By Dr. Michael Cerami, DC
LLD or Leg Length Discrepancy leads to hip rotation and causes pain. How can you possibly move around with such a significant global imbalance and not have a problem? It is quite common, and I usually see an imbalance of anywhere from ½” to 1 ½” of discrepancy between the left and right leg on most new patients. In most cases it takes less than 6 visits to straighten the pelvis and legs out, see accompanying before and after photos) but sometimes the correction process takes a bit longer as in the case below.
During an initial examination, I check pelvic alignment front/back and side to side as well as foot position and knee alignment. I also will test the lower extremity muscle group to determine whether each muscle is firing. These tests along with other functional movement screenings will paint a picture of where the source of the problem is located and that’s where we’ll go to work; unwinding the “focal loading” points of the body to create sustainable change.
The reason I mention this process is to describe how we assess and correct hip rotation. To the untrained eye/person/therapist/physician, it would seem much easier to just put a lift or shim in the shoe and level things out. The problem is that most times, this will not adequately correct the imbalance. In my 36 years of practice, I have prescribed a heel lift on less than 30 patients when I couldn’t correct the imbalance using chiropractic adjustments and muscle work. The imbalance in these cases were confirmed through x-ray imaging.
It’s difficult if not hard to tell if you have LLD; here’s how to check: Look at your leg length while lying on your back. Lay on a flat surface with your shoes off and have a friend lift both of your feet off the floor (holding the back of the heel bone behind and under your ankles) about 18”. Keeping the inner ankles together and the legs parallel and in alignment with the spine, see if the ankles touch each other or become misaligned. A misalignment at the ankles will usually indicate hip rotation. Under a ¼” difference is probably OK but anything more is significant and indicates imbalance. Pain is not a good gauge for this test as I’ve seen many patients whose ankles more than a 2” difference and were not experiencing any symptoms.
Challenging case report: This patient is a bike rider that had labrum (hip) surgery which caused a severe imbalance in his hip alignment and leg length. When this patient went for his bike fit, the only way the fitter could make him balanced was to provide an extreme amount of shimming to the bottom of his bike shoe (photo). This helped but caused other problems and the patient could not ride comfortably for any extended distance.
When I started making corrections on this patient, we would get a ¼ to ½” change each visit but some of the imbalance would return before the next session so we provided exercises he could perform at home to speed things up. The progress was slow but measurable and eventually got 90% of the rotation removed by summer’s end and the patient celebrated by riding his fastest ever Snowbird Hillclimb race and finished in the top 10 of his classification.
I think there are a few important take home points here for athletes and patients:
- Hip rotation and resulting muscle imbalances cause bio-mechanical distortions that affect the hip knee and feet.
- It you have lift in your shoe or a lot of shims in your bike shoe consider finding out if the “upstream’ cause is your hips.
- Once the problem is resolved, exercises can help maintain the correction.
- Get your hip rotation fixed BEFORE you get fit for that expensive or new bicycle.
Left: Before Right: After