I would like to finish my brief discussion of Limb Length Discrepancy with answers to the last 7 of the 13 general rules presented in Part 4. We have already discussed 1-6 in Part 4. But, I will list these first before moving on.
- The basic mantra of "Start Low and Go Slow"
- The Orthopedic Rule of "Do Not Treat under 1/2 inch" is Just Wrong
- There is a corelation between demands in activity and the amount of lift needed
- Full Length Lifts are preferred for athletes due to the time spent on the ball of their feet
- Heel Lifts (and full length lifts) should be a separate entity to custom orthotic devices
- If you are dealing with complex biomechanics, make one change at a time
- Lifts over 1/4 inch should be lessened as they go distal
When using lifts over 1/4 inch, it is important do to block forward motion with these full length lifts. Some version of 1/8 or 1/4 full length, another 1/8 sulcus length, another 1/8 or 1/4 just under the heel tends to work well. You can get some version of 3/8 inch under the forefoot, but 1/4 internal in a shoe is typically max.
8. See if your lift applied corrects for gait changes you were blaming on the short leg syndrome
If you remember the 5-6 gait changes you saw that you assumed were part of a limb length discrepancy presention (head tilt, shoulder drop, dominance to one side, asymmetrical arm swing, uneven belt line, and asymetrical foot motions), the observation that changes instantly is dominance to one side. The rest may take months after full correction to change, or never change at all do to rigidity settling in the system. However, I have been very happy to see dominance change instantly. 80% of adults fall (or our dominant) on their long side, and 20% fall to their short side. In children, this is perhaps 50-50, as which leg is growing faster at the time of the exam changes from year to year.
This right sided dominance is suggesting a long right leg and should be corrected with a lift under the short left side.
9. Maintain forefoot flexibility with full length lifts with cross striations
One of the potential problems with full length lifts is that it can block forward motion in the sagittal plane. The theories of Dr Howard Dananberg made this clear for me. Simply makes some cross cuts in the frontal plane from medial to lateral in the lifts under the metatarsal heads can eliminate this problem. We know if we block forward motion then back pain can occur, and this can be what we are trying to help.
10. Full Length lifts can be cut off at the sulcus for less digital pressure (as in the image above)
The use of full length lifts can produce a crowding problem at the toes. Most full length lifts are done this way, or at least starting with the second layer of 1/8 inch. Each layer is usually 1/8 inch which is softer to the body than just using full thickness lifts in one piece.
11. Lifts can be added (by certain companies) to the midsole of athletic shoes
This is something I have only done several times. This is for a patient who needs 1/2 inch lift or more, but wants to wear athletic shoes. In the San Francisco Bay Area I used Bernardo's Shoe Repair https://bernardo-shoe-repair.edan.io/, but the most common one is Americanheelers. Check out how they keep the lifts light and flexible by honeycombing.
12. Lifts are added to outsoles by local cobblers
All cobblers have the skill level to apply outsole lifts. They may only be on the hair stylist's shoes due to the hours of prolonged standing, and not needed otherwise. Your job is to point out there problem and give them solutions. It was common for my runners to use lifts for running, but at no other time. I definitely encourage the lifts for the highest demand activities.
Perhaps you can see the components most prescribed. These include: the lift is lessened as you move from the heel to the forefoot, the honeycombing of the lift is not seen but it keeps it lighter, and the forefoot has grooves cut in to keep our flexibility moving forward. It is huge adjustment for patients to put lifts externally as they are pushing they actual foot farther away from the ground. Clearing stairs is a big challenge. This is why internal lifts are used first to make sure the patient will want to wear them for the stability or comfort they get. External lifts, or outsole lifts, can be a big challenge.
13. Lifts of any sort can be helped by power lacing and/or tongue padding
Internal lifts are the majority of lifts that you will prescribe. At times, they increase heel slippage, so Power Lacing comes to the rescue, and occasionally the use of tongue padding to hold the heel down. Power lacing, also called Stability or Runner's knot, greatly adds to the stability of the shoe. I have added a video to this post to explain Power Lacing. You actually do not need to skip the third eyelet if there is enough lace to tie a good knot.
https://youtu.be/Lj40hKy-uqI?si=av7TQ0Jh1ty4JvZ4
