Overview

Neuromuscular. Muscle imbalance causing different pull on pelvis (anterior superior Ilium or posterior inferior ilium). Muscle tightness/shortness especially piriformis (which lead to an external rotation of the femur thus shortening of the leg) and QL (raising ipsilateral iliac crest). Genu recurvatum, valgus, varus. Asymmetrical fallen arches or over pronation. Polio, Cerebral palsy. Trauma. Fracture. Injury epiphyseal plate. Iatrogenic (such as hip or knee surgery). Idiopathic. Hip disorder (such Legg-Perthes-Calve? or Slipped capital femoral epiphysis). Advanced degenerative changes.

Causes

Some children are born with absence or underdeveloped bones in the lower limbs e.g., congenital hemimelia. Others have a condition called hemihypertrophy that causes one side of the body to grow faster than the other. Sometimes, increased blood flow to one limb (as in a hemangioma or blood vessel tumor) stimulates growth to the limb. In other cases, injury or infection involving the epiphyseal plate (growth plate) of the femur or tibia inhibits or stops altogether the growth of the bone. Fractures healing in an overlapped position, even if the epiphyseal plate is not involved, can also cause limb length discrepancy. Neuromuscular problems like polio can also cause profound discrepancies, but thankfully, uncommon. Lastly, Wilms? tumor of the kidney in a child can cause hypertrophy of the lower limb on the same side. It is therefore important in a young child with hemihypertrophy to have an abdominal ultrasound exam done to rule out Wilms? tumor. It is important to distinguish true leg length discrepancy from apparent leg length discrepancy. Apparent discrepancy is due to an instability of the hip, that allows the proximal femur to migrate proximally, or due to an adduction or abduction contracture of the hip that causes pelvic obliquity, so that one hip is higher than the other. When the patient stands, it gives the impression of leg length discrepancy, when the problem is actually in the hip.

Symptoms

The symptoms of limb deformity can range from a mild difference in the appearance of a leg or arm to major loss of function of the use of an extremity. For instance, you may notice that your child has a significant limp. If there is deformity in the extremity, the patient may develop arthritis as he or she gets older, especially if the lower extremities are involved. Patients often present due to the appearance of the extremity (it looks different from the other side).

Diagnosis

The evaluation of leg length discrepancy typically involves sequential x-rays to measure the exact discrepancy, while following its progression. In addition, an x-ray of the wrist allows us to more carefully age your child. Skeletal age and chronological age do not necessarily equal each other and frequently a child's bone age will be significantly different than his or her stated age. Your child's physician can establish a treatment plan once all the facts are known: the bone age, the exact amount of discrepancy, and the cause, if it can be identified.

Non Surgical Treatment

The non-surgical intervention is mainly usedfor the functional and environmental types of leg length discrepancies. It is also applied to the mild category of limb length inequality. Non-surgical intervention consists of stretching the muscles of the lower extremity. This is individually different, whereby the M. Tensor Fascia latae, the adductors, the hamstring muscles, M. piriformis and M. Iliopsoas are stretched. In this non-surgical intervention belongs also the use of shoe lifts. These shoe lifts consists of either a shoe insert (up to 10-20mm of correction), or building up the sole of the shoe on the shorter leg (up to 30-60mm of correction). This lift therapy should be implemented gradually in small increments. Several studies have examined the treatment of low back pain patients with LLD with shoe lifts. Gofton obtained good results: the patients experienced major or complete pain relief that lasted upon follow-up ranging from 3 to 11 years. Helliwell also observed patients whereby 44% experienced complete pain relief, and 45% had moderate or substantial pain relief. Friberg found that 157 (of 211) patients with LBP, treated with shoe lifts, were symprom-free after a mean follow-up of 18 months.



leg length discrepancy exercises

Surgical Treatment

The bone is lengthened by surgically applying an external fixation device to the leg. The external fixator, a scaffold-like frame, is connected to the bone with wires, pins, or both. A small crack is made in the bone and the frame creates tension when the patient or family member turns its dial. This is done several times each day. The lengthening process begins approximately five to 10 days after surgery. The bone may lengthen 1 millimeter per day, or approximately 1 inch per month. Lengthening may be slower in a bone that was previously injured. It may also be slower if the leg was operated on before. Bones in patients with potential blood vessel abnormalities, such as cigarette smokers, may also need to be lengthened more slowly. The external fixator is worn until the bone is strong enough to support the patient safely. This usually takes about three months for each inch. Factors such as age, health, smoking and participation in rehabilitation can affect the amount of time needed.

Overview



Plantar fasciitis is an inflammation of the long band of connective tissue running from the heel to the ball of the foot. The plantar fascia acts like a bowstring and supports the arch and several muscles inside the foot. When there is increased stress on the arch, microscopic tears can occur within the plantar fascia, usually at its attachment on the heel. This results in inflammation and pain with standing and walking and sometimes at rest.

Causes

Many things can cause heel pain. Most commonly seen at our Troy, MI office are heel spurs, which are small growths on the heel bone. Heel pain can be caused from heavy activities and increased weight that put extra pressure on feet. Dr. Weinert often treats heel pain in athletes, runners and women who are pregnant. There are other cases where Dr. Weinert has related a patient?s heel pain to arthritis, stress fractures, fractures, bone tumors, cysts, achilles tendonitis and Haglund's deformity. The main cause of heel pain is usually a biomechanical problem in the foot and it?s, in a nutshell, having a foot out of alignment. There are numerous conditions. One of the most prevalent is called talotarsal dislocation syndrome. What that is in lay terms is you?ve just got a misalignment of your ankle on your heel and as you bear weight you?re getting a collapse of the ankle on the heel causing the foot to be out of alignment. So the plantar fascia, bones, joints, and ligaments receive constant stress. This stress occurs at the point where the plantar fascia (the major tissue that connects your toes to your heel) meets the heel. Many patients explain the pain as being in the middle of the inside of the heel. As a patient bears weight, they get the collapse of the foot and that ligament pulls. And if you think of a rubber band constantly getting pulled on that area of the insertion on the heel, you eventually start getting some micro tears in that ligament and causing inflammation and pain specifically right there in middle area of the heel. Plantar fasciitis is also a common source of heel pain. The plantar fascia, a band of tissue that runs from your heel to your toes, can become strained and inflamed due to overuse and wear and tear. This band of tissue can only withstand so much pressure and when it gives way, the pain can be severe and requires immediate and effective treatment.

Symptoms

The most common complaint is pain and stiffness in the bottom of the heel. Heel pain may be sharp or dull, and it may develop slowly over time or suddenly after intense activity. The pain is typically worse in the morning, when taking your first steps of the day. After standing or sitting for a while. When climbing stairs.

Diagnosis

A biomechanical exam by your podiatrist will help reveal these abnormalities and in turn resolve the cause of plantar fasciitis. By addressing this cause, the patient can be offered a podiatric long-term solution to his problem.

Non Surgical Treatment

Rest until there is no more pain. This is the most important element of treatment as continuing to walk or run on the injured foot will not allow the injury to heal. Wear soft trainers with lots of cushioning or pad the heel of shoes with shock absorbing insoles or heel pads. These should be worn in both shoes, even if only one heel is bruised. Wearing a raise in only one shoe causes a leg length difference which can cause other problems. Replace running shoes if they are old. A running shoe is designed to last for around 400 miles of running. After this the mid soles are weakened through use.

Surgical Treatment

Only a relatively few cases of heel pain require surgery. If required, surgery is usually for the removal of a spur, but also may involve release of the plantar fascia, removal of a bursa, or a removal of a neuroma or other soft-tissue growth.

heel spur shoes

Prevention



Wear properly fitting shoes. Place insoles or inserts in your shoes to help control abnormal foot motion. Maintain a healthy weight. Exercise and do foot stretches as they have been shown to decrease the incidence of heel pain.