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
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
the limb unilaterally without osseous shortening, (mm) Notes on Position Taken
environmental limb length inequality may be consid- 3 56
Subotnick suggests that a limb length inequality
ered as simply another example of a functional limb greater than 3 mm may require intervention for
length inequality. In this respect, we consider envi- runners
5 Friberg et al18 have used 5 mm of limb length
ronment to be an etiological factor and not a
discrepancy as an operational definition for the
separate classification of limb length inequality. condition
Finally, Reid and Smith46 proposed a measurement 6 Holmes et al31 have considered 6 mm of limb
classification system to categorize limb length inequal- length discrepancy as a clinically significant
ity in which a 0- to 30-mm discrepancy is considered magnitude
Journal of Orthopaedic & Sports Physical Therapy
CLINICAL
athletic population56
50.0 5.0 50% of the total population congenital causes of anatomical or true limb length
thought to have a limb length inequality.
inequality of 5 mm or more18 A functional limb length inequality may result from
See comments 4.011.0 376 normal subjects indicate
that normal difference in limb adaptive shortening of soft tissues, joint contractures,
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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,
COMMENTARY
to 11 mm for skeletally mature such as excessive asymmetric pronation. They suggest
individuals45
that foot pronation is accompanied by decreased
longitudinal arch height compared to the
Copyright 2003 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
ported unequivocally. Giles and Taylor20 observed with limb length inequality.4 Excessive pronation may
that a limb length inequality of 10 mm or more is also be the cause of a functional limb length inequal-
more common in patients with LBP, while investiga- ity, effectively shortening a limb.8 According to
tions by Fisk and Baigent13 and Soukka et al54 did Resseque and Volpe,47 severe pronation can lead to
not find such a correlation. Soukka et al54 reported ankle joint pathology. DAmico et al8 used the
Copyright 2003 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
that a group of symptom-free subjects and a subject Electrodynogram system to demonstrate increased
group with a history of LBP had similar distributions pronation and weight-bearing force at the medial side
of limb length inequality up to 10 mm. They suggest of the foot on the longer limb side. Donatelli11 has
that a mild limb length inequality of 5 mm or less suggested that this excessive pronation can lead to
may be unrelated to LBP. Even though a limb length plantar fasciitis, a flat foot, ligamentous laxity, a tight
inequality may have a significant influence on spine Achilles tendon, forefoot varus, calcaneovalgus, ankle
position, some patients with a significant limb length joint equinus, or hallux valgus.11 We would like to
inequality may be able to accommodate it without note, however, that we have not consistently observed
experiencing LBP.44 Pain in the lower back may excessive asymmetric foot pronation either on the
Journal of Orthopaedic & Sports Physical Therapy
result from a number of causes and often occurs in side of the longer limb or on the side of the shorter
the absence of limb length inequality.37 limb in patients with anatomical limb length inequal-
Hip pathologies have also been studied in relation ity.
to limb length inequality. Fisk and Baigent13 identi- Leppilahti et al36 explored limb length inequality
fied hip osteoarthritis, and Gofton and Trueman21 as a possible factor in Achilles tendon rupture. These
identified hip arthrosis, as common problems in the investigators studied 48 patients with a limb length
hip joint of the longer limb. This finding was inequality greater than 5 mm, and reported that the
supported by both Friberg14 and Rothenberg.49 prevalence of injury to the Achilles tendon was
Friberg14 suggests that the hip joint in the longer relatively equal between the shorter limb and the
limb would likely be in a varus position, which longer limb. Limb length inequality, therefore, does
decreases the load-bearing surface of the femoral not appear to be related to Achilles tendon rupture.
head. Increased pressure at the articular surface may In a study of 371 Finnish Army conscripts,
then effect chondral damage. Rothenberg49 also has Friberg15 reported that limb length inequality may
suggested that sciatica is more likely to occur on the have a predisposing role in causing stress fractures in
longer-limb side, while trochanteric bursitis may oc- either the femur, tibia, fibula, or metatarsals. Friberg
cur more often on the shorter-limb side. reported a positive correlation between limb length
Limb length inequality has also been associated inequality and stress fractures, but did not provide
with a number of knee problems. Holmes et al31 statistical measures or methods to support this state-
reported that 7 of 61 cyclists with knee pain associ- ment.
CLINICAL
used to determine limb length inequality: telero- rotation. Nevertheless, radiography does have internal
entgenography, orthoroentgenography, scanography, sources of error. Clarke6 studied the effect of varying
and computed tomography. the tube focal (source-to-image) distance and position
A teleroentgenogram is a single exposure of the of the tube focal point on radiographic findings. He
standing subject, imaging the entire lower extremities used a human skeleton that was adjusted for known
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using a long film and an X-ray source-to-image unilateral discrepancies at the iliac crest and femoral
distance of 2 m. A ruler is placed in the center of the head for a combined difference of 20 mm, and iliac
COMMENTARY
film cassette to assist measurement and to act as a rotations of 15. Radiographs were taken from a
magnification marker of known size.39,55 Stanitski55 distance of 100 cm and 200 cm and with a 5-cm
suggests that the advantages of teleroentgenography height difference in the tube focal point. Radio-
Copyright 2003 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
are the ability to demonstrate axial deformities, graphs from 200 cm were more accurate (03 mm)
frontal-plane deformities, and limb length inequality than from 100 cm. Kujala et al34 studied the effect of
all on 1 film. Limitations of teleroentgenography are varying the vertical height of the tube focal point
an inherent inaccuracy in patients with a hip or knee when imaging the entire lower extremity. The X-ray
flexion contracture and that the technique is subject beam was first centered over the femoral heads and
to a magnification error.39,55 Stanitski55 reports an images were taken. The X-ray focal point was then
average magnification error of approximately 6%, moved to the level of the knees without adjusting for
which is easily corrected by placing a magnification horizontal differences (eg, genu valgum). Kujala et
marker of known dimensions on the film. Mannello al34 concluded that this method resulted in no
Journal of Orthopaedic & Sports Physical Therapy
has suggested that teleroentgenography is adequate vertical projection error. A horizontal projection er-
for children but impractical for adults due to the size ror of 10.5% resulted in only a 0.7 overestimation in
of the films required and the distortion of the beam the varus angle at the knee. The results of these
related to the source-to-image distance.39 studies suggest that imaging accuracy may improve
Orthoroentgenography attempts to avoid the mag- slightly using a tube focal distance of 200 cm and by
nification error experienced with teleroentgenograms centering the focal point of the X-ray beam at the
by using separate exposures at the hips, knees, and horizontal level of anatomic interest.
ankles on the same long film. A ruler is again placed Foot placement also has been noted as an impor-
on the film cassette to aid in measurement. tant variable in obtaining accurate radiographs.13,20
Orthoroentgenography is subject to the same limita- Placing the feet of a subject 15 to 20 cm apart
tions regarding patients with fixed joint contractures. increased the accuracy of the image for measuring
Patients can unintentionally introduce error into the purposes. This position creates a parallelogram be-
readings by moving between exposures.55 Friberg14 tween the hips and the feet, eliminating error intro-
devised a novel method of ascertaining limb length duced by weight shift or sway at the hips and
inequality radiographically that reduced radiation ex- preserving the relative heights of the bilateral ante-
posure. He exposed only the hip joints and surround- rior superior iliac spines.13 Giles and Taylor20 recom-
ing structures with subjects in standing. Limb length mend a modification of using the arbitrary distance
inequality was determined by the difference in femo- of 15 to 20 cm, and suggest that the patient place the
ral head heights as compared to a true horizontal feet immediately below and in line with the femoral
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.
CLINICAL
malleolus. Several variations include measuring from or functional in nature. Beattie et al3 also determined
the anterior superior iliac spine to the lateral mal- qualitatively that clinicians should exercise caution
leolus, from the umbilicus to the medial malleolus, when making clinical decisions regarding patient
and from the xiphosternum to the medial malleolus. treatment when tape measurements of limb length
The indirect methods generally involve palpating inequality are 5 mm or less.
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bony landmarks such as the iliac crests or anterior Hoyle et al32 reported intraclass correlation coeffi-
superior iliac spines with the patient standing while cients (ICCs) between repeated tape measurements
COMMENTARY
the examiner assesses for levelness of the palpated from the anterior superior iliac spine to the medial
landmarks. One method includes placing objects of malleolus that were similar to those reported by
known thickness, such as wooden blocks or book Friberg et al.18 The ICC3,1 for 25 subjects between 2
Copyright 2003 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
pages, under the shorter limb for correction until the examiners for the left limb was 0.99 with a range of
bony landmarks are assessed as level.1,13,28,35,58 Some differences between examiners of 5.0 to 23.0 mm.
investigators have also used a pelvic leveling device to The ICC3,1 for 25 subjects between 2 examiners for
aid in the assessment of the bony landmarks during the right limb was 0.98 with a range of differences of
indirect assessment.24,33,43 0.0 to 28.5 mm. All repeated measurements were
Direct Methods A great deal of criticism and debate reported to differ significantly between examiners,
surrounds the accuracy of tape measure methods for though they were highly correlated. The authors
assessment of limb length inequality.55 Friberg has concluded, therefore, that tape measurements by
reported cases for which an actual limb length different clinicians should not be compared. The
Journal of Orthopaedic & Sports Physical Therapy
inequality of up to 25 mm has been overlooked and study by Hoyle et al32 did have 2 major methodologi-
even attributed to the wrong limb by different clini- cal problems. Subjects were measured repeatedly with
cians.14 Clarke6 compared the supine measurements an insufficient interval between measurements to
of limb length inequality for 2 examiners to radio- prevent rater bias, and it is not clear if examiners
graphic measures, both measured to the nearest 5 were masked to each others results.
mm. The examiners used a tape measure method to Woerman and Binder-Macleod58 compared the re-
measure the distance between the anterior superior sults of measurements by 20 examiners on 5 subjects
iliac spine and the medial malleolus. Both examiners using 4 different direct methodologies of assessing
reported measurements that were within 5 mm of the limb length inequality. All measurements were com-
radiographic determinations of limb length inequality pared to radiographs. The method using tape mea-
for only 20 (40%) of the 50 subjects. For the 21 surements from the anterior superior iliac spine to
subjects who had a limb length inequality of 10 mm the medial malleolus differed from the radiographic
or more, both observers were within 5 mm of measurements by a mean difference of 7.3 10.1
radiographic results for only 7 subjects (33%). mm. The method using tape measurements from the
Friberg et al18 compared the reliability of tape anterior superior iliac spine to the lateral malleolus
measurements from the anterior superior iliac spine had a mean difference of 6.0 16.0 mm. The
to the medial malleolus with a radiographic method method using tape measurements from the umbilicus
designed by Friberg.14 Three observers and 21 sub- to the medial malleolus had a mean difference of
jects were involved in the study. Each subject had a 4.2 9.9 mm, and tape measurements from the
by the use of supine radiographs, which may not iliac spine height and the horizontal difference be-
reflect limb lengths during functional weight bearing. tween the left and right anterior superior iliac
Investigators who do not support the use of the spines.43
tape measure methods cite the following sources of Several research reports suggest that simple palpa-
measurement error: difficulty in palpating bony land- tion and a visual estimate of iliac crest height is not
Copyright 2003 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
marks,3,4,14,16,20,43,58 iliac asymmetries that may mask reliable.7,8,38 Clarke6 compared clinical assessment
or accentuate a limb length inequality,3,18,20,38,58 uni- using iliac crest palpation to radiographic evaluation.
lateral deviations in the long axis of the lower limb Both examiners in the study were correct to within 5
(eg, genu valgum),3,4,58 asymmetrical position of the mm for only 16 of 50 subjects when their measure-
umbilicus,58 and joint contractures.4,58 Although obe- ments were compared to radiographic measurements.
sity is commonly identified as a factor which affects Twenty-one subjects were identified as having a limb
accurate palpation and measurement, Mann et al38 length inequality of 10 mm or more based on the
failed to demonstrate a correlation between a sub- radiographic measurements. In these individuals,
jects percentage of body fat and differences in rater both examiners identified the inequality to within 5
Journal of Orthopaedic & Sports Physical Therapy
agreement of limb length inequality. Difference in mm in only 9 cases when their clinical assessments
thigh circumference3,4,58 has also been identified as a were compared with radiographic determinations of
factor which may hamper accurate measurement of a limb length inequality.
limb length inequality, although Woerman and Subsequent studies have improved upon this
Binder-Macleod58 contend that the method using method by placing wooden blocks or floor tiles of
tape measurements from the anterior superior iliac known thickness under the suspected shorter
spine to the lateral malleolus eliminates the contour limb.1,13,35,58 Fisk and Baigent13 acquired radiographs
of the thigh as a source of measurement error. Mann of 107 subjects with limb length inequality and
et al38 reported that palpation of the iliac crests in compared the images to the iliac crest palpation and
standing subjects was not reliable, although experi- block correction method. The clinical assessments of
enced physical therapists were more reliable than less the examiners were incorrect by more than 5 mm for
experienced student examiners. 31 subjects (29%). Further examination of the radio-
We prefer to not use direct supine measurements graphs, however, indicated that 8 of these 31 subjects
of limb length inequality for many of the reasons had an iliac asymmetry, making radiographic assess-
identified in the preceding content and because the ment difficult. Aspegren et al1 compared the iliac
method involves 6 procedures for which error may be crest palpation and block correction method to
introduced into the determination of limb length radiographic identification of limb length inequality
inequality. A proximal and a distal bony landmark for 41 subjects. Twenty-six (63%) of 41 subjects were
must be identified and marked on both extremities. measured within 3 mm of the radiographic values. Six
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.
CLINICAL
inequality and whether or not the patient is symptom- strike during running compared to walking.
atic. Several authors suggest that no treatment is Subotnick56 extrapolated this information to suggest
required if a patient is asymptomatic,5,25,55 but that a 6.4-mm limb length inequality in a running
Gofton21 advocates intervention in patients without athlete may be as significant as a 19.2-mm limb
symptoms as an important strategy for the prevention length inequality in nonathletes. Theoretically, one
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of future pathology. might argue that a limb length inequality may not be
The need for intervention may be obvious in cases as detrimental for running as it is for walking or
COMMENTARY
of severe limb length inequality. Surgery may be standing because running does not involve any peri-
appropriate for those individuals with a severe ana- ods of bilateral stance. Studies are needed to deter-
tomical limb length inequality9 or a scoliosis that mine if limb length inequality is associated with
Copyright 2003 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
results in a functional shortening of the lower limb. running injuries because of factors such as asymmet-
The primary goal of spinal surgery is fixation or ric ground reaction force patterns or asymmetric soft
correction of the spinal curvature with a secondary tissue extensibility.
reduction of the functional limb length inequality. Implementation of lift therapy for limb length
Surgical techniques to shorten or lengthen the lower inequality is currently based on clinical judgment and
limb have been used for the tibia, the femur, or both experience.40 A uniform protocol for intervention
to achieve symmetry.45,55 The Ilizarov technique has has not been established, but guidelines regarding
been used successfully to lengthen a bone.47,52 This is the implementation of lift therapy have been recom-
achieved through osteotomy and distraction of the mended.2,4,5,9,57 Most clinicians agree that lift therapy
Journal of Orthopaedic & Sports Physical Therapy
bony components with external fixation. The bone is for the treatment of limb length inequality should be
held in place while osteoblastic activity fills in the implemented in small increments to facilitate adjust-
newly created space. The external fixation can then ment to each change in lift magnitude.4,5,9,14,23,49
be adjusted in small increments (1 mm/d).52 At the Blustein and DAmico5 suggest an interval of 2 weeks
termination of distraction elongation, fixation is nec- between lift therapy adjustments and that each lift
essary to allow maturation and strengthening of the increment should not be more than 3 to 6 mm. They
new bone. This method may require several months, further suggest that correction of limb length in-
depending on the magnitude of desired lengthening. equality should be no greater than one-half of the
Lengthening may be required for both the femur and difference between limb lengths.5
tibia in extreme cases of limb length inequality. Blake and Ferguson4 published an example of a lift
Osteotomy and excision may also be performed to therapy progression for a 9-mm correction of limb
shorten the contralateral longer limb. In cases of length inequality. In the first week, a full-length 3-mm
functional shortening, such as with a tight Achilles lift was advocated. A 3-mm heel lift can be added
tendon or tight hamstrings, surgery to release a during the second week. At week 3, the previous lifts
contracture is performed only after conservative treat- can be removed and replaced with a 6-mm full-length
ments have failed. lift. A 3-mm heel lift can be added at week 5. Finally,
In many cases of limb length inequality, nonin- the previous lift material can be exchanged for a
vasive techniques such as shoe lifts4,5,20,22,49,56 or 9-mm full-length lift at week 7. The schedule and
orthotics,4,5,44,56 may be more appropriate. A func- amount of lift therapy introduced in this example was
shoes owned by a patient, intervention usually is less when clinicians believe a musculoskeletal complaint is
expensive if internal lift materials are used that can associated with limb length inequality.
be transferred from one pair of shoes to another.14
We have opted for an intervention strategy that is
Regardless of the location of the corrective lift or the
dictated to some degree by the patients age. The
magnitude of the lift employed, McCaw40 suggests
previously reviewed literature suggests that structural
that the magnitude of the corrective lift should be
Copyright 2003 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
As indicated previously, the results of several stud- inside and along the full length of the foot with any
ies suggest that lift therapy helps correct scoliosis remaining necessary lift tapered from heel to
associated with limb length inequality in younger midfoot. Patients are asked to use this magnitude of
patients and that a residual curve may persist in older lift for 1 to 2 weeks and note any change in
patients. 14,19,20,44,49 Giles and Taylor 20 and symptoms. If positive effects are noted, then incre-
Rothenberg49 suggest that the spine is more supple ments of 3.2 mm are added and used for similar
in younger patients as compared to older patients, amounts of time until the patient has determined the
and that scoliosis associated with a limb length optimum magnitude of corrective lift. Placing all of
inequality may be reversible in younger individuals the corrective lift on the bottom of the shoe (outside
with limb length inequality correction. Papaioannou the shoe) is considered if the desired magnitude of
et al44 further supported the findings that the lift is greater than 10 mm and if the patients heel is
scoliosis secondary to limb length inequality in pa- being pushed out of the shoe during terminal stance
tients aged 17 to 39 years was partially correctable to with the lift inside the shoe. We use a similar strategy
a residual scoliosis of up to 10. for patients older than 40, except that the initial
Several other authors have examined patient re- corrective lift is 3.2 to 6.4 mm regardless of the
sponse to lift therapy. Friberg14 studied patients with magnitude of limb length inequality determination.
a limb length inequality of 8.7 to 12.3 mm as Finally, it should be noted that no studies were
determined by standing radiographs. Seventy-three identified for which correction of limb length in-
percent (213/290) of the patients who previously equality was used as an intervention for pathologies
CLINICAL
rate and useful method for detection of limb length 8. DAmico JC, Dinowitz HD, Polchaninoff M. Limb
inequality. Based on the available research, however, length discrepancy. An electrodynographic analysis. J
we recommend the use of a lower-quarter screening Am Podiatr Med Assoc. 1985;75(12):639643.
9. Danbert RJ. Clinical assessment and treatment of leg
examination26 when a limb length inequality is sus- length inequalities. J Manipulative Physiol Ther.
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COMMENTARY
measurement: a preliminary study. J Manipulative
bearing and nonweight-bearing positions. Each com- Physiol Ther. 1983;6(2):6166.
ponent of the lower extremity is systematically 11. Donatelli R. Abnormal biomechanics of the foot and
examined to determine possible contributing factors ankle. J Orthop Sports Phys Ther. 2002;9:1116.
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to limb length inequality. 12. Egan D. Letter to the editor. Spine. 2000;25:2844.
13. Fisk JW, Baigent ML. Clinical and radiological assess-
Palpation of pelvic landmarks with block correction ment of leg length. N Z Med J. 1975;81(540):477480.
has the strongest support from clinical investiga- 14. Friberg O. Clinical symptoms and biomechanics of
tions.28,33,58 Tape measurement methods have often lumbar spine and hip joint in leg length inequality.
been used clinically3,6 although they have exhibited Spine. 1983;8(6):643651.
15. Friberg O. Leg length asymmetry in stress fractures. A
weaker reliability than the iliac crest palpation and clinical and radiological study. J Sports Med Phys
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that the greater trochanters and as many pelvic 16. Friberg O. Leg length inequality and LBP. Lancet.
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S. Ruptures of the Achilles tendon: relationship to length inequality in people of working age. The associa-
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and ankle. Foot Ankle Int. 1998;19(10):683687. questionable. Spine. 1991;16(4):429431.
37. Magee DJ. Orthopedic Physical Assessment. Philadel- 55. Stanitski DF. Limb-length inequality: assessment and
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38. Mann M, Glasheen-Wray M, Nyberg R. Therapist agree- 1999;7(3):143153.
ment for palpation and observation of iliac crest 56. Subotnick S. Limb length discrepancies of the lower
heights. Phys Ther. 1984;64(3):334338. extremity (the short leg syndrome). J Orthop Sports Phys
Journal of Orthopaedic & Sports Physical Therapy