Short Leg and Gait

Jenisa Oberbeck, DO
September 24, 2019
Objectives and Readings
✤ Discuss the evaluation of a short leg

✤ Discuss the compensatory patterns associated with a short leg

✤ Demonstrate the use of the Heilig formula for treatment of a short leg

✤ Discuss appropriate timelines in treatment of a short leg

✤ Describe the 8 phases of the gait cycle

✤ Discuss the muscles involved in each phase of the gait cycle

✤ Discuss the sacral and innominate mechanics during the normal gait cycle

✤ Describe pathological gait patterns

✤ FOM 4th edition pages 128-129, 724-729

Short Leg Syndrome

✤Condition in which an anatomical or functional leg length

discrepancy results in:
✤Sacralbase unleveling
✤Vertebral sidebending & rotation

✤Innominate rotation

✤Classifications
✤Anatomical

✤Functional
Short Leg Syndrome

Signs and Symptoms:

1) Sacral base unleveling (lower on the side of the short leg)
2) Anterior innominate rotation on the side of the short leg
3) Posterior innominate rotation on the side of the long leg
4) Lumbar curve will sidebend away from the short leg and rotate toward the long leg
5) Lumbosacral (Ferguson’s angle) will increase 2 ◦ - 3 ◦

6) Pelvis side-shifts and rotates toward the side of the long leg
7) Most caudal curve is away from short leg with rotation toward
How to Evaluate for Short Leg

✤Check for uneven shoe wear

✤Screening for Scoliosis

✤The spine will tend to bend away from the short leg

✤Check for asymmetry

✤Check standing flexion test

✤Measure leg length (supine)

✤Any sacral base unleveling (SBU) of > 5 mm should be addressed…seen on weight-bearing

radiographs
Leg Length Supine

The patient is supine

Reseat the pelvis

Place your thumbs inferior to the medial malleoli

Compare leg lengths bilaterally by comparing thumb

positions without putting traction on either side
 A B
Measuring Leg Lengths

Measuring true leg length can be done one of two ways

A) Measure from ASIS to the inferior aspect of the medial

malleolus and then compare bilaterally

B) Measure from the superior aspect of the greater

trochanter to the inferior aspect of the medial malleolus
and then compare bilaterally

*Remember to treat all somatic dysfunctions especially in

the pelvis, sacrum, thoracolumbar spine, and the lower
extremity before assessing for leg length discrepancy*
¼” = 6mm
Short Leg Syndrome
✤Treatment
✤ OMT directed at the spine, pelvis, sacrum and lower extremities in order
to remove as much somatic dysfunction as possible and improve
secondary vertebral sidebending and rotation
✤ Re-evaluate land marks (greater trochanters, iliac crests, ASISs, PSISs, ITs,
sacral bases, ILAs), measurements, standing flexion test
✤ If
a leg length discrepancy is still present and short leg syndrome is
suspected then measure the leg lengths
✤ Order standing postural x-rays, or leg length scanograms (CT), to quantify
differences in the heights of the femoral heads or sacral base unleveling.
✤ Consider a heel lift if difference is >5mm
Confirm history

✤ Pt may have acquired leg length

discrepancy

✤ Trauma, radiation, infection, tumor,

surgery, etc.

✤ s/p THA
 Reduction of lumbar scoliosis by use of a heel
lift to level the sacral base
✤ Robert Irvin, DO, Reduction of lumbar scoliosis by use of a heel lift to level the sacral base. JAOA vol
91, January 1991

✤ 51 adults w/ mild idiopathic scoliosis (no rotation)

✤ Measured SBU & lateral bending to see lower limit of the relationship (2-17mm)

✤ (2) AP x-rays before & after

✤ Heel lift to level sacral base (short leg)

✤ 6.7mm —> 2.6mm SBU; and improvement of lumbar spine lateral bending

✤ Although significant lateral bend still present, it was reduced

Reduction of lumbar scoliosis by use of a heel
lift to level the sacral base
Reduction of lumbar scoliosis by use of a heel
lift to level the sacral base
Reduction of lumbar scoliosis by use of a heel
lift to level the sacral base
Evaluation- Old School

✤ Standing Postural X-rays

✤ Treat the patient first to remove functional

leg length discrepancy

✤ Shoes off

✤ Instruct to stand with equal weight on both

sides

✤ X-ray machine must be parallel to the floor

✤ AP view
Measurements

✤ Iliac crest heights

✤ Sacral base unleveling

✤ Femoral head heights

✤ May choose to assess pelvic rotation

Reference Line

✤ Drawn perpendicular on the film

✤ Draw in the middle of the sacral base

✤ Notice the line is not running through

the pubic symphysis
Iliac Crest Heights

✤ Draw a line from the top of the iliac

crests to the reference line on either
side

✤ The difference between the 2 lines is

the amount of iliac crest unleveling
Femoral Head Heights

✤ Draw a line from the top of the

femoral heads to the reference line on
either side

✤ The difference between the 2 lines is

the amount of femoral head
unleveling
Weight Bearing Lines

✤ Draw a line vertically from the top of

the femoral head on either side. This
is where the weight of the body rests
upon the femurs
Sacral Base Unleveling
Sacral Ala Superior
Articular
✤ To find sacral base unleveling Process

✤ Find the sacral ala

✤ Find the superior articular process

✤ Find the space where the 2 meet

✤ Draw a line connecting the two

Sacral Base Unleveling

✤ Draw a line connecting the space

between the sacral ala and the
superior articular processes on either
side (black line) out through the
weight bearing lines (orange lines)

✤ At the point of intersection with the

weight bearing lines, draw a
perpendicular line back to the
reference line (purple)
Sacral Base Unleveling

✤ Measure the distance

between the two purple
lines (white bracket) at the
point of intersection with }
the reference line

✤ Divide this amount by 2 to

get the amount of sacral
base unleveling
Pelvic Rotation

✤ Assess pelvic rotation by looking at

the natal crease

✤ The natal crease should be located

along the reference line

✤ If it isn’t, this is indicative of pelvic

rotation
Typically……

✤ Side of sacral base unleveling –> lumbar convexity

✤ Usually beginning point of compensation

✤ Pelvis rotates posteriorly on the side of the long leg

and/or anteriorly on the side of the short leg
Heel Lift Consideration

✤ Sacral Base Unleveling – Xray evaluation (>1/4”)

✤ Length of Time Present

✤ Amount of Compensation – sidebending, rotation, wedging of vertebrae

HEILIG FORMULA: L = SBU / (D+C)

Heilig Formula

✤ Developed by Dr. David Heilig DO as a safe, progressive way to treat a short leg with a heel lift

✤
Lift = Sacral Base Unleveling (SBU) /{Duration (D) + Compensation (C)}
✤ D = 1 for 1-10 yrs

2 for 11-30 yrs

3 for >30 yrs

✤ C = 0 sidebending only

1 rotation toward convexity

2 wedging, altered facets

Heilig Formula

Example:

43 yo female with 3/4” SBU for the past 31 yrs with a compensation of rotation
toward the convexity, no other spinal deformities

SBU = (3/4”)/(D 31 years) 3 + (C Rotation) 1

SBU = (3/4”)/4 or

(3/4”) x (1/4) = 3/16”

Patient will ultimately need ~3/16” (5mm) heel lift

Lift Therapy
✤ Apply lift to the side of the short leg

✤ The final lift should be ½ to ¾ of the measured discrepancy if not acute

✤ For the Fragile Patient (Arthritic/Osteoporotic/Acute Pain/Elderly) – start w/ 1/16” (1.5mm) heel lift on the side of
the short leg

✤ Reassess every 2 weeks

✤ Stable – start w/ 1/8”(3mm) lift and reassess every 2 weeks

✤ Don’t replace by more than ¼”(6mm) at a time —> contralateral hip rotation will result

✤ If you wanted to correct up to ½” (12mm) inch total, ¼” to the inside of shoe, ¼” to the outside of shoe

✤ Maximum heel lift possible is ½”. If more height is needed use an anterior sole lift extending from heel to
toe to stop contralateral pelvic rotation.
Various Heel Lifts
Side Notes

✤ Before adding a lift – check foot pronation – use orthotic to correct pes
planus

✤ The lift should be used in each pair of shoes a patient wears….no open-
backed shoes! (flip flops)

✤ Start Slow with Heel Lift Wear….an hour or two/day to start (depending
on level of activity/occupation) then increase duration to minimize chances
of compensatory back/hip/leg pain
Goals of Treatment

✤ Correction of Postural Defects

✤ Alleviation or Decreased Pain
✤ Shift of Body Weight
✤ Overall Realignment of Biomechanics of Musculoskeletal
System
✤ Remember to treat all somatic dysfunctions in the pelvis,
sacrum, thoracolumbar spine, and the lower extremity before
assessing for leg length discrepancy
Ilizarov Procedure
✤ Used to lengthen a significantly shorter
limb

✤ Break the limb and attach the external

fixator that is adjusted up to 4 times a day,
lengthening the fracture by 1 mm a day.
GAIT
Definitions

✤ One “gait cycle”

✤ A single cycle from heel strike to next heel strike of same foot (2 steps)

✤ “Stance”
✤ Period when foot is in contact with ground

✤ “Swing”
✤ Period when foot is NOT in contact with ground
GAIT
Gait Cycle Basics

✤ One complete Gait Cycle involves 2 steps (1 leg)

✤ Swing and Stance Phases
✤ Stance phase is subdivided into 3 Subgroups {60%}
✤ Initial double stance {10%}
✤ Single limb stance (R/L) {40%}
✤ Terminal double limb stance {10%}
✤ Swing phase {40%}
Gait

✤ Average stride length is 28 - 32 inches

✤ Stride is same foot to same foot
✤ Changes with age, pain, disease, fatigue

✤ Average cadence is 90-120 steps per minute

✤ Women higher by 6-9 steps per minutes

✤ Average speed 3 mph

✤ Gait cycle is made up of 8 segments

 Phases of the Walking (gait) Cycle (Stance and
Swing )
Stance Phase- when the foot is on the ground; divided into 5 phases:
1. Initial Contact (heel strike)
2. Loading
3. Midstance
4. Terminal
5. Preswing

Swing Phase- leg is moving forward divided into 3 phases:

1. Initial Swing
2. Midswing
3. Terminal Swing
Walking Cycle cont…

✤ 60% of the walking cycle is spent in the stance phase.

✤ Of this 25% is spent in double stance
✤ 40% of the walking cycle is spent in swing phase
✤ Both phases occur simultaneously on opposite sides of the body.
✤ Normal gait involves the smooth coordinated transition from one
phase to the other, from one side of the body to the other.
Gait
 Functions of the 8 Phases of Walking Gait

1. Initial contact or heel strike

✤ Establish contact with leading foot, begin STANCE
GAIT
Functions of the 8 Phases of Walking Gait

2. Loading response or flat foot

✤ Shock absorption
✤ Begin weight bearing

✤ Continue progression of forward movement

GAIT
Functions of the 8 Phases

3. Mid-stance
✤ Limb & trunk stability
✤ Progression over stationary foot
GAIT
Functions of the 8 Phases

4. Terminal stance or heel lift or heel off

✤ Progression past stationary foot
✤ Prepare for swing
GAIT
Functions of the 8 Phases

5. Pre-swing or toe off

✤ Weight release from stationary foot
✤ Position limb for swing
GAIT
Functions of the 8 Phases

6. Initial swing or early swing

✤ Prepare for foot clearance
✤ Advance foot from trailing position
GAIT
Functions of the 8 Phases

7. Mid-swing
✤ Foot clearance
✤ Limb advancement
GAIT
Functions of the 8 Phases

8. Terminal swing or late swing

✤ Prepare for stance (positioning)
✤ Complete limb advancement
GAIT
Requirements for Normal Gait

✤ Stability in stance

✤ Foot clearance in swing

✤ Prepare for initial contact

✤ Adequate step length

✤ Energy conservation
Requirements of Gait

✤ Foot clearance in swing

✤ Requires coordination of entire limb
✤ Ankle dorsiflex
✤ Knee flex
✤ Hip flex
✤ Retain stability in stance
Requirements of Gait

✤ Adequate step length

✤ Too short
✤ Expend energy
✤ Minimal progress
✤ Too long
✤ Lose balance
✤ Strain ligaments and muscle

✤ Adequate gait requires motion of the sacrum and innominates

 Preswing: Toe Off
To permit the body to move forward on
the right, trunk rotation in the thoracic
area occurs to the left accompanied by
Lumbar side-bending to the left and
rotating to the right
L5 NSlRr
 The body of the sacrum is moving to the
left, about a left oblique axis. This shifts
the weight of the body to the left foot to
allow lifting of the right foot. The shifting
vertical center of gravity moves to the left
sacroiliac, locking the mechanism into
mechanical position to establish
movement of the sacrum on the left
oblique axis
Shallow Sulcus Left
Deep Sulcus Right
This sets the pattern so the
sacrum can torsionally
(obliquely) turn to the left as
L5 rotates right. The
Sacrum rotated left
L5 rotated right sacrum rotates in the
opposite direction (left) of
the lumbar spine.
Initial Swing - Early
Tension on the right hamstrings (yellow
arrow) begin as the weight swings to the
left and there is a slight posterior
movement of the right innominate (red
Axis arrow).
This movement is on a transverse axis
towards the inferior part of the sacral
body.
The movement is further increased by
the weight of forward thrust of the
propelling leg action in mid-swing. (blue
arrow)
Rotation of the sacrum about the
oblique axes allows for the foot to Top view
be placed further in front on a
more straight path which allows
for a longer stride with better
balance.
WADDLING
Is not
Efficient!

Posterior view
Pelvis - Initial Contact

Left innominate (blue arrow) rotates

posteriorly, allowing the limb to swing
forward (hip flexion). Right innominate
(gray arrow) rotates anteriorly, allowing
for further hip extension
The right
sacral
sulcus PSIS
is deep inferior
Pelvis

✤ Summary of pelvic motion

✤ Anterior leg has posterior innominate and
anterior sacral base (deep sulcus).
✤ Posterior leg has anterior innominate.
 Mid Stance
As the right heel strikes the ground, trunk
torsion and accommodation begin to reverse
themselves.
Why do we need to know this?

“Somatic dysfunctions may accentuate and retain portions of motion

described above. These are called physiologic somatic dysfunctions,
because the muscles, connective tissue, and joints remain in positions
that are normally a part of the physiologic motion but are
dysfunctions when the body should have returned to a neutral
position but did not do so……
Why do we need to know this?

….Nonphysiologic somatic dysfunction is generally induced by

trauma. It is evidenced by the joint, muscle, and connective tissue
elements being in positions and/or relationships that are not part of
the normal walking physiologic range of motion and do not involve
physiologic axes of motion. Examples include innominate shears.
These are usually very painful and debilitating.”
 Summary of Movement of the Pelvic Bones
During Ambulation
✤ Dynamic motion of the sacrum and innominates occur during walking.
✤ Asweight bearing shifts to the left leg, left lumbar sidebending engages the ipsilateral oblique
sacral axis by shifting weight to that sacroiliac joint.
✤ The sacrum now revolves forward on the right side, creating a deep sacral sulcus and a (left on
left sacral torsion).
✤ With the next step, this process reverses as weight bearing changes to the other leg (right on
right sacral torsion).
✤ The sacral base is constantly moving forward on one side, then the other, about the oblique axes.
✤ Asthis occurs, the innominates are rotating in opposite directions to each other about a
transverse sacral axis.
✤ One side rotates anteriorly as the other side rotates posteriorly.
Gait Cycle Basics

https://www.youtube.com/watch?v=wJqBeGe3ZEc

https://www.youtube.com/watch?v=8kNo-cJcacU
Pathologic Gait

Causes:
✤ Disuse/atrophy
✤ Primary muscle disease – polymyositis, dermatomyositis, muscular
dystrophy, Guillain-Barre
✤ What is the most common bacterial cause of Guillain-Barre?
✤ What is the most common viral cause of Guillain-Barre?
✤ Neurologic impairment – foot drop/slap {L5}, impaired proprioception,
Parkinson's, Cerebral Palsy, Huntington’s Chorea, Cerebellar Dysfunction
Types of Abnormal Gaits

✤ Antalgic – Pain/Injury
✤ Ataxic – Cerebellar dysfunction
✤ Choreiform – “hyperkinetic” involuntary motions
✤ Diplegic – Cerebral Palsy
✤ Hemiplegic- Stroke
✤ Myopathic – “waddling” movement
✤ Neuropathic - High Steppage/Equine Gait
✤ Shuffling – Parkinsonian “bradykinetic”
Antalgic Gait

✤ Typically Seen in patients with an injured bone/joint in the lower

extremity (patients with moderate/severe DJD in hip/knee/ankle)

✤ Shortened stance phase on the effected leg (Pain/Injury)

✤ Lengthened stance phase on the contra-lateral healthy side

Antalgic Gait

https://www.youtube.com/watch?v=rLyEZubc4tk
Ataxic Gait

✤ Typically due to Cerebellar dysfunction/injury

✤ Wide stance to maintain balance

✤ Patient will favor swaying to the side of the injury

✤ Think of an intoxicated patient trying to pass a tandem leg sobriety

test
Ataxic Gait

https://www.youtube.com/watch?
v=FpiEprzObIU&index=7&list=PLD74972DCFB2D58C8
Choreiform Gait

✤ Choreiform – “hyperkinetic” uncoordinated, jerking involuntary motions

✤ Typically Seen in Sydenham Chorea (following G.A.S. in kids occurring in 20-30% of acute rheumatic fever cases)

✤ Or Huntington’s Disease
✤ - Autosomal Dominant inheritance/mutation
✤ - mid adult usual presentation

✤ - CAG triplets in Huntingtin gene

✤ (CAGCAGCAGCAG…..)

✤- CAG is the Genetic Code for which amino acid?

✤ Glutamine
✤- Which Chromosome is this gene found on?
✤ Chromosome 4, short arm
Choreiform Gait

https://www.youtube.com/watch?
v=QORlwMeWOeU&index=6&list=PLD74972DCFB2D58C8
Diplegic Gait

✤ Typically Seen in patients with Cerebral Palsy (CP)

✤ Extensor spasm (toe walking)

✤ Narrow base causing dragging of legs/feet

✤ “Scissoring of both legs” tight Adductor muscles (if not surgically

released as child)
Diplegic Gait

https://www.youtube.com/watch?
v=eLuxTFHoZAA&list=PLD74972DCFB2D58C8&index=2
Hemiplegic or Spastic Gait

✤ Typically Seen in Stroke Patients

✤ Extended Lower Extremity

✤ Flexed Upper Extremity

✤ Swing Phase of Gait involves an Internally Rotated Leg with

Circumduction to clear the ground
Hemiplegic Gait

https://www.youtube.com/watch?
v=y160w4sAQNw&list=PLD74972DCFB2D58C8
Myopathic Gait Patterns

✤ Gluteus Maximus weakness

✤ Gluteus Medius weakness (Trendelenberg)

✤ Trendelenberg – contralateral hip tilts down during stance phase

✤ Hyperlordotic posture of patient

Myopathic Gait Patterns

https://www.youtube.com/watch?
v=b5rIEx9SsCo&index=4&list=PLD74972DCFB2D58C8
Neuropathic Gait

✤Neuropathic (High Steppage/Equine Gait)

✤Dorsiflexion restriction causing hip/knee flexion
✤Foot Drop….Which Nerve is effected?
✤CMT – Charcot Marie Tooth

✤Peripheral motor and sensory nerves

✤Most common inherited neurologic disorders
(1/2,500)
✤- presenting in childhood to early adulthood
✤- patients benefit from use of an AFO
 AFO
Ankle Foot Orthosis

Used in foot drop

Neuropathic Gait

https://www.youtube.com/watch?
v=F_F7DdAD7yU&list=PLD74972DCFB2D58C8&index=3
Parkinsonian/Shuffling Gait

✤ Flexion/Stooped Posture
✤ Bradykinesia
✤ Short,Shuffling Steps
✤ Drugs causing Parkinson Type effects?
✤ Dopamine Receptor Blockers:
✤ Prochlorperzine (Compazine)
✤ Metoclopramide (Reglan)
✤ Olanzapine (Zyprexa)
✤ Risperidone (Risperdal)
✤ Haloperidol (Haldol)
Parkinsonian/Shuffling Gait

https://www.youtube.com/watch?
v=7SyTpEdhBLw&list=PLD74972DCFB2D58C8&index=5
 References

✤ Photo by Rist Art on Unsplash (slide 1)

✤ Salih, S., & Hamer, A. (2013, September 1). Hip and Knee Replacement. Surgery, 31(9),
482-487 (slide 9)

✤ Irvin, R., DO. (1991, January). Reduction of lumbar scoliosis by use of a heel lift to level
the sacral base. JAOA, 91. (slides 10-13, 24)

✤ Gilroy. (2018) Atlas of Anatomy (3rd ed). Thieme Medical. Figure 19.1 llustrator:
Wesker/Voll (slides 14-19, 21-23)

✤ Figure 2.14A (slide 20)

 References Continued

✤ https://www.orthopedicshoelift.com/blog/wp-content/uploads/2013/08/Athletic-Shoe-
Lift-30.jpg (slide 29)

✤ https://www.gnrcatalog.com/product-p/gbmlms.htm (slide 29)

✤ https://www.amazon.com/FootSmart-LevelSteps-Adjustable-Heel-Lift/dp/B07BZ1MJYV
(slide 29)

✤ https://www.yahoo.com/entertainment/16-best-weezer-songs-since-120430309.html (slide 32)

✤ https://en.wikipedia.org/wiki/Ilizarov_apparatus#/media/File:Ilizarov_on_right_leg.jpg
(slide 32)
 References Continued
✤ Photo by Karl JK Hedin on Unsplash (slide 33)

✤ Moore, K.L., Agur, A.M.R., & Dalley, A.F. (2011) Lower limb. In Clinically oriented anatomy Philadelphia:
Wolters Kluwer. (slides 35, 42, 44, 46, 48, 50, 54, and 56)

✤ Image by Honey Kochphon Onshawee from Pixabay (slide 37)

✤ Neumann Donald A: Kinesiology of the musculoskeletal system: foundations for physical rehabilitation
2nd edition St. Louis, 2010 Mosby, Figure 15-10 (slide 40)

✤ Tugui, R. D., & Antonescu, D. (2013). MAEDICA – a Journal of Clinical Medicine. Cerebral Palsy Gait,
Clinical Importance, 8(4), 388-393. doi:10.26574/maedica (slide 57)

✤ https://www.sciencesource.com/archive/Walking-gold-skeleton-SS251038.html (slides 65, 67, and 69)

 References Continued
✤ DiGiovanna, E. L., Schiowitz, S., & Dowling, D. J. (2005). An osteopathic approach to diagnosis and treatment. (3rd ed.)
Philadelphia, PA: Lippincott Williams and Wilkins. Page 296 (slide 67)

✤ https://www.slideshare.net/Drraveesoni/movement-disorders-53890175 (slide 81)

✤ Ropper, A. H., Samuels, M. A., Klein, J. P., & Prasad, S. (n.d.). Adams and Victor's Principles of Neurology (11th ed.).
McGraw-Hill Education. (slides 83, 85, and 93)

✤ Diagnosing Parkinson’s Disease From Gait, Daryl Chang, Marco Alban-Hidalgo, Kevin Hsu Computer Science
Department, Stanford University, Stanford, CA 2014, https://pdfs.semanticscholar.org/
2885/6bad53ccd2e81feea72ca5c2511c92a3e84f.pdf?_ga=2.27789492.948067519.1561136333-487692929.1523894460

✤ Greenberg, D. A., Simon, R. P., & Aminoff, M. J. (2018). Clinical neurology (10th ed.). New York: McGraw-Hill
Education. (slide 94)

✤ Swartz, M. H. (2014). Textbook of physical diagnosis. Philadelphia: Saunders/Elsevier. Figure 18-60 (slide 95)