 cm and 200 cm and with a 5-cm
height difference in the tube focal point. Radio-
graphs from 200 cm were more accurate (03 mm)
than from 100 cm. Kujala et al34 studied the effect of
varying the vertical height of the tube focal point
when imaging the entire lower extremity. The X-ray
beam was first centered over the femoral heads and
images were taken. The X-ray focal point was then
moved to the level of the knees without adjusting for
horizontal differences (eg, genu valgum). Kujala et
al34 concluded that this method resulted in no
vertical projection error. A horizontal projection er-
ror of 10.5% resulted in only a 0.7 overestimation in
the varus angle at the knee. The results of these
studies suggest that imaging accuracy may improve
slightly using a tube focal distance of 200 cm and by
centering the focal point of the X-ray beam at the
horizontal level of anatomic interest.
Foot placement also has been noted as an impor-
tant variable in obtaining accurate radiographs.13,20
Placing the feet of a subject 15 to 20 cm apart
increased the accuracy of the image for measuring
purposes. This position creates a parallelogram be-
tween the hips and the feet, eliminating error intro-
duced by weight shift or sway at the hips and
preserving the relative heights of the bilateral ante-
rior superior iliac spines.13 Giles and Taylor20 recom-
mend a modification of using the arbitrary distance
of 15 to 20 cm, and suggest that the patient place the
feet immediately below and in line with the femoral
225
 heads. This method allows for individual differences
among subjects with regard to frame size. Giles and
Taylor20 reported a mean error of 1.12 mm using this
method.
The reliability of radiographs has been examined
by Friberg et al18 and Leppilahti et al.36 Friberg et
al18 reported a mean error for repeated radiographic
measures of 0.6 mm with a range of 0 to 2.0 mm,
although the parameters used to determine this
statistic were poorly defined. Leppilahti et al36 exam-
ined the radiographs of 15 subjects taken at 2
separate times during the same day. They reported a
mean error of repeated measures of 1.0 mm, with a
range of 0.0 to 2.0 mm and a correlation coefficient
of 0.96, suggesting acceptable reliability.
Considering the previous literature, our preference
has been to use standing anterior-posterior radio-
graphs of the pelvis to assess limb length inequality
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Copyright 2003 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
Journal of Orthopaedic & Sports Physical Therapy
when clinical assessment methods are unacceptable
(eg, difficulty palpating pelvic landmarks). The tech-
nique we use is similar to the previously reviewed
methods of Friberg14 and Giles and Taylor.20 We
request that patients wear the shoes that they most
commonly wear with any inserts or orthotics in place,
since shoe wear and orthotics may influence foot
posture and, therefore, functional limb length. The
patient is asked to assume a comfortable stance width
and a comfortable foot toe-in/toe-out angle, and to
extend both knees. The tube focal distance is set at
200 cm and the beam focal point is centered at the
midline of the body slightly above the level of the
greater trochanters. A metal ruler is placed along the
thigh just lateral or anterolateral to the greater
trochanter and a metal chain is allowed to hang
freely from the radiograph cassette to serve as a
vertical reference (Figure 1). A horizontal line is

FIGURE 1. Standing anterior-posterior radiograph of the pelvis to assess limb length inequality. A metal chain hangs freely from the film
cassette (left side of the visual field) to indicate the true vertical in space. A metal ruler is positioned just anterolateral to the patients greater
trochanter (right side of the visual field) to provide a linear conversion factor. A line is drawn perpendicular to the vertical reference such
that the line is tangent to the most superior aspect of 1 femoral head (the patients right femoral head on this radiograph). The distance is
then measured from this line to the more superior or inferior contralateral femoral head and converted to a real space distance using the
linear conversion factor provided by the metal ruler. Assessment of this radiograph indicates that the patients left lower limb is 17 mm
longer than the right lower limb.

226 J Orthop Sports Phys Ther Volume 33 Number 5 May 2003

 drawn on the acquired radiograph such that the line
is tangent to the most superior aspect of the more
inferior femoral head. The vertical distance from this
line to the more superior femoral head is measured
to the nearest mm and then converted to a real-space
distance using the linear conversion factor provided
by the metal ruler that was imaged on the radio-
graph. This real-space difference in femoral head
height is taken as the magnitude of the limb length
inequality. Readers should note that this method does
not differentiate between structural and functional
limb length inequalities.
Clinical Assessment
Two general clinical methods for assessing limb
length inequality are direct and indirect methods.
Direct methods involve measuring limb lengths with a
tape measure between 2 defined points. A common
direct method involves measuring limb length be-
tween the anterior superior iliac spine and the medial
malleolus. Several variations include measuring from
the anterior superior iliac spine to the lateral mal-
leolus, from the umbilicus to the medial malleolus,
and from the xiphosternum to the medial malleolus.
The indirect methods generally involve palpating
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bony landmarks such as the iliac crests or anterior
superior iliac spines with the patient standing while
the examiner assesses for levelness of the palpated
landmarks. One method includes placing objects of
known thickness, such as wooden blocks or book
Copyright 2003 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
pages, under the shorter limb for correction until the
bony landmarks are assessed as level.1,13,28,35,58 Some
investigators have also used a pelvic leveling device to
aid in the assessment of the bony landmarks during
indirect assessment.24,33,43
Direct Methods A great deal of criticism and debate
surrounds the accuracy of tape measure methods for
assessment of limb length inequality.55 Friberg has
reported cases for which an actual limb length
Journal of Orthopaedic & Sports Physical Therapy
inequality of up to 25 mm has been overlooked and
even attributed to the wrong limb by different clini-
cians.14 Clarke6 compared the supine measurements
of limb length inequality for 2 examiners to radio-
graphic measures, both measured to the nearest 5
mm. The examiners used a tape measure method to
measure the distance between the anterior superior
iliac spine and the medial malleolus. Both examiners
reported measurements that were within 5 mm of the
radiographic determinations of limb length inequality
for only 20 (40%) of the 50 subjects. For the 21
subjects who had a limb length inequality of 10 mm
or more, both observers were within 5 mm of
radiographic results for only 7 subjects (33%).
Friberg et al18 compared the reliability of tape
measurements from the anterior superior iliac spine
to the medial malleolus with a radiographic method
designed by Friberg.14 Three observers and 21 sub-
jects were involved in the study. Each subject had a
J Orthop Sports Phys Ther Volume 33 Number 5 May 2003
radiograph taken to determine the presence of a
limb length inequality. Examiners then measured
each subject with a tape measure twice over the
course of 3 months. Repeated measurements by the
same examiner conflicted regarding which limb was
the shorter limb 28% of the time, even when the
limb length inequality as assessed by radiographs was
25 mm. One rater, who first identified 1 limb as
being 10 mm shorter than the contralateral limb,
then identified the contralateral limb as being 15 mm
shorter 3 months later for the same subject. Friberg
et al14 further reported that if the limb length
inequality was 5 mm or less radiographically, then
88% of the tape measurements were incorrect with
overestimation of up to 20 mm. DeBoer et al10 also
reported that the method using tape measurements
from the anterior superior iliac spine to the medial
malleolus is of little value clinically when the limb
length inequality is small. Furthermore, it fails to
determine if the limb length inequality is anatomical
CLINICAL
or functional in nature. Beattie et al3 also determined
qualitatively that clinicians should exercise caution
when making clinical decisions regarding patient
treatment when tape measurements of limb length
inequality are 5 mm or less.
Hoyle et al32 reported intraclass correlation coeffi-
cients (ICCs) between repeated tape measurements
COMMENTARY
from the anterior superior iliac spine to the medial
malleolus that were similar to those reported by
Friberg et al.18 The ICC3,1 for 25 subjects between 2
examiners for the left limb was 0.99 with a range of
differences between examiners of 5.0 to 23.0 mm.
The ICC3,1 for 25 subjects between 2 examiners for
the right limb was 0.98 with a range of differences of
0.0 to 28.5 mm. All repeated measurements were
reported to differ significantly between examiners,
though they were highly correlated. The authors
concluded, therefore, that tape measurements by
different clinicians should not be compared. The
study by Hoyle et al32 did have 2 major methodologi-
cal problems. Subjects were measured repeatedly with
an insufficient interval between measurements to
prevent rater bias, and it is not clear if examiners
were masked to each others results.
Woerman and Binder-Macleod58 compared the re-
sults of measurements by 20 examiners on 5 subjects
using 4 different direct methodologies of assessing
limb length inequality. All measurements were com-
pared to radiographs. The method using tape mea-
surements from the anterior superior iliac spine to
the medial malleolus differed from the radiographic
measurements by a mean difference of 7.3 10.1
mm. The method using tape measurements from the
anterior superior iliac spine to the lateral malleolus
had a mean difference of 6.0 16.0 mm. The
method using tape measurements from the umbilicus
to the medial malleolus had a mean difference of
4.2 9.9 mm, and tape measurements from the
227
 xiphosternum to the medial malleolus had a mean
difference of 19.9 16.2 mm.
Beattie et al3 compared miniscanogram determina-
tion of limb length inequality with supine tape
measurements from the anterior superior iliac spine
to the medial malleolus. Nineteen subjects and 2
examiners participated in the study. The ICC1,1 values
comparing first, second, and averaged tape measure-
ments with the radiographic measurements were 0.68,
0.79, and 0.79, respectively. Ten of the subjects had a
history of limb length inequality, or lower extremity,
pelvic girdle, or spinal dysfunction that required
medical intervention. For these 10 subjects, the
agreement between the radiographic determinations
of limb length inequality and the mean of 2 tape
measurements was an ICC1,1 value of 0.85. For the 9
normal subjects the ICC1,1 was 0.64 for agreement
between the radiographic measurements and the
mean of 2 tape measurements. The authors con-
cluded that the tape measure method employed was
relatively valid when the mean of 2 measures was
used. These results are dissimilar to earlier stud-
ies,6,18,32 which do not support the use of the supine
tape measure method to assess limb length inequality.
The validity of the Beattie et al3 study may be limited
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by the use of supine radiographs, which may not
reflect limb lengths during functional weight bearing.
Investigators who do not support the use of the
tape measure methods cite the following sources of
measurement error: difficulty in palpating bony land-
Copyright 2003 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
marks,3,4,14,16,20,43,58 iliac asymmetries that may mask
or accentuate a limb length inequality,3,18,20,38,58 uni-
lateral deviations in the long axis of the lower limb
(eg, genu valgum),3,4,58 asymmetrical position of the
umbilicus,58 and joint contractures.4,58 Although obe-
sity is commonly identified as a factor which affects
accurate palpation and measurement, Mann et al38
failed to demonstrate a correlation between a sub-
jects percentage of body fat and differences in rater
Journal of Orthopaedic & Sports Physical Therapy
agreement of limb length inequality. Difference in
thigh circumference3,4,58 has also been identified as a
factor which may hamper accurate measurement of a
limb length inequality, although Woerman and
Binder-Macleod58 contend that the method using
tape measurements from the anterior superior iliac
spine to the lateral malleolus eliminates the contour
of the thigh as a source of measurement error. Mann
et al38 reported that palpation of the iliac crests in
standing subjects was not reliable, although experi-
enced physical therapists were more reliable than less
experienced student examiners.
We prefer to not use direct supine measurements
of limb length inequality for many of the reasons
identified in the preceding content and because the
method involves 6 procedures for which error may be
introduced into the determination of limb length
inequality. A proximal and a distal bony landmark
must be identified and marked on both extremities.
228
Difficulty finding the identical location on paired
bony landmarks (eg, the same location on each
medial malleolus), therefore, results in 4 possible
sources of measurement error. Once the landmarks
are identified and marked, measurements between
the proximal and distal landmark must be made for
both extremities. These measurements introduce 2
additional sources of measurement error into the
computation of limb length inequality. These 6 po-
tential sources of measurement error are always
present in addition to many of the other issues that
may affect the assessment of functional limb length
inequality (ie, asymmetric soft tissue, asymmetric foot
postures during weight bearing, etc).
Indirect Methods Indirect methods for assessment of
limb length inequality use palpation of bony land-
marks, most commonly the iliac crests or anterior
superior iliac spines. These methods involve assessing
if bony landmarks are level or if limb length inequal-
ity is present. Simple visual estimates have been used,
as well as the use of blocks or book pages of known
thickness under the shorter limb until iliac crests or
anterior superior iliac spines appear level.1,6,13,28,35,58
Another method estimates limb length inequality
based on the angle of difference in anterior superior
iliac spine height and the horizontal difference be-
tween the left and right anterior superior iliac
spines.43
Several research reports suggest that simple palpa-
tion and a visual estimate of iliac crest height is not
reliable.7,8,38 Clarke6 compared clinical assessment
using iliac crest palpation to radiographic evaluation.
Both examiners in the study were correct to within 5
mm for only 16 of 50 subjects when their measure-
ments were compared to radiographic measurements.
Twenty-one subjects were identified as having a limb
length inequality of 10 mm or more based on the
radiographic measurements. In these individuals,
both examiners identified the inequality to within 5
mm in only 9 cases when their clinical assessments
were compared with radiographic determinations of
limb length inequality.
Subsequent studies have improved upon this
method by placing wooden blocks or floor tiles of
known thickness under the suspected shorter
limb.1,13,35,58 Fisk and Baigent13 acquired radiographs
of 107 subjects with limb length inequality and
compared the images to the iliac crest palpation and
block correction method. The clinical assessments of
the examiners were incorrect by more than 5 mm for
31 subjects (29%). Further examination of the radio-
graphs, however, indicated that 8 of these 31 subjects
had an iliac asymmetry, making radiographic assess-
ment difficult. Aspegren et al1 compared the iliac
crest palpation and block correction method to
radiographic identification of limb length inequality
for 41 subjects. Twenty-six (63%) of 41 subjects were
measured within 3 mm of the radiographic values. Six
J Orthop Sports Phys Ther Volume 33 Number 5 May 2003
 of 41 subjects had measurements within 4 to 6 mm of
the radiographic values. Eight of 41 subjects had
measurements within 7 to 9 mm. Only 1 subject had
a difference between the 2 measurement methods of
more than 10 mm. Aspegren et al1 concluded that no
statistically significant difference existed between ra-
diographic measurements and the iliac crest palpa-
tion and block correction method when they
evaluated mean error for all data. Lampe et al35
reported a mean difference of 0.9 mm between
radiographic determination of limb length inequality
and measurements using the iliac crest palpation and
block correction method. The 95% confidence level
interval reported by Lampe et al,35 however, indi- FIGURE 2A. The independently fabricated, rigid pelvic leveling
cated the possibility of error in the range of 15 mm device used by Jonson and Gross33 to assess limb length inequality.
for outliers. Woerman and Binder-Macleod58 also A line level is affixed to a pair of sliding calipers.
reported that the mean difference between iliac crest
palpation and block correction measurements com-
pared to radiographic measurements was 2.2 2.6
mm. Woerman and Binder-Macleod58 concluded,

CLINICAL
therefore, that this indirect method was the most
accurate and precise clinical method for determining
limb length inequality compared with the 4 direct
tape measurement methods included in their investi-
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gation.
A modification of the iliac crest palpation and
block correction method was studied by Hanada et

COMMENTARY
al28 using book correction as opposed to blocks,
shims, or floor tiles. The investigators examined 34
Copyright 2003 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

subjects with a limb length inequality of 7 to 53 mm

induced by having the subjects stand on a measurable
number of book pages. The magnitude and side of
the induced limb length inequality were randomized.
Two examiners, who were masked to the induced
limb length inequality, then used book pages to make
a correction under the shorter limb. All of the
subjects induced limb length inequality and correc-
tions were assessed radiographically. ICCs were re-
Journal of Orthopaedic & Sports Physical Therapy

ported, though the ICC formula used was not

identified. Intrarater reliability ICC was 0.98 with a
mean difference of 1.6 2.5 mm. Interrater reliability
ICC was 0.91 with a mean difference of 1.0 5.9 mm.
Construct validity ICC was 0.62 and concurrent valid-
ity ICC was 0.76. The investigators concluded that the
iliac crest palpation and block correction method
using book correction was highly reliable and moder- FIGURE 2B. The rigid pelvic leveling device being used to assess
whether a patients iliac crests are level.
ately valid.
A variation of the indirect method using block
correction involves use of a pelvic leveling device.24,33 7.5 2.9 mm. The authors suggested that this
Jonson and Gross33 studied 18 subjects and 2 examin- method had fair but unacceptable reliability for
ers using an independently fabricated, rigid pelvic clinical use.
leveling device and corrective blocks (Figures 2A and Gross et al24 also assessed the reliability and validity
2B). Intrarater reliability of the iliac crest palpation of a more flexible, commercially available pelvic
and block correction method with the pelvic leveling leveling device (Figure 3A). This device assesses limb
device showed an ICC2,1 of 0.87 with an absolute length inequality by placing the 2 moveable arms of
difference of 4.3 4.5 mm. Interrater reliability the pelvic leveling device on the iliac crests (Figure
ICC2,1 was 0.70 with an absolute difference of 3B). A leveling bubble on the horizontal cross-arm

J Orthop Sports Phys Ther Volume 33 Number 5 May 2003 229


FIGURE 3A. Commercially available pelvic level model 5029A (JA
Preston Corporation, Jackson, MI).
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Copyright 2003 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
Journal of Orthopaedic & Sports Physical Therapy
FIGURE 3B. Commercially available pelvic leveling device being
used to assess whether a patients iliac crests are level.
indicates the degree to which the 2 movable arm
positions are level. Wooden shims or blocks of known
height are placed under the shorter limb until the
leveling bubble is centered. The height of the
wooden blocks is assessed as the magnitude of the
limb length inequality. Radiographic measurements
of 32 subjects were compared to the results of the
measurements obtained by 2 examiners using the
pelvic leveling device. ICC2,1 for intrarater reliability
230
was 0.84 with an absolute mean difference of
2.9 5.2 mm. Interrater reliability ICC2,1 was 0.77
with an absolute mean difference of 4.9 4.6 mm.
Validity for 1 tester was indicated by an ICC2,1 of 0.64
with an absolute mean difference of 5.8 5.8 mm.
An ICC2,1 of 0.76 indicated validity for a second
tester with an absolute mean difference of 5.5 3.7
mm. The first tester identified the wrong limb as the
shorter limb in 5 subjects (16%). The second tester
identified the wrong limb as the shorter limb in 4
subjects (12.5%). Both examiners identified 3 sub-
jects (9%) as having a limb length inequality when
none was present radiographically. The first tester
assessed opposite limbs as the shorter limb on re-
peated measures for 3 subjects (9%). The authors
concluded that reliability and validity were unaccept-
able to support clinical use of the commercial pelvic
leveling device.
The Orthotractor is another example of a pelvic
leveling device. This device has not been used in
conjunction with block correction.43 The device rests
on the examiners wrists with 2 pylons that extend
from the horizontal and rest on the examiners
thumbs. The 2 rigidly attached arms of the
Orthotractor are placed on the subjects left and
right anterior superior iliac spines. Limb length
inequality is determined using the angle created by
the difference in height of the 2 anterior superior
iliac spines and the distance between the anterior
superior iliac spines. Okun et al43 have suggested that
the device can discriminate between structural and
functional limb length inequality. They suggest that
this is accomplished by examining the anterior supe-
rior iliac spine heights of subjects in a neutral
calcaneal stance position and again in a relaxed
calcaneal stance position. No attempt was made to
establish reliability or validity of the device as com-
pared to radiographic measurements. Intrarater dif-
ferences ranged from 1.9 to 4.6 mm. A possible
methodological error is the inability to control for
wrist elevation of the examiner, which would compro-
mise the identified angle. More research is needed to
determine the reliability and validity of the
Orthotractor before it can be accepted for clinical
use.
Results for the iliac crest palpation and block
correction method appear more accurate and precise
than other clinical assessment methods described in
the literature, either direct or indirect, though no
uniform agreement exists and further investigation is
warranted. Clinicians should recognize that asymmet-
ric pelvic rotations in planes other than the frontal
plane may be associated with limb length inequality.7
We suggest, therefore, that the greater trochanters
and as many pelvic landmarks as possible (eg, iliac
crests, anterior superior iliac spines, posterior iliac
spines, and ischial tuberosities) should be palpated
when the block correction method is used. The basis
J Orthop Sports Phys Ther Volume 33 Number 5 May 2003
 for this suggestion is that the palpation of bony
landmarks can be a difficult task3,4,14,16,20,43,58 and
iliac asymmetries may mask or accentuate a limb
length inequality.3,18,20,38,58 Friberg et al18 reported
that reliability was questionable and validity was low
for tape measurement methods and the iliac crest
palpation and block correction method. A rigid
pelvic leveling device used in conjunction with the
iliac crest palpation and block correction method
may have the potential to improve reliability of
clinical assessments of limb length inequality and
merits future study. Clinicians should exercise caution
when undertaking intervention strategies for limb
length inequality less than 5 mm when the identified
limb length inequality has been determined using
clinical techniques.
INTERVENTION STRATEGIES
Intervention for limb length inequality generally
has been dictated by 2 factors: the magnitude of the
inequality and whether or not the patient is symptom-
atic. Several authors suggest that no treatment is
required if a patient is asymptomatic,5,25,55 but
Gofton21 advocates intervention in patients without
symptoms as an important strategy for the prevention
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of future pathology.
The need for intervention may be obvious in cases
of severe limb length inequality. Surgery may be
appropriate for those individuals with a severe ana-
tomical limb length inequality9 or a scoliosis that
Copyright 2003 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
results in a functional shortening of the lower limb.
The primary goal of spinal surgery is fixation or
correction of the spinal curvature with a secondary
reduction of the functional limb length inequality.
Surgical techniques to shorten or lengthen the lower
limb have been used for the tibia, the femur, or both
to achieve symmetry.45,55 The Ilizarov technique has
been used successfully to lengthen a bone.47,52 This is
achieved through osteotomy and distraction of the
Journal of Orthopaedic & Sports Physical Therapy
bony components with external fixation. The bone is
held in place while osteoblastic activity fills in the
newly created space. The external fixation can then
be adjusted in small increments (1 mm/d).52 At the
termination of distraction elongation, fixation is nec-
essary to allow maturation and strengthening of the
new bone. This method may require several months,
depending on the magnitude of desired lengthening.
Lengthening may be required for both the femur and
tibia in extreme cases of limb length inequality.
Osteotomy and excision may also be performed to
shorten the contralateral longer limb. In cases of
functional shortening, such as with a tight Achilles
tendon or tight hamstrings, surgery to release a
contracture is performed only after conservative treat-
ments have failed.
In many cases of limb length inequality, nonin-
vasive techniques such as shoe lifts4,5,20,22,49,56 or
orthotics,4,5,44,56 may be more appropriate. A func-
J Orthop Sports Phys Ther Volume 33 Number 5 May 2003
tional limb length inequality may be corrected with a
custom orthotic that provides proper arch support.4,9
Subotnick56 reported anecdotal success with the use
of lifts for cases of limb length inequality of 12.5 mm
or less.
Evidence in the literature regarding the use of lift
therapy is inconsistent.5,14,25,40,46,49,56 Gross25 could
not justify the use of routine lift therapy to correct
less than 5 mm of limb length inequality. In his
sample of 35 marathon runners, 16 out of 17 runners
with a limb length inequality greater than 5 mm were
asymptomatic without the use of lift therapy. Four of
the remaining 18 runners were using a lift to correct
their limb length inequality of less than 5 mm. Other
authors suggest that running athletes with a limb
length inequality may be more prone to injuries and
may require lift therapy for a smaller limb length
inequality as compared to their nonathlete counter-
parts.46,56 Donatelli11 has suggested that a 3-fold
increase in weight-bearing forces is incurred at heel
CLINICAL
strike during running compared to walking.
Subotnick56 extrapolated this information to suggest
that a 6.4-mm limb length inequality in a running
athlete may be as significant as a 19.2-mm limb
length inequality in nonathletes. Theoretically, one
might argue that a limb length inequality may not be
as detrimental for running as it is for walking or
COMMENTARY
standing because running does not involve any peri-
ods of bilateral stance. Studies are needed to deter-
mine if limb length inequality is associated with
running injuries because of factors such as asymmet-
ric ground reaction force patterns or asymmetric soft
tissue extensibility.
Implementation of lift therapy for limb length
inequality is currently based on clinical judgment and
experience.40 A uniform protocol for intervention
has not been established, but guidelines regarding
the implementation of lift therapy have been recom-
mended.2,4,5,9,57 Most clinicians agree that lift therapy
for the treatment of limb length inequality should be
implemented in small increments to facilitate adjust-
ment to each change in lift magnitude.4,5,9,14,23,49
Blustein and DAmico5 suggest an interval of 2 weeks
between lift therapy adjustments and that each lift
increment should not be more than 3 to 6 mm. They
further suggest that correction of limb length in-
equality should be no greater than one-half of the
difference between limb lengths.5
Blake and Ferguson4 published an example of a lift
therapy progression for a 9-mm correction of limb
length inequality. In the first week, a full-length 3-mm
lift was advocated. A 3-mm heel lift can be added
during the second week. At week 3, the previous lifts
can be removed and replaced with a 6-mm full-length
lift. A 3-mm heel lift can be added at week 5. Finally,
the previous lift material can be exchanged for a
9-mm full-length lift at week 7. The schedule and
amount of lift therapy introduced in this example was
231
 not based on reported evidence, but on the authors
clinical judgment. Subotnick56 has suggested a ta-
pered shape for lift intervention that involves full
correction at the heel, 50% correction at the metatar-
sal regions of the foot, and 25% correction at the
toes.
Some authors recommend correcting the shorter
limb side using an internal lift inside the
shoe,4,5,14,46,49,56 or adding an external lift to the
sole.4,5,14,46,49,56 Another suggestion involves removing
material from the shoe on the longer limb side in
combination with adding a lift to the shorter limb
side.40 Recommendations regarding the amount of
lift that should be placed inside the shoe are variable.
Blustein and DAmico5 state that no more than 6 mm
of lift should be placed inside the shoe, while
Danbert9 and Friberg14 support the use of up to 9
mm of internal lift. Subotnick56 advocates up to 12.5
mm of lift inside the shoe. Friberg14 contends that lift
correction greater than 10 mm requires an external
shoe lift.
One factor to consider in lift placement is the
decrease in available shoe volume for the foot after
placement of the lift material inside the shoe. Be-
cause lift therapy usually is recommended for all
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shoes owned by a patient, intervention usually is less
expensive if internal lift materials are used that can
be transferred from one pair of shoes to another.14
Regardless of the location of the corrective lift or the
magnitude of the lift employed, McCaw40 suggests
that the magnitude of the corrective lift should be
Copyright 2003 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
directly proportional to the magnitude of the limb
length inequality. McCaw also suggests that the mag-
nitude of lift should be inversely proportional to how
long the inequality has been present due to the
musculoskeletal compensations that may have oc-
curred over time.
EFFICACY OF LIFT INTERVENTION
Journal of Orthopaedic & Sports Physical Therapy
As indicated previously, the results of several stud-
ies suggest that lift therapy helps correct scoliosis
associated with limb length inequality in younger
patients and that a residual curve may persist in older
patients. 14,19,20,44,49 Giles and Taylor 20 and
Rothenberg49 suggest that the spine is more supple
in younger patients as compared to older patients,
and that scoliosis associated with a limb length
inequality may be reversible in younger individuals
with limb length inequality correction. Papaioannou
et al44 further supported the findings that the
scoliosis secondary to limb length inequality in pa-
tients aged 17 to 39 years was partially correctable to
a residual scoliosis of up to 10.
Several other authors have examined patient re-
sponse to lift therapy. Friberg14 studied patients with
a limb length inequality of 8.7 to 12.3 mm as
determined by standing radiographs. Seventy-three
percent (213/290) of the patients who previously
232
complained of LBP, sciatica, or hip pain, reported
they were symptom free following lift therapy. Fifteen
percent (45/290) reported their symptoms were re-
duced, and 12% (33/290) reported no change in
symptoms. With increasing age, symptoms were less
likely to be affected by lift therapy. Helliwell29 also
reported improvement in symptoms with lift therapy
for subjects with chronic LBP. Forty-four percent
(8/18) of his subjects were symptom free after lift
therapy, 28% (5/18) reported substantial improve-
ment, 17% (3/18) reported moderate improvement,
and 11% (2/18) reported no improvement in symp-
toms. Two limitations of Helliwells study were the
small sample size and the tape measurement method
that was used to assess limb length inequality. Two
other groups of investigators have reported positive
outcomes using joint manipulation in conjunction
with lift therapy.13,20 Whether the positive results were
due to the manipulation, lift therapy, or both is
unclear.
Limited data, therefore, are available to support lift
therapy for treatment of LBP and reduction of
scoliosis deformity for patients with limb length
inequality. Clinical judgment, in combination with
this limited body of literature, may guide intervention
when clinicians believe a musculoskeletal complaint is
associated with limb length inequality.
We have opted for an intervention strategy that is
dictated to some degree by the patients age. The
previously reviewed literature suggests that structural
compensations for limb length inequality are less
responsive to lift correction in older individuals than
in younger patients. Our clinical experience also
suggests that older patients may experience more
adverse effects from lift intervention than younger
patients. Our strategy, therefore, for patients younger
than 40 has been to identify the magnitude of limb
length inequality and begin the intervention with
50% correction, placing as much material as possible
inside and along the full length of the foot with any
remaining necessary lift tapered from heel to
midfoot. Patients are asked to use this magnitude of
lift for 1 to 2 weeks and note any change in
symptoms. If positive effects are noted, then incre-
ments of 3.2 mm are added and used for similar
amounts of time until the patient has determined the
optimum magnitude of corrective lift. Placing all of
the corrective lift on the bottom of the shoe (outside
the shoe) is considered if the desired magnitude of
lift is greater than 10 mm and if the patients heel is
being pushed out of the shoe during terminal stance
with the lift inside the shoe. We use a similar strategy
for patients older than 40, except that the initial
corrective lift is 3.2 to 6.4 mm regardless of the
magnitude of limb length inequality determination.
Finally, it should be noted that no studies were
identified for which correction of limb length in-
equality was used as an intervention for pathologies
J Orthop Sports Phys Ther Volume 33 Number 5 May 2003
 other than those affecting the spine and adjacent soft
tissues. Additional research is needed to investigate
the efficacy of corrective lift for patients who demon-
strate clinically significant limb length inequality that
may be associated with other lower extremity
orthopaedic conditions. Clinically, we have observed
that limb length inequality has been associated often
with excessive stretching of the iliotibial band on the
side of the shorter limb when patients compensate
with spinal side-bending toward the contralateral
longer limb side. We have used lift correction therapy
as one component of our intervention strategy when
patients with iliotibial band friction syndrome of the
shorter limb have presented with this alignment
profile.
CONCLUSION
Little agreement exists concerning the most accu-
rate and useful method for detection of limb length
inequality. Based on the available research, however,
we recommend the use of a lower-quarter screening
examination26 when a limb length inequality is sus-
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pected. A benefit of the screening examination is that
the patient is examined in standing, sitting, supine,
and prone. This permits assessment in both weight-
bearing and nonweight-bearing positions. Each com-
ponent of the lower extremity is systematically
examined to determine possible contributing factors
Copyright 2003 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
to limb length inequality.
Palpation of pelvic landmarks with block correction
has the strongest support from clinical investiga-
tions.28,33,58 Tape measurement methods have often
been used clinically3,6 although they have exhibited
weaker reliability than the iliac crest palpation and
block correction measurement method.58 We suggest
that the greater trochanters and as many pelvic
Journal of Orthopaedic & Sports Physical Therapy
landmarks as possible (eg, iliac crests, anterior supe-
rior iliac spines, posterior superior iliac spines, and
ischial tuberosities) should be palpated when the
block correction method is used. If a tape measure
method is used, measurement from the anterior
superior iliac spine to the lateral malleolus is the
most reliable technique,58 and using the mean of 2
measurements increases reliability.3 If a more compre-
hensive assessment is indicated, we suggest the use of
radiography as the most accurate and reliable
method for determining the presence and magnitude
of a limb length inequality. Clinicians should exercise
caution when designing interventions for limb length
inequality of less than 5 mm when the limb length
inequality has been assessed using clinical meth-
ods.3,10 Finally, most authors agree that lift therapy
should be implemented gradually in small incre-
ments4,5 and that corrective lift should be more
conservative and gradual for older patients.
J Orthop Sports Phys Ther Volume 33 Number 5 May 2003
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J Orthop Sports Phys Ther Volume 33 Number 5 May 2003