Copyright 1997 by The Journal of Bone and Joint Surgery, Incorporated

The Effect of Limb-Length Discrepancy on Gait*

BY KIT M. SONG, M.D.f, SUZANNE E. HALLIDAY, M.SC4, AND DAVID G. LITTLE, F.R.A.C.S.S, DALLAS, TEXAS
Investigation performed at Texas Scottish Rite Hospital for Children, Dallas

ABSTRACT: We evaluated the gait of thirty-five neurologically normal children who had a limb-length discrepancy of the lower extremities that ranged from 0.8
to 15.8 per cent of the length of the long extremity (0.6
to 11.1 centimeters). The twenty-two boys and thirteen girls had an average age of thirteen years (range,
eight to seventeen years). No patient had a substantial angular or rotational deformity of the lower extremities. We found no correlation between the actual
discrepancy or the per cent discrepancy and any of
the dependent kinematic or kinetic variables, including
pelvic obliquity.
Discrepancies of less than 3 per cent of the length
of the long extremity were not associated with compensatory strategies. When a discrepancy was 5.5 per
cent or more, more mechanical work was performed
by the long extremity and there was a greater vertical displacement of the center of body mass. Clinically, this degree of discrepancy was manifested by
the use of toe-walking as a compensatory strategy.
Children who had less of a discrepancy were able to
use a combination of compensatory strategies to normalize the mechanical work performed by the lower
extremities.
Some authors have recommended that a limb-length
discrepancy of two centimeters or more at the end
of osseous growth should be treated operatively32735;
however, we were unable to find a well designed study
to support this recommendation. Several reports have
suggested that inequality in the lengths of the lower extremities is associated with back pain10'224262932, dysfunction of the knee52325, and osteoarthrosis of the hip10131426.
We found only one study regarding the biomechanical
alterations in gait secondary to an acquired limb-length
discrepancy22.
We evaluated the effect of limb-length discrepancy on the gait of otherwise healthy children. We documented the strategies used to compensate for large
discrepancies, and we also attempted to identify a thresh*No benefits in any form have been received or will be received
from a commercial party related directly or indirectly to the subject
of this article. No funds were received in support of this study.
(Children's Hospital and Medical Center, 4800 Sand Point Way
N.E., P.O. Box 5371/CH-59, Seattle, Washington 98105-0371.
JTexas Scottish Rite Hospital for Children, 2222 Welborn
Street, Dallas, Texas 75219.
New Children's Hospital, Sydney, Australia.

1690

old of discrepancy above which there were biomechanical alterations in gait.

Materials and Methods
We reviewed the records of 275 patients who had
been evaluated at our institution, between 1985 and
1993, for a limb-length discrepancy. Approval for this
study was obtained from the Institutional Review
Board. The criteria for inclusion were a minimum age
of seven years (to ensure that the child had established a mature pattern of walking34); a clinically detectable limb-length discrepancy; less than 10 degrees
of angular difference between the two extremities in
any plane; less than 10 degrees of difference in the total range of motion of the hips, knees, and ankles in
any plane; and normal neurological and cognitive function. Children who had had an operation to equalize
the lengths of the extremities within the preceding six
months, had had an injury of the lower extremity that
had necessitated immobilization or the use of crutches
within the previous six months, or had had pain in the
lower extremity or back that restricted their activity
were excluded from the study. Forty-three children met
our criteria for inclusion, and thirty-five of these children and their families agreed to return to our hospital for evaluation.
There were twenty-two boys and thirteen girls, with
an average age of thirteen years (range, eight to seventeen years). Fourteen patients had a short left extremity
and twenty-one had a short right extremity. The etiology
of the limb-length discrepancy was idiopathic in nine
patients, a congenitally short femur in six, fibular hemimelia in five, congenital hemihypertrophy in five, tibial
bowing in four, fracture of the femur in three, Aitken
type-A proximal femoral focal deficiency1 in three, and
fracture of the tibia in one (Fig. 1). An additional two
children had had closed reduction of a congenital dislocation of the hip, after which a limb-length discrepancy
developed without radiographic evidence of avascular
necrosis of the hip or acetabular dysplasia. Three patients had two diagnoses each. Nine children had had
an operative procedure to correct the discrepancy: six
had had an epiphysiodesis of the distal aspect of the
femur as well as of the proximal aspect of the tibia and
fibula more than one year before the study, and three
had had a femoral or tibial lengthening with removal of
the frame at least eight months before the study.
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T H E E F F E C T O F LIMB-LENGTH DISCREPANCY ON GAIT

13

Tibial Shortening
Femoral Shortening

9 -
7.4

7.4

7.5

s 74
u
C
3.1
3.0

3.2 3.2

3 --

li

I 1111 11111

- II

9"

11

!j

FIG. 1
Bar graph of the diagnosis, the amount of limb-length discrepancy (LLD), and the distribution of the discrepancy between the femur and
the tibia for each patient. The absolute discrepancy between the long limb and the short limb is given in centimeters above each column.
PFFD = proximal femoral focal deficiency.

We selected patients who had a limb-length discrepancy without associated neurological, structural, or muscular abnormalities that could alter the biomechanics
of gait. Initially, we had intended to include only patients who had less than a 15 per cent difference in
maximum torque per body weight between each of
the muscle groups in the long extremity and the corresponding group in the short extremity. This degree
of variability was considered acceptable on the basis
of reports that such a difference is seen in otherwise
healthy individuals2-15-19. However, all of our patients had
more than this degree of variability between at least
one pair of muscle groups. The differences could not
be correlated with the underlying diagnosis, degree of
discrepancy, primary site of discrepancy (tibia or femur),
or compensatory strategies. We could not determine
whether these differences were due to the underlying
etiology of the limb-length discrepancy or were secondary adaptations to the discrepancy.
All patients had a physical examination, which included evaluation of the range of motion and the presVOL. 79-A, NO. 11, N O V E M B E R 1997

ence of angular deformity, instrumented gait analysis,

and isokinetic testing of the muscles of the lower extremities. An orthoroentgenogram 16 was made if one
had not been made within the previous four months.
The limb-length discrepancy was measured with use of
blocks placed beneath the short limb, a tape measure
from the anterior superior iliac spine to the medial malleolus4928, surface markers used in gait analysis, and the
orthoroentgenogram. The limb-length discrepancy was
expressed as the absolute difference in centimeters as
measured on the orthoroentgenogram and as a percentage of the length of the long extremity.
The children walked at a self-selected speed along
a fifteen-meter runway that included a calibrated space
of 2.5 meters. A videotape of each walk was made
simultaneously from the frontal and sagittal planes.
Reflective markers were placed on the patient at several anatomical landmarks: the base of the sacrum midway between the posterior superior iliac spines, both
anterior superior iliac spines, the lateral epicondylar
ridge of the distal end of the femur along the flexion-

1692

K. M. SONG, S. E. HALLIDAY, A N D D. G. LITTLE

1.6

i Toe-Walking
Planri grade

"tfc
-0.4 --

% Gait Cycle

FIG. 2-A
Graph of the average kinetic differences between children who used toe-walking as a compensatory strategy and those who walked
plantigrade. Children who use toe-walking do not have the normal internal dorsiflexion moment after foot-contact. Because the foot is being
forced into dorsiflexion (DF) by contact of the toes with the floor, the plantar flexors of the ankle are recruited immediately, resulting in an
internal plantar flexion (PF) moment (positive numbers on the y axis) during the initial phase of stance. The dotted lines indicate one standard
deviation. HC = heel-contact, TO = toe-off, and bw = body weight.

extension axis of the knee, the lateral aspect of the thigh

along the axis of the knee (on a ten-centimeter-long
aluminum wand fastened here), the most prominent
point of the lateral malleolus along the transmalleolar
axis, in line with the transmalleolar axis (on an aluminum wand), the midfoot between and slightly proximal
to the second and third metatarsal heads, the posterior aspect of the glenohumeral joint, and the radial
styloid process. Three-dimensional kinematic data were
recorded with a six-camera sixty-hertz VICON system (Oxford Metrics, Oxford, England). Kinetic data
were recorded with two force-plates instrumented with
strain-gauges (AMTI, Newton, Massachusetts). Four
force-plate strikes were recorded for each extremity for
each patient. Joint angles; internal moments; and powers
in the sagittal, transverse, and coronal planes were calculated with VICON Clinical Manager software (Oxford Metrics). These values were calculated separately
for each extremity since the software averages the
lengths of the limbs as a scaling parameter when the
location of the center of the hip joint is determined.
Cadence, velocity, step length, and percentage of gait
cycle in single and double-limb stance were also recorded. The total mechanical work performed by each
lower extremity was determined by integrating and adding the absolute values of the areas under the hip, knee,
and ankle power curves in all planes8.
We calculated a position for the total center of body
mass segmentally in the x, y, and z directions for each
trial, and determined the displacement of the center of
body mass during the gait cycle, on the basis of the

assumptions that each upper extremity was 5 per cent

of the total body mass, the head and trunk were 58 per
cent, each thigh was 10 per cent, and each shank and
foot was 6 per cent. We calculated the rate of loading
at heel-contact from the vertical z force of the forceplate for each trial. Heel-contact velocity and acceleration were estimated from the displacement of the heel
marker for each trial, and a coefficient of variation for
the four trials for each extremity was determined.
A Cybex II machine (Lumex, Bayshore, New York)
was used to test isokinetically the muscle strength of the
hip flexors and extensors with the patient in the supine
position, the plantar flexors and dorsiflexors of the ankle with the patient in the prone position, the abductors
and adductors of the hip with the patient in the sidelying position, and the flexors and extensors of the knee
with the patient seated. The hip and ankle were tested
at 30 degrees per second, and the knee was tested at 60
degrees per second. The peak torque per body weight
was selected from one of five trials.
We calculated the Spearman non-parametric and
Pearson correlation coefficients between the absolute
or per cent limb-length discrepancy and the difference
between the long and short limbs with regard to the
dependent kinematic and kinetic variables for the pelvis, hip, knee, and ankle. Spearman coefficients of more
than 0.8 were considered clinically predictive. With use
of the Pearson correlation coefficient, we looked for any
relationship between the per cent limb-length discrepancy and the dependent kinetic and kinematic variables
in the twenty-eight children who had a discrepancy of
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T H E E F F E C T O F LIMB-LENGTH DISCREPANCY ON G A I T

Long Limit
Short Limb

-0.6-"-

% Gait Cycle
FIG. 2-B

Graph of the average differences in moments about the knee in the sagittal plane between the two extremities in children who used
persistent flexion of the long limb as a compensatory strategy. The long limb has a larger internal extension moment (positive numbers on the
y axis) about the knee than the short limb does because of the flexed position during stance. The dotted lines indicate one standard deviation.
H C = heel-contact, TO = toe-off, and bw = body weight.

less than 6 per cent and in the seven who had a discrepancy of 6 per cent or greater.
Classification of Compensatory Strategies
Two of us (K. M. S. and S. E. H.) independently
reviewed the videotapes for each patient and compared
our impressions and conclusions with regard to the compensatory strategies of vaulting, toe-walking, circumduction, and persistent flexion of the long limb. Often,
a child used more than one compensatory strategy,
with the number of compensatory mechanisms tending to increase with increasing limb-length discrepancy
(r = 0.65). There was complete agreement between
the two of us with regard to eight patients who toewalked with the short extremity and nineteen who persistently flexed the long extremity as compensatory
strategies. With the description by the senior one of us
(K. M. S.) considered to be the more accurate, we agreed
on fourteen of the nineteen patients who used vaulting
and on four of the six who used circumduction as a
strategy. Seven children did not use any compensatory
strategy.
Paired t tests were used to compare the coefficients
of variation of the long extremity with those of the
short extremity to determine whether the variables
were more consistent for one extremity. Two-sample t
tests were used to determine if there were any differences between the long and short extremities with regard to dependent gait and Cybex variables that would
provide objective criteria with which to define the compensatory strategies.
VOL. 79-A, NO. 11, N O V E M B E R 1997

Children who were visually classified as using toewalking did not have the normal first and second ankle
rockers described by Perry30. All of the patients had an
internal plantar flexion moment about the ankle at footcontact on the short side (Fig. 2-A), and this was used
to define this compensatory strategy objectively.
The compensatory strategy of persistent flexion
of the long limb implied that the average flexion and
extension moments about the hip or knee were more
than one standard deviation greater on the long side
than on the short side (Fig. 2-B). Children who were
visually classified as persistently flexing the long limb
did indeed have greater peak flexion of the hip (p <
0.001) and knee (p < 0.001) and greater extension moments about the hip (p < 0.02) and knee (p < 0.02) on
the long side. They had a smaller peak flexion moment about the hip (p < 0.03) and greater flexion of
the knee (p < 0.007) and hip (p < 0.001) on the long side
than did children who did not use this strategy. Four
children who were thought initially to use this strategy
on the basis of the videotape did not meet the objective
criteria and were reclassified: two used circumduction,
one used vaulting, and one did not use any detectable
strategy.
There was no difference in flexion or extension of
the hip or knee, extension moments about the hip or
knee, or vertical displacement of the center of mass in
the children who were visually classified as using vaulting compared with those who did not use this strategy.
The children who were visually identified as using circumduction did not differ from the other children with

1694

K. M. SONG, S. E. HALLIDAY, AND D. G. LITTLE

15.8

16

15.2
13.5

14

12 -

Toe-Walking

Plantigrade

11.7
10.8

C I O "
7.6 7.6
5.9
5.3 5.3

3.5
2 8 2.9 2.9
1.8
1.2 1.2 1.4 _

2
0 8

r-,

2.2 2.2 2-3 2 - 4 2 - 4

4.5 4-6 4 - 7

16

r-i

iiM.
1

3.8 3.9 3.9 4.1

4-"4
4

+*++

10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35

Patients
FIG. 3
Bar graph of the per cent limb-length discrepancy in children who used toe-walking as a compensatory strategy and in those who walked
plantigrade.

regard to abduction, adduction, or rotation of the hip;

abduction and adduction moments about the hip; or hip
powers in the coronal plane.
Results
The range of measurable limb-length discrepancy
was 0.6 to 11.1 centimeters, or 0.8 to 15.8 per cent of the
length of the long extremity (Fig. 1). The per cent difference in limb length between the short and long extremities did not vary among the four methods used to
measure limb length. The relative contribution of the
femur and tibia to the inequality varied and was not
found to be a factor in our analysis. The average discrepancy for the seven patients who had no observable
compensatory strategy was 1.64 2.83 centimeters
(2.2 4.5 per cent). The average discrepancy for the
children who used toe-walking as a compensatory strategy was 6.54 2.83 centimeters (10.4 4.5 per cent) (Fig.
3). The threshold discrepancy associated with the use of
toe-walking was 5.5 per cent (p = 0.05).
Eight children had persistent pelvic obliquity (average, 7.8 1.4 degrees), with dipping of the pelvis on the
side of the short extremity, throughout the gait cycle.
Nine children had a range of pelvic obliquity of more
than 2.37 degrees, which is one standard deviation
above the pelvic obliquity seen in normal adult controls
tested in our laboratory. Two children had both an increased range of pelvic obliquity and persistent pelvic
obliquity, which were not correlated with the degree of
limb-length discrepancy (Fig. 4).
The average walking velocity was 1.23 0.16 meters
per second. The differences in velocity among the chil-

dren were minimum, allowing for comparison of the

kinetic data among patients.
The differences between the long and short extremities with regard to most dependent kinematic, kinetic,
and cadence variables appeared to be significant. However, no Spearman correlation coefficient between the
absolute or per cent limb-length discrepancy and the
difference between the long and short extremities with
regard to any of the dependent variables was more than
0.8. Thus, there was no predictive relationship between
the magnitude of the discrepancy and the performance
of the two extremities. In the group of seven children
who had a limb-length discrepancy of 6 per cent or
greater, the Pearson correlation coefficient was more
than 0.8 (p < 0.05) for greater generation of total hip
power and decreased negative work (energy absorption) on the long side.
Over-all, the long limb performed more mechanical
work than the short limb (Table I), and the differences
were significant at the hip (p < 0.01), knee (p < 0.02),
and ankle (p < 0.003) and for the entire limb (p <
0.0001). When we examined the differences in work
according to the compensatory strategy used, we found
that patients who walked plantigrade, used circumduction, or vaulted over the long extremity had no difference between the extremities with regard to the amount
of mechanical work performed. Patients who used toewalking had more asymmetry and performed more total work with the long limb than with the short limb
compared with patients who walked plantigrade (p <
0.0001), with the primary differences at the hip (p <
0.02) and knee (p < 0.001) being significant. Patients
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1695

THE EFFECT OF LIMB-LENGTH DISCREPANCY ON GAIT

TABLE I
MECHANICAL WORK OF THE LONG AND SHORT LIMBS, ACCORDING TO COMPENSATORY STRATEGY*

Ankle
Short limb
Long limb
Knee
Short limb
Long limb
Hip
Short limb
Long limb
Total
Short limb
Long limb
P valuet

Only
Persistent
Flexion of
Long Limb

Persistent
Flexion of
Long Limb
and ToeWalking

0.40 0.11
0.51 0.10

0.40 0.14
0.43 0.08

Persistent
Flexion of
Long Limb

Full
Extension of
Long Limb

0.40 0.12
0.48 0.10

0.40 0.09
0.47 0.08

<0.001

0.31 0.11
0.46 0.14

0.44 0.20
0.43 0.11

<0.01

0.38 0.06
0.47 0.16

0.19 0.04
0.44 0.12

0.40 0.09
0.42 0.08

<0.02

0.35 0.09
0.40 0.08

0.43 0.07
0.45 0.08

<0.008

0.37 0.09
0.38 0.08

0.32 0.09
0.43 0.08

1.22 0.25
1.37 0.22

<0.0001

1.05 0.21
1.34 0.26
<0.02

1.26 0.28
1.35 0.18

<0.01

1.14 0.20
1.36 0.28

0.90 0.09
1.30 0.24
<0.01

ToeWalking

Plantigrade
Walking

0.39 0.13
0.42 + 0.07

0.39 0.09
0.49 0.12

0.20 0.05
0.43 0.11

0.42 0.16
0.45 0.13

0.32 0.08
0.42 0.08
0.92 0.09
1.27 0.24
>0.05

P Value

P Value

P Value

<0.05

<0.01

*The values are given as the average work and the standard deviation in joules per kilogram. The level of significance was p < 0.05.
|The long limb compared with the short limb.

who walked with persistent flexion of the long limb had

more total work done by the long limb (p < 0.01) as
well as more work at the hip (p < 0.008) and knee (p <
0.01) than those who walked with full extension of
the long limb. These differences were significant for the
seven children who used both persistent flexion and
toe-walking (p < 0.01). We could detect no significant
difference between the long and short limbs with regard
to the mechanical work performed in the twelve children who used persistent flexion but not toe-walking.
Testing in our laboratory demonstrated that one

standard deviation for normal displacement of the center of body mass in adults is +1.9 to -2.1 per cent of body
height. In the present study, five of the nine patients
in whom the displacement exceeded this range used
toe-walking as a compensatory strategy. The average
vertical displacement of the center of body mass was
2.9 0.55 per cent of body height for patients who used
toe-walking and 2.1 0.57 per cent of body height for
patients who walked plantigrade; this difference was
significant (p < 0.0001). The threshold for increased displacement of the center of body mass was a 5.5 per cent
15.8

16 x

15.2

14

13.5
I

^ |

12

I
10

11.7

Increased Range of Pelvic Obliquity and Persistent Pelvic Obliquity

I

^3

Normal Obliquity

10.8 I

Increased Persistent Pelvic Obliquity

Increased Range of Pelvic Obliquity

7.6 7.6

5.9
5.3 5.3 5.5 5.6

6
4.5 4.6 4.7
4

3.5

3.8 3.9 3.9

4 1

2.8 2.9 2.9

2

2.2 2.2 2.3 2.4 2.4

1.2 1.2 1.4

nfl
1

10 11

12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35

Patients
FIG. 4

Bar graph showing the relationship between the per cent limb-length discrepancy and the pelvic obliquity for each patient.
VOL. 79-A, NO. 11, NOVEMBER 1997

1696

K. M. SONG, S. E. HALLIDAY, AND D. G. LITTLE

limb-length discrepancy (p = 0.05). We found that the

medial-lateral acceleration of the center of body mass
was greater for the short extremity at the point of footcontact, which suggested more rapid transfer of mass to
the short limb. However, this was not reflected by abnormal shear forces at the foot or by different rates of
loading between the extremities.
Discussion
Limb-length discrepancy is a common clinical finding. Rush and Steiner32 found that as many as 70 per cent
of 1000 consecutive non-selected adult men had some
degree of discrepancy. Edinger and Biedermann 7 found
that 45 per cent of 325 subjects had a discrepancy of
more than five millimeters. Hult2'1 reported that 30 per
cent of 1137 Swedish laborers had a discrepancy of 1.0
to 1.5 centimeters, 4 per cent had a discrepancy of
2.0 to 2.5 centimeters, and 0.7 per cent had a discrepancy of as much as 4.5 centimeters. Some authors have
claimed that a limb-length discrepancy leads to mechanical and functional changes in gait2735 and increased energy expenditure 3 . Treatment has been recommended
for discrepancies of less than one to more than five
centimeters3-17-2627-35, but the rationale for these recommendations has not been well defined.
The degree of limb-length inequality that may cause
functional problems and the mechanism by which it
affects gait and stance have been the subject of few
studies. Gross found no noticeable functional or cosmetic problems in a study of seventy-four adults who
had less than two centimeters of discrepancy'7 and
thirty-five marathon runners who had as much as 2.5
centimeters of discrepancy18. Kaufman et al.22 reported
asymmetrical gait, as measured by a force-plate, at
a threshold discrepancy of 3.7 per cent in a study of
twenty children who had a limb-length discrepancy.
Greater heel-contact forces for the long extremity33 and
correctable supination deformity of the foot of the
short extremity5 have been demonstrated in studies of
adults who had a discrepancy of two centimeters or less.
Small discrepancies have been shown to alter joint moments and powers36 as well as postural sway25. The seven
patients in the present study who did not appear to use
any compensatory strategy had an average limb-length
discrepancy of 2.2 4.5 per cent and did not have any
demonstrable kinematic or kinetic asymmetry of gait.
We believe that treatment of these small discrepancies
to prevent asymmetrical gait is not warranted.
Morscher26 suggested that limb-length discrepancy
resulted in persistent pelvic obliquity during doublelimb stance and that larger discrepancies led to greater
obliquity. He believed that pelvic obliquity led to uncovering of the femoral head of the long extremity with an
abnormal concentration of forces at the acetabular margin accelerating degenerative osteoarthrosis of the hip.
Similarly, pelvic obliquity with lateral sacral inclination
has been thought to require additional work by the

abductor muscles of the hip21 and the lumbar paraspinous muscles, placing extra strain on spinal ligaments
and leading to fixed spinal deformities1013. Phelps et
al.31 reported persistent obliquity of 10 to 20 degrees
in seven patients who had a limb-length discrepancy
of two to six centimeters, but they did not provide information about associated angular, rotational, or neurological abnormalities. We did not find a correlation
between limb-length discrepancy and pelvic obliquity or
abductor muscle strength, as measured with Cybex testing, in our patients. Only eight of our thirty-five patients
had persistent pelvic obliquity during gait, and the average pelvic obliquity during gait was no different than
that of normal controls. Although pelvic obliquity can
occur in association with a limb-length discrepancy, we
believe that it is not a common finding and that most
otherwise healthy individuals develop compensatory
strategies to maintain a level pelvis during gait.
The compensatory strategies observed in the present study were equinus positioning of the ankle of the
short limb (toe-walking), vaulting over the long limb,
increased flexion of the long limb, and circumduction of
the long limb. These strategies have been suggested by
other authors3222731; however, we were unable to find any
objective description of the movements. We were able
to define objective criteria for the strategies of toewalking and increased flexion of the long limb. We initially believed that circumduction would be evident as
increased abduction and external rotation of the hip
during the swing phase of gait and that vaulting would
result in an increased vertical translation of the center of gravity of the body between the single-limb and
double-limb phases of stance for the long and short
extremities. However, we were unable to demonstrate
these findings in the patients who were thought to use
circumduction or vaulting. The lack of definable objective criteria and the poor interobserver agreement regarding the appearance of these two strategies suggest
that they are complex movements that are often used in
combination with other strategies. The combination of
several strategies may shift the timing of kinematic alterations to portions of the gait cycle during which they
are not as apparent.
Inman et al.21 showed that compensatory strategies
dampen oscillations of the center of body mass and
decrease over-all energy expenditure during gait. Our
patients who used toe-walking had increased mechanical work performed by the long limb and had greater
vertical translation of the center of body mass during
gait than did normal controls. Total mechanical work is
a measure of concentric and eccentric muscle contractions crossing a joint. It does not take into account the
energy expenditure of isometric muscle forces, but it
is associated with the energy needed to produce the
work30. The true metabolic cost of the compensatory
strategies used by our patients is unknown since we did
not measure this parameter. Phelps et al.31 did not find
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T H E E F F E C T OF LIMB-LENGTH DISCREPANCY ON G A I T

1697

that patients who had as much as six centimeters of

limb-length discrepancy had more oxygen consumption
or oxygen cost than normal adult controls. We believe
that individuals who have a smaller discrepancy are
able to normalize mechanical work and the metabolic
cost of walking between the extremities with use of the
compensatory strategies previously described. However, when a discrepancy of 5.5 per cent is reached,
toe-walking as a compensatory strategy cannot equalize
the work performed by the two extremities. We found
that most of the difference in mechanical work in our
patients occurred at the knee and hip in the sagittal
plane. Eng and Winter8 reported that, during gait, 74 per
cent of the work at the hip, 85 per cent of the work at
the knee, and 95 per cent of the work at the ankle is
performed in the sagittal plane. Although pain over the
greater trochanter secondary to overactivity of the ab-

have a limb-length discrepancy26, we did not find this

symptom in our patients.
Moseley27 believed that adults do not use the adaptive strategies that are employed by children because
the strength-to-weight ratio is greater in children. Nineteen of our thirty-five patients used increased flexion of
the long extremity as a compensatory mechanism. We
cannot say whether the compensatory strategies used by
these children will be maintained in adult life. The lack
of differences in work between the long and short extremities in the patients who had a smaller limb-length
discrepancy suggests that compensatory strategies provide an efficient gait pattern that may serve these children well as adults. The results of this study are not
applicable to adults who have an acute acquired limblength discrepancy,

i i i
j 1 i
i
i
dUCtOr mUSCleS h a s b e e n r e p o r t e d i n i n d i v i d u a l s WhO

NOTE: The authors thank Sameer Kolangaradath and Cindy Smith for their invaluable
research assistance and Richard Browne, Ph.D., for his editorial assistance.

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