Should you be concerned with leg length discrepancy? Does it really cause pain and should you get it fixed? Chances are, you probably don’t.
A client recently told me that he had chronic hip and low back pain for almost a year, and his physical therapist had told him that it is likely because his left leg is “longer” than the other leg. His previous massage therapist attempted to “correct” his leg-length discrepancy by doing several bouts of hip and knee traction and stretching, which actually made his pain worse. As I stood there and listened to his story, taking note of the way he spoke and his body language, I wonder if his pain was more than just a leg length issue.
Like most flavors of pain, many factors contribute to how we perceive and respond to it. For example, my client may worry that his leg-length inequality may prevent him from hiking and golfing — two of his favorite pastimes. He might worry that his pain won’t go away, which interferes with his job and disrupts his sleep quality. Given what we know about the biopsychosocial model of pain (BPS), leg-length discrepancy may not be a big contributor to pain for some people.
How prevalent is leg-length discrepancy?
A little more than 2 out of 100,000 people has leg-length discrepancy, at least in France in the mid-1980s. Based on data from a whopping 2.68 million French sample in 1987, about 1 in 1,000 people use some sort of correctives for their leg-length discrepancy. (1) A 2005 review published in Chiropractic and Osteopathy estimated that most people with leg-length discrepancy have a 9-millimeter difference or less, based on a sample population of more than 1,600 people. Fewer than seven percent have more than a 14-millimeter difference. (2) There is no difference between gender and height.
Dr. Gary A. Knutson, who is the author of the 2005 review and a practicing chiropractor for more than 35 years in Bloomington, Indiana, identified pelvic torsion in the sagittal and frontal planes as a primary effect of leg-length discrepancy. “Mechanically, in the standing position, the weight of the body in the pelvis induces a force vector through the hip joints and towards the feet. With asymmetry of the leg-lengths, the pelvis, being pushed down on the femoral heads, must rotate or torsion,” he wrote. Such compensation is even more obvious among those with greater leg-length discrepancy up to two centimeters, which often leads subjects to stand with a “contrapposto” like an ancient Roman statue. (2)
However, other factors could contribute to pelvic torsion, such as asymmetry of the pelvic bones, degree of movement of the sacroiliac joint, and hyptertonic suprapelvic muscles, and we cannot reliably tell how much leg-length discrepancy someone has by examining pelvic tilts and X-rays or using tape measurement.
“The problem is conflating anatomic leg-length inequality (aLLI) which is true leg-length inequality, with putatitve functional or physiological leg-length inequality (fLLI), which is the appearance of leg-length inequality caused by a physiologic dysfunction, most likely involving muscles and pelvic torsion. How these differing types of leg-length inequality may overlap and cause pain and dysfunction,” Dr. Knutson told Massage & Fitness Magazine in an email interview.
“Most manual therapists recognize fLLI as a real phenomenon. However, since it has yet to be validated, we cannot be sure, and many consider fLLI to be a phantom, a figment of our imaginations. I get that, and there are some smart people working on methods to validate this phenomenon. However, until this is done, fLLI is not considered when some in the health or research professions look at the problem of LLI. In addition, measurement of aLLI is often done visually, or with badly aligned X-ray, and any findings may thus be the result of fLLI.”
Does leg-length discrepancy cause low back pain?
Patients and clients who have leg-length discrepancy and lateral pelvic tilts often have one side of their torso “scrunched” up, which is easily seen by an extra fold of skin on the side of the abdomen. While it may look uncomfortable to some of us and we tend to jump to conclusions that this is the source of their pain, the evidence about the leg-length discrepancy and pain is quite mixed.
Dr. Knutson found a large range of leg-length discrepancy — 5 to 30 millimeters — that could be associated with chronic low back pain. However, the consensus is not so much about the leg length difference but it is more about how much load is placed upon the lower body and for how long. Although subjects with greater leg-length discrepancy (10 millimeters or greater) reported having low back pain more than those with less discrepancy (18% of 1309 subjects), Dr. Knutson pooled data from 164 asymptomatic subjects and found that about 15 percent of this sample had leg-length disc pancyof 10 millimeters or greater.
So this raises the question of why this specific population reported no pain. (2,4) Another study of 247 subjects no difference in reports of low back pain with a leg-length discrepancy of 10 to 20 millimeters. (5)
A few studies also found no significant correlation between leg-length inequality and back pain among adults with huge leg-length discrepancies since childhood. One study from Finland had 81 subjects with an average of 12 millimeters of leg-length discrepancy found that most of them had not reported any low back pain during the average time of 35 years. (6) Another study of 23 young adults with an average of 29 millimeters also found no back pain complaints. (7)
Even among amputees who had their lower leg amputated, there were no differences in leg-length discrepancy between those with low back pain and those without. However, the sample is tiny (9 with pain, 8 without) so the effect size may be negligible. Still, this study raised questions whether leg-length discrepancy is significant enough to contribute low back pain. (8)
So why do some people who have a huge leg-length discrepancy do not have pain?
“First, some people are more flexible than others — like children — and their body can adapt to the anatomic inequality. The body seems to be able to compensate for relatively small amounts of true anatomic inequality,” Dr. Knutson explained. (13,14)
“Second, pain can be the result of a functional or physiologic inequality and not anatomic. Thus, anatomic leg-length inequality may be present, but the pain is the result of fLLI pathophysiology, not the result of the aLLI. When there is pain involved in the kinetic chain, leg-length inequality is often poorly measured, and that measurement gives no distinction between anatomic and functional leg-length inequality. So, what is a functional problem is often blamed on an anatomic one, and vice-versa.”
Another reason why many clinicians believe that leg-length discrepancy is a strong factor in contributing to back pain is because of their training, education, and way of thinking.
“Why does the back hurt? I was taught [it’s because of] herniated discs, atrophied muscles, lifting improperly, sacral torsions…I could go on. But we know now that pain is more complicated than anatomy most of the time. We know that most of us are ‘asymmetrical’, and if we take the time to really listen to people’s symptoms, their back pain didn’t start when they were walking as children,” Dr. Sarah Haag, who is a practicing physical therapist at Entropy Physiotherapy and Wellness in Chicago, Illinois, explained in an online interview.
“How would even a ‘significant’ leg length difference all of the sudden be the lynch-pin to solving a person’s back pain? Spoiler alert: It doesn’t.
“People can have really crazy deformities and NOT have pain. Pain is a multi-factorial, personal experience of a person. If it were as simple as correcting a leg-length inequality, we’d have solved the most expensive and debilitating healthcare issue in the world.”
While Dr. Knutson’s review found hardly any evidence that there is a strong relationship between leg-length discrepancy and back pain, some recent research reported otherwise. An Australian study found a strong correlation between leg-length discrepancy and degenerative disc disease in the hip and low lumbar spine, which may be a source of low back pain. What is interesting is that among the 255 subjects studied (121 women, 134 men), middle-age men with leg-length discrepancy reported higher incident of pain than matching women. Among the latter, there were not much difference between those with leg-length discrepancy and without. However, younger men and women with leg-length discrepancy reported more pain than those with no such difference. (9)
But like in Knutson’s review, the authors suggested, “This correlation is consistent with the notion that abnormal or excessive joint loading, as occurs in the hip joint and lumbar spinal joints as a result of [leg-length discrepancy}, may predispose these to the development of [degenerative disc disease].” They cautioned that this sample population may not reflect on the general population since the patients were recruited from their chiropractic practices. Even though they reported a strong correlation, the study does not establish causation effect. (Remember statistics 101: Correlation does not always equate to causation.)
Another study from Finland found that those with greater than five millimeters had higher reports of low back pain than those with less than five millimeters, especially among those who had to stand for long hours at work. However, the study design itself is quite interesting because the subjects consisted of 218 workers — 169 pork meat cutters (31 females and 138 males) who had physically demanding work, and 50 customer service workers (41 females and 9 males) who sat most of the day.
The authors admitted that small sample population, especially among the latter group, is quite small and may not accurately reflect on the general population. Also, the large difference between the number of subjects compared may not be reflect as accurately as having a closer ratio. However, like the aforementioned study, a longitudinal study is needed to determine how strong is the relationship between leg-length discrepancy and risk of low back pain. (10)
“People can have really crazy deformities and NOT have pain. Pain is a multi-factorial, personal experience of a person. If it were as simple as correcting a leg-length inequality, we’d have solved the most expensive and debilitating healthcare issue in the world.” ~ Dr. Sarah Haag
Knee and hip pain has similar story as leg-length discrepancy
While most research find that people with leg-length discrepancy tend to also have higher reports of hip and knee pain, the differences between those with and without leg-length discrepancy aren’t very significant.
A 2009 North Carolina study examined over 3,000 people with hip, groin, and knee pain living in various counties in rural North Carolina. The study found that 226 people with a leg-length discrepancy of two millimeters or more reported more symptoms of pain than those without the discrepancy. However, this group were more likely “to be older, have a higher mean body mass index (BMI), report symptoms most days in the knee or hip, have radiographic knee or hip [osteoarthritis], and report a history of joint problems.”
The authors stated, “Moderate-to-severe symptoms were more common in participants with [leg-length discrepancy] than without [leg-length discrepancy], though this was not statistically significant in either knee or hip joint. We cannot determine causality from this cross-sectional study.” (11)
Another study with 1,430 subjects find a lack of an association between pain in the greater trochanter and leg-length discrepancy. Among the 271 subjects with hip pain, 37 of them had a leg-length inequality of one millimeter or greater while the remaining ones had no leg-length discrepancy. (12)
Should you be worried about leg-length inequality?
While it seems like leg-length discrepancy is associated with pain, we should not mistaken association (and correlation) with causation. Still, some therapists and trainers try to “correct” this issue with “aggressive” hands-on therapies and specific exercises. Considering the complexity of the topic, what should we ask when reading such research?
“First: how was the leg-length inequality measured? Quantifying true anatomic leg-length inequality is difficult. In my review paper, I only used studies that had used more accurate and reliable measuring techniques,” Dr. Knutson suggested.
“Second, was consideration given to a functional problem? Simple measures of leg-length discrepancy do not necessarily give good data on what the cause of the problem really is. That aLLI and fLLI can overlap, and given the most common measurement methods it becomes problematic if not impossible to delineate one cause from another. Wrong cause, wrong treatment.”
If you are not research savvy yet you are interested in it, Dr. Haag, recommends that you take a course.
“I had to. And I’ve taken several of them because I still feel like I have room for improvement,” she recalled. “Always critically assess what you’ve read.”
Dr. Haag also gave a few tips for reading scientific literature:
1. Watch out for grand claims for strong findings in the abstract or conclusions. If they make grand claims, there should be rock solid data to support them.
2. Read the methods section! Google the stats they used. Make sure they measured that they said they did, and that they used a reliable measure. Also, review the different study designs. Did the researchers choose a study design that can actually answer the question they’re posing?
4. Be confident that you are still clever even if a study doesn’t make sense.
“I used to HATE reading literature,” Haag said. “I’d muddle through, be frustrated that it didn’t make sense, and at the end it would just say ‘more studies are needed.’ Sometimes the studies were poorly done. Sometimes they disagreed with the findings. I didn’t want to be the dummy so I’d just stay quiet. But knowing that you’re trying to learn more, and asking thoughtful questions to researchers and other clinicians is a fantastic way to grow your knowledge. Questioning should be encouraged!”
Given our current understanding of the biopsychosocial model of pain, is leg-length discrepancy a significant factor in pain contribution based on current and past research? It’s a gray area and the answer depends on the individual patient.
“Hearing their story and [observe] their behavior of their pain are the keys,” Dr. Haag said. “I’ve had more patients than I can count start their story of low back pain with ‘I’ve been told I have a leg length discrepancy by my (fill in well-meaning professional/friend/relative), and that’s why I have low back pain’.
“Depending on when their pain started, how it ebbs and flows with time of day, activity, or mood are all important! If the person in front of me tells me their pain skyrockets when they don’t wear their one-centimeter heel lift, I’m not going to take that away from them. I will instead full assess them and see if I can help them not need that heel lift — regardless if using it improves biomechanics in some small way or if it’s just a security blanket in their shoe.”
Given our current understanding of pain and the current evidence about leg-length discrepancy and pain, clinicians may likely give it too much credit for causing pain.
“Simple measures of leg-length inequality do not necessarily give good data on what the cause of the problem really is,” Dr. Knutson said. “aLLI and fLLI can overlap, and given the most common measurement methods, it becomes problematic if not impossible to delineate one cause from another. Wrong cause, wrong treatment.”
“In physical therapy school, I was taught to check for leg-length discrepancy — complete with routines to ‘be more accurate,’ Dr. Haag added. “This included having the patient lift up their pelvis and sit it back down, then straighten their legs, then I’d grasp their ankles and traction gently (supposedly to correct for any positional contribution to the leg length inequality I might find). Once in the correct position, I could ‘eyeball’ it, using my dominant eye, again, for accuracy. I also learned the difference between ‘functional leg-length inequality ’ and ‘true leg-length inequality’.
“What I don’t recall learning is why all of this may matter. And if it did matter, what in the world was I going to do about it?”
While treating leg-length discrepancy is beyond the scope of practice of massage therapists and personal trainers, remember that scope of practice of massage therapists and many factors could contribute to how each person sense pain, which likely explains why some people with a large leg-length discrepancy have very little or pain versus some with a small leg-length discrepancy and have excruciating pain. This is similar to why some people do not have chronic low back pain or chronic low back pain despite imagings find structure “abnormalities.”
Providing a safe environment to decrease our patients’ and clients’ sense of threat and increase their confidence of moving better and knowledge about pain are some of the steps we can do, as long as we stay within our scope of practice, scope of practice of massage therapists, and acknowledge their problem.
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