Table Of ContentProgress in
Orthopaedic
Surgery Vol. 1
Editorial Board
N. Gschwend, Zurich· D. Hohmann, Erlangen . J. L. Hughes,
Jackson' D. S. Hungerford, Baltimore' G. D. MacEwen, Wil
mington . E. Morscher, Basel . J. Schatzker, Toronto
H. Wagner, Nuremberg/Altdorf . U. H. Weil, New Haven
Leg Length Discrepancy
The Injured Knee
Edited by David S. Hungerford
Contributors
W. Bandi, Interlaken· J. Eichler, Wiesbaden . G. Figner, Basel·
P. Heidensohn, Erlangen . E. Hogue, Jackson . D. Hohmann,
Erlangen· J. L. Hughes, Jackson· Ch. Kieser, Zurich·
E. Meyer, Hanover· E. Morscher, Basel· W. Miiller, Basel·
D. Petersen, Hanover . A. Riittimann, Zurich . H. Wagner,
Nuremberg/Altdorf . M. Weigert, Erlangen
With 100 Figures
Springer-Verlag
Berlin Heidelberg N ew York 1977
Editor: David S. Hungerford, The Johns Hopkins University,
School of Medicine, The Good Samaritan Hospital, 5601 Loch
Raven Boulevard, Baltimore, Maryland 21239, USA.
ISBN-13: 978-3-642-66551-6 e-ISBN-13: 978-3-642-66549-3
DOl: 10.1007/978-3-642-66549-3
Library of Congress Cataloging in Publication Data. Leg length discrepancy. (Progress in
orthopaedic surgery; v. 1) Consists chiefly of articles from Der Orthopade, v. 1, 1972, and v. 3,1974.
Bibliography: p. Includes index. L Leg length inequality-Addresses, essays, lectures. 2. Knee
Wounds and injuries-Addresses, essays, lectures. I. Hungerford, David S. II. Bandi, W. III. Series.
[DNLM: L Leg length inequality. 2. Knee injuries. WI PR677B v. 11WE850 L496] RD779.3.L43
617'.398 76-57743
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Under § 54 of the German Copyright Law where copies are made for other than private use, a fee is
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© by Springer-Verlag Berlin Heidelberg 1977
Softcover reprint of the hardcover 1st edition 1977
The use of registered names, trademarks, etc. in this publication does not imply, even in the absence
of a specific statement, that such names are exempt from the relevant protective laws and regulations
and therefore free for general use.
Foreword by H. Wagner
Research worldwide in the field of orthopaedic surgery has resulted in such an
abundance of scientific and technical knowledge that textbooks no longer can
keep abreast of new developments while journals, on the other hand, fail to
provide a comprehensive broad view.
To satisfy the orthopaedic surgeon's need for information, the German
language journal Der Orthopiide was founded in 1972. Since then, the journal
has published the latest results of scientific research applicable to practice, and
provided review papers which have also been of interest to those in allied
specialities. This form of disseminating scientific knowledge has met with
acceptance and found a wide circle of readers stretching beyond the boundaries
of Europe. Many other orthopaedic surgeons have expressed an interest in the
information contained in this publication but have found the language barrier
insurmountable. A new series Progress in Orthopaedic Surgery has been created
in order to make this information available. It will present both the .work of
European authors in English and also original papers from American ortho
paedic surgeons.
Each volume will provide a broad overview of the current state of knowledge
in one or two themes of orthopaedic surgery. The choice of themes will be
decided by the editors with major emphasis on diagnosis, prevention, and
treatment of orthopaedic disorders. The editors will call upon authorities in the
field to supply these current reports.
It is the editors' wish that this new series will build bridges across language
barriers and enrich the exchange of information in orthopaedic surgery.
Nuremberg/A ltdorf December 1976
Foreword by David S. Hungerford
Two timely topics have been selected by the editors for the initial volume of the
new series Progress in Orthopaedic Surgery. The series begins with primarily
European contributions on a subject which is more prevalent in Europe than in
many of the English speaking countries. It is therefore not surprising that signifi
cant advances have been achieved in the evaluation and treatment of significant
leg length discrepan~y based on the need to solve the associated complex tech
nical problems. This section on leg length discrepancy comprehensively covers
the problem from diagnosis, methods of quantifying discrepancy, and patho
mechanics to non-surgical and surgical treatment of the discrepancy. Recogniz
ed experts in the field have concisely presented their experience. Together these
articles comprise a section which represents the "state of the art" for evaluation
and treatment of leg length discrepancy.
The second topic deals with the injured knee. Dr. Muller presents a com
prehensive overview of the soccer player's knee. With the growing interest and
involvement of this sport in the United States involving all age groups, this
article will be particularly appreciated. Professors Bandi and Wagner deal with
the question of cartilage injury in the knee. Certainly such lesions occur more
frequently than they are diagnosed. Professor Bandi brings his long-standing
interest and experience in patella pathology to bear on the question of a trau
matic etiology of chondromalacia patellae. Professor Wagner elucidates a
variety of kinds of cartilage injury, both direct and indirect, with practical
suggestions for diagnosis and treatment.
The first volume of Progress in Orthopaedic Surgery has been edited to
introduce English-speaking orthopaedists to the works and thinking· of their
German-speaking colleagues. Outstanding work on timely topics has been
selected with the hope that this series will provide a common ground for com
munication between these two important language groups.
Baltimore December 1976
Contents
Foreword by H. Wagner V
Foreword by D. S. Hungerford VII
Leg Length Discrepancy 1
J. L. Hughes, R. E. Hogue: Basic Rehabilitation Principles of Persons with Leg
Length Discrepancy: An Overview 3
E. Morscher: Etiology and Pathophysiology of Leg Length Discrepancies 9
E. Morscher, G. Figner: Measurel1)ent of Leg Length 21
J. Eichler: Methodological Errors in Documenting Leg Length and Leg Length
Discrepancies 29
E. Meyer, D. Petersen: Equalization of Leg Length with Orthopaedic Shoe
Measures 41
P. Heidensohn, D. Hohmann, M. Weigert: Subtrochanteric Shortening and
Lengthening Osteotomy 63
H. Wagner: Surgical Lengthening or Shortening of Femur and Tibia. Technique
and Indications 71
The Injured Knee 9S
A. Ruttimann, Ch. Kieser: The Importance of Arthrography Following Trauma
to the Knee Joint 97
W. Muller: The KneeJ oint of the Soccer Player (Its Stresses and Damages) 117
x
Contents
W. Bandi: Trauma-Induced Chondromalacia Patellae 131
H. Wagner: Traumatic Injuries to the Articular Cartilage of the Knee 143
Subject Index 157
List of Contributors 159
Leg Length Discrepancy
Basic Rehabilitation Principles of Persons
with Leg Length Discrepancy:
An Overview
J. L. Hughes* and R. E. Hogue**
A sucessful rehabilitation program is built upon a thorough evaluation of the
patient's physical and emotional problems. A person with leg length discrepancy
may have functional, cosmetic, or pain problems. Proper identification of these
problems is imperative if the treatment is to bear desired results. It is necessary
for the physician and therapists to work with the patient in a team approach
from the very beginning. The team approach enables the proper priorities to be
placed on the problem areas; to try to correct all problem areas at once would be
futile. For some patients cosmesis is the overriding factor in their desire to have
corrective measures performed. In others, function may be the most inportant
factor. Some defects may be minor to the evaluators but major to the patient, or
vice versa.
Once the initial team evaluation is accomplished, a therapy program should be
planned and implemented whether it be surgical, conservative, or both. Imple
mentation of the treatment program should not mean the end of the evaluation.
Evaluation is an ongoing process until there is mutual satisfaction by the evalua
tors and the patients. Ongoing evaluation also enables the examiners to deter
mine the success of the treatment program and make necessary modifications if
the need should arise.
Evaluation of the patient with leg length discrepancy should be centered in
four major areas. In all of these areas of investigation the findings should be prop
erly recorded so that an adequate data base may be obtained for making future
decisions and for comparing future analysis. Initially, one should look at the
affected limb in order to ascertain the etiology of the leg length discrepancy.
This includes a thorough evaluation of the neuromuscular components of the
extremity, as well as the joints that are incorporated in the extremity. Attention
* Chairman, Division of Orthopaedic Surgery, University of Mississippi Medical
School, Jackson, Mississippi, USA
** Chairman, Department of Physical Therapy, School of Related Health Professions,
University of MisSissippi School of Medicine, and Chairman, Physical Therapy &
Kinesiology, Mississippi Methodist Rehabilitation Center
4 J. L. Hughes and R. E. Hogue
should be paid to the soft tissues and their probable contracted state. One should
also look at the sound leg in as thorough a manner as the affected side. The
pelvis, and thoracic and lumbar spine must be evaluated to determine their
functional and anatomical state. Lastly, a thorough knowledge of the patient's
attitude and desires should be obtained, for if there are major defects in these
areas even the most skilled rehabilitation program will fail. Once these basic
premises are understood, the thorough evaluation can proceed.
Many of the factors mentioned in this article will be reviewed in greater detail
by the other participants in this volume. However, this overview will provide the
framework within which that detail can be placed.
A complete evaluation program of the patient with a leg length discrepancy
should include the following measur&ments.
Leg Length
Measurement of the leg length should be done in supine, standing, and sitting
positions. These are the functional positions which are most frequently used
during the day. One method of measuring the leg length is from the anterior
superior iliac spine to the medial malleolus, or from the anterior superior iliac
spine to the tip of the lateral malleolus. This is done with the patient in a supine
position. Each segment of the lower extremity should also be measured. In the
standing position, one should have several thicknesses of boards available to
determine the functional discrepancy of the shortened leg. These boards should
be inserted between th~ sole-of the foot and the floor until the pelvis becomes
level. This is accomplished by the observer viewing the iliac crest posteriorly. A
gross measurement of pelvic obliquity can be obtained by measuring from the
patient's umbilicus to the anterior superior iliac spine. Even though the clinical
measurements are important, they cannot take the place of an adequately con
trolled radiologic study of the pelvis and the lower extremities to determine the
absolute leg length discrepancy.
Circumference
Measurements should be accomplished about the thigh approximately 8 to 10
inches above the tibial tubercle and around the calf approximately 6 to 8 inches
below the tibial tubercle. These measurements determine differences in the
contralateral muscle mass and, in addition, can be used as a guide to determine
the results of the strengthening exercises.
Strength
The patient's strength should be tested manually at all joints of the lower extrem
ities and, in addition, the anterior and posterior spinal and abdominal muscles
should be tested. A percentage, numerical, or letter system may be used to
