With the client prone, the hip is moved through internal and external rotation. A significant amount of internal rotation relative to the degree of external rotation may indicate the presence of increased femoral anteversion.
Clinical examination for femoral anteversion can be accomplished two ways: 1. Reider’s test For this test the patient lies prone, and the therapist stands on the side being examined. One hand grasps the ankle, and the other hand is placed flat on the lateral aspect of the hip. The hip is now internally rotated until the greater trochanter is most lateral, a position which reflects a neutral position of the femoral neck. Now the amount of internal rotation is visualized and/or measured to assess the amount of anteversion (Measuring Femoral Antetorsion, 2000). 2. Passive hip internal rotation Cibulka (2004) recommends using passive hip internal rotation to assess for abnormal femoral anteversion. Leg length discrepancy (LLD) Although the presence of discrepancies in leg length is generally accepted, there is minimal consensus as to how clinically relevant it is (Cahanin et al., 2019). We will look at recent applicable studies as a means of providing sufficient background to assist an evaluating clinician in determining if a leg length discrepancy is present and its possible effect on a specific runner’s biomechanics and injury development. Types of LLD There are two types of LLDs, structural and functional. Structural LLD A structural LLD exists when there is a difference in the actual length of the femur and/or tibia on one side compared to the other. Radiographic evidence has shown that 90% of the normal population has a measurable variance in bony leg length, and the difference is greater than 9 mm in 20% of the normal population. Functional LLD A functional LLD is not due to an osseous inequity but to an alteration in lower limb mechanics. Causes include soft tissue shortening, joint contracture, mechanical axis malalignment, and foot biomechanics. An example of a functional LLD is a runner with increased pronation in one foot versus the other where the increase in pronation serves to shorten the lower extremity on that side. Visualizing an LLD in standing When assessing for an LLD in standing, the clinician should check for specific compensations used by the patient to level out the difference in height. These compensations include: Long side ● Foot pronation ● Ankle dorsiflexion ● Knee flexion
Indirect measurement in standing With the client standing, the clinician compares the height of the iliac crests, ASISs, greater trochanters, and knee joint lines for inequalities in height. With this method, special attention must be paid to symmetrical alignment of the lower extremity. For example, assessment and be skewed by differences in foot position or knee position (flexion, extension, hyperextension). The Galeazzi Test for LLD (also known as the Allis Test or the Skyline Test) For this test, the client lies supine with the hips passively flexed to 45 degrees and the knees flexed to 90 degrees. The medial malleoli are placed together. If the tibias are unequal, one knee will sit higher than the other when viewed from the feet. If the femurs are unequal, one knee will project further forward when viewed from the side (Admin, 2023). The Weber-Barston maneuver (also known as the Fitzgerald Test) While in supine, the client performs a bridging maneuver, lifting the hips and setting them back down. (This helps ensure symmetrical placement of the hips). Now the clinician actively extends both legs simultaneously. The levels of the medial malleoli are compared. This test is considered positive if the difference in malleoli position is greater than 1 cm (Admin, 2023). Since no one test for LLD has been shown to be reliable, clinicians may improve accuracy by using multiple tests. Effect of leg length discrepancy on biomechanics There is evidence that a leg length discrepancy can affect lower extremity function. Korontzi et al. (2023) designed a study that artificially induced a leg length discrepancy and then assessed its effect on treadmill-based running and walking. In terms of spatiotemporal gait parameters, they found that step length decreased on the short side and increased on the long side while walking, but no changes in step length were seen with running. Stance time increased on the long side and decreased on the short side with running, while ground reaction forces increased on the short side. There was no impact on electromyographic (EMG) activity of the thoracic and lumbar trunk extensors or hip abductors. Miyagi et al. (2023) found that a leg length discrepancy increased the lateral shift of the center of mass of the body during stance phase, which creates a pelvic drop toward the short side when the LLD exceeds 2.5 cm. LLD and running In a study of high school runners, Rauh (2018) found that a mild leg length discrepancy did not predispose runners to injury, but a leg length discrepancy of greater than 1.5 cm led to greater injury rates.
● Hip flexion and internal rotation ● Innominate posterior rotation Short side ● Foot supination ● Ankle plantarflexion ● Knee extension ● Hip extension and external rotation ● Innominate anterior rotation Measuring LLD Direct measurement in supine
With the client in supine, the therapist uses a tape measure to measure the distance from the anterior iliac spine to the medial malleolus. This method has been criticized for its accuracy because iliac asymmetries may mask an LLD or accentuate it. Accuracy can be improved by measuring multiple times and taking the average.
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