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The most common treatment for discrepancies in leg length is the use of a simple heel lift, which can be placed within the shoe. In cases where the length discrepancy is moderate, an external build up to the shoe is usually more comfortable. In severe cases, surgery can be used to make the longer leg shorter (or impede its growth), and/or make the shorter leg longer.
Although prone "functional leg length" is a widely used chiropractic tool in their Activator technique, it is not a recognized anthropometric technique, since legs are usually of unequal length, and measurements in the prone position are not entirely valid estimates of standing X-ray differences. Measurements in the standing position are far more reliable. Another confounding factor is that simply moving the two legs held together and leaning them imperceptibly to one side or the other produces different results.
Clinical measurement of leg length conventionally uses the distance from the anterior superior iliac spine to the medial malleolus. Projectional radiographic measurements of leg length have two main variants:
- Teleroentgenogram, which projects the entirety of both legs at the same time.
- Orthoroentgenogram, which takes separate images of the hip, knee and ankle.
On X-rays, the length of the lower limb can be measured from the proximal end of femoral head to the center of the plafond of the distal tibia.
X-ray images (normally during weightbearing) can be obtained to rule out other conditions or to see if the patient also has osteoarthritis. The menisci themselves cannot be visualised with plain radiographs. If the diagnosis is not clear from the history and examination, the menisci can be imaged with magnetic resonance imaging (an MRI scan). This technique has replaced previous arthrography, which involved injecting contrast medium into the joint space. In straightforward cases, knee arthroscopy allows quick diagnosis and simultaneous treatment. Recent clinical data shows that MRI and clinical testing are comparable in sensitivity and specificity when looking for a meniscal tear.
Because wear on the hip joint traces to the structures that support it (the posture of the legs, and ultimately, the feet), proper fitting shoes with adequate support are important to preventing GTPS. For someone who has flat feet, wearing proper orthotic inserts and replacing them as often as recommended are also important preventive measures.
Strength in the core and legs is also important to posture, so physical training also helps to prevent GTPS. But it is equally important to avoid exercises that damage the hip.
Physical examination shows that the lower legs angle inward. An x-ray of the knee and the lower leg confirms the diagnosis.
Magnetic Resonance Imaging (MRI) produces a 3-dimensional image that allows for exceptional evaluation of soft tissue structures, as well as the detection of boney change and the presence of excessive fluid accumulation associated with inflammation. Like CT, an MRI image may be viewed in various planes of orientation, improving visualization of anatomic structures and any associated pathologic change. MRI is considered the gold standard for diagnosing soft tissue injury within the foot. While it can provide a definitive diagnosis in cases where other imaging modalities have failed, it does have several limitations. Available magnet size restricts imaging to the level of the stifle or elbow, or below. MRI takes a significant amount of time acquire an image, which translates to long anesthesia times and therefore reduces the size of the area that may be imaged in a single session. The area thought to be associated with lameness must be placed in the MRI. MRI is therefore inappropriate for any lameness that can not be localized to a specific region of the limb. Additionally, MRI has limited availability and high cost compared to the other imaging modalities.
Horses may undergo standing MRI, where the horse is sedated and imaged with a low-field magnet (0.27 Tesla), or it may be placed in a high-field magnet (1.5 or 3 Tesla) while under general anesthesia. Low-field magnets produce less resolution and the subtle swaying of the standing horse leads to motion artifact (blurring of the image), especially in the case of the knee or hock, leading to reduced image quality. However, standing MRI tends to be cheaper, and it eliminates the risks of general anesthesia, such as further damage to the injured area or additional injury that may occur during anesthetic recovery.
The diagnosis of the cause of a limp is often made based on history, physical exam findings, laboratory tests, and radiological examination. If a limp is associated with pain it should be urgently investigated, while non-painful limps can be approached and investigated more gradually. Young children have difficulty determining the location of leg pain, thus in this population, "knee pain equals hip pain". SCFE can usually be excluded by an x-ray of the hips. A ultrasound or x-ray guided aspiration of the hip joint maybe required to rule out an infectious process within the hip.
Computed tomography (CT) is an imaging modality that produces a 3-dimensional radiograph. A series of plain radiographs are taken in a spiral around the site of interest, and the individual 2-D radiographs are converted into a 3-D image by a computer. The image may be manipulated to view in different planes, such as cross-section, making it possible to see an injury from multiple perspectives and improving diagnostic capabilities when compared to plain radiographs. Like plain radiographs, CT is not as useful for soft tissue lesions when compared to boney lesions. However, CT requires general anesthesia, and is more costly and less available than plain radiographs, limiting its use in general practice. CT provides a large amount of data with exceptional speed, taking only seconds to minutes to complete. When compared to MRI, it is not only significantly faster (MRI takes 1–2 hours to produce an image), but also less expensive. Its combination of speed and imaging capabilities makes it beneficial for use prior to orthopedic surgery, especially in the case of complicated fractures, as it allows for visualization from all sides so that the surgeon may determine the best approach and method of correction prior to cutting. Upon completion of the CT, the horse may be rolled straight into the surgery suite for immediate surgical treatment.
A doctor may begin the diagnosis by asking the patient to stand on one leg and then the other, while observing the effect on the position of the hips. Palpating the hip and leg may reveal the location of the pain, and range-of-motion tests can help to identify its source.
X-rays, ultrasound and magnetic resonance imaging may reveal tears or swelling. But often these imaging tests do not reveal any obvious abnormality in patients with documented GTPS.
Shin splints can be diagnosed by a physician after taking a thorough history and performing a complete physical examination. The physical examination uses gentle pressure to determine whether there is tenderness over a 4–6 inch section on the lower, inside shin area. The pain has been described as a dull ache to an intense pain that increases during exercise, and some individuals experience swelling in the pain area. People who have previously had shin splints are more likely to have it again.
Vascular and neurological examinations produce normal results in patients with shin splints. Radiographies and three-phase bone scans are recommended to differentiate between shin splints and other causes of chronic leg pain. Bone scintigraphy and MRI scans can be used to differentiate between stress fractures and shin splints.
It is important to differentiate between different lower leg pain injuries, including shin splints, stress fractures, compartment syndrome, nerve entrapment, and popliteal artery entrapment syndrome. These conditions often have many overlapping symptoms which makes a final diagnosis difficult, and correct diagnosis is needed to determine the most appropriate treatment.
If shin splints are not treated properly, or if exercise is resumed too early or aggressively, shin splints can become permanent.
Diagnosis is based on symptom and confirmed with X-rays. In children an MRI may be required.
A meniscal tear can be classified in various ways: by anatomic location, by proximity to blood supply, etc. Various tear patterns and configurations have been described. These include:
- Radial tears;
- Flap or parrot-beak tears;
- Peripheral, longitudinal tears;
- Bucket-handle tears;
- Horizontal cleavage tears; and
- Complex, degenerative tears.
These tears can then be further classified by their proximity to the meniscus blood supply, namely whether they are located in the “red-red,” “red-white,” or “white-white” zones.
The functional importance of these classifications, however, is to ultimately determine whether a meniscus is repairable. The repairability of a meniscus depends on a number of factors. These include:
- Age/strength
- Activity level
- Tear pattern
- Chronicity of the tear
- Associated injuries (anterior cruciate ligament injury)
- Healing potential
This condition is usually curable with appropriate treatment, or sometimes it heals spontaneously. If it is painless, there is little cause for concern.
Correcting any contributing biomechanical abnormalities and stretching tightened muscles, such as the iliopsoas muscle or iliotibial band, is the goal of treatment to prevent recurrence.
Referral to an appropriate professional for an accurate diagnosis is necessary if self treatment is not successful or the injury is interfering with normal activities. Medical treatment of the condition requires determination of the underlying pathology and tailoring therapy to the cause. The examiner may check muscle-tendon length and strength, perform joint mobility testing, and palpate the affected hip over the greater trochanter for lateral symptoms during an activity such as walking.
Osteitis pubis may be diagnosed with an X-ray, where irregularity and widening of the pubic symphysis are hallmark findings. Similar change is also demonstrated with Computed Tomography (CT), but the multi-planar nature of CT has a higher sensitivity than conventional radiography. Though not well visualised on ultrasound (US), thickening of the superior joint capsule with cyst formation is a clue to the diagnosis, as well as secondary changes (i.e. tendinosis) of the adjacent adductor muscles - particularly the adductor longus and rectus abdominis. US is also useful for excluding a hernia, which may co-exist with osteitis pubis and warrant additional treatment.
Both US and CT may be used for injecting the pubic symphysis with corticosteroid as part of an athlete's treatment program. Magnetic resonance imaging combines the diagnostic advantages of CT and ultrasound, also shows bone marrow edema, and has the advantages of not being operator dependent (unlike US), nor using radiation (such as CT and X-rays). As such, MRI is the modality of choice for evaluation, diagnosis, and treatment planning.
X-rays of the hip may suggest and/or verify the diagnosis. X-rays usually demonstrate a flattened, and later fragmented, femoral head. A bone scan or MRI may be useful in making the diagnosis in those cases where X-rays are inconclusive. Usually, plain radiographic changes are delayed 6 weeks or more from clinical onset, so bone scintigraphy and MRI are done for early diagnosis. MRI results are more accurate, i.e. 97 to 99% against 88 to 93% in plain radiography. If MRI or bone scans are necessary, a positive diagnosis relies upon patchy areas of vascularity to the capital femoral epiphysis (the developing femoral head).
A self-treatment recommended by the U.S. Army for a soft tissue injury of the iliopsoas muscle treatment, like for other soft tissue injuries, is a HI-RICE (Hydration, Ibuprofen, Rest, Ice, Compression, Elevation) regimen lasting for at least 48 to 72 hours after the onset of pain. "Rest" includes such commonsense prescriptions as avoiding running or hiking (especially on hills), and avoiding exercises such as jumping jacks, sit-ups or leg lifts/flutter kicks.
Stretching of the tight structures (piriformis, hip abductor, and hip flexor muscle) may alleviate the symptoms. The involved muscle is stretched (for 30 seconds), repeated three times separated by 30 second to 1 minute rest periods, in sets performed two times daily for six to eight weeks. This should allow one to progress back into jogging until symptoms disappear.
Anterior-posterior (AP) X-rays of the pelvis, AP and lateral views of the femur (knee included) are ordered for diagnosis. The size of the head of the femur is then compared across both sides of the pelvis. The affected femoral head will appear larger if the dislocation is anterior, and smaller if posterior. A CT scan may also be ordered to clarify the fracture pattern.
Risk factors for developing shin splints include:
- Excessive pronation at subtalar joint
- Excessively tight calf muscles (which can cause excessive pronation)
- Engaging the medial shin muscle in excessive amounts of eccentric muscle activity
- Undertaking high-impact exercises on hard, noncompliant surfaces (ex: running on asphalt or concrete)
- Smoking and low fitness level
While medial tibial stress syndrome is the most common form of shin splints, compartment syndrome and stress fractures are also common forms of shin splints. Females are 1.5 to 3.5 times more likely to progress to stress fractures from shin splints. This is due in part to females having a higher incidence of diminished bone density and osteoporosis.
The hip should be reduced as quickly as possible to reduce the risk of osteonecrosis of the femoral head. This is done via inline manual traction with general anesthesia and muscle relaxation, or conscious sedation. Fractures of the femoral head and other loose bodies should be determined prior to reduction. Common closed reduction methods include the Allis method and Stimson method. Once reduction is completed management becomes less urgent and appropriate workup including CT scanning can be completed. Post-reduction, patients may begin early crutch-assisted ambulation with weight bearing as tolerated.
Children who develop severe bowing before the age of 3 may be treated with knee ankle foot orthoses. However, bracing may fail, or bowing may not be detected until the child is older. In some cases, surgery may be performed. Surgery may involve cutting the shin bone (tibia) to realign it, and sometimes lengthen it as well.
Other times, the growth of just the outer half of the tibia can be surgically restricted to allow the child’s natural growth to reverse the bowing process. This second, much smaller surgery is most effective in children with less severe bowing and significant growth remaining.
Return to normal function and cosmetic appearance is expected if the knee can be properly aligned.
Treatment may be with or without surgery, depending on the type of fracture.
A limp at one hospital emergency department was the presenting complaint in 4% of children. It occurs twice as commonly in boys as in girls.
Anteroposterior (AP) and lateral radiographs the include the entire length of the lower leg (knee to ankle) are highly sensitive and specific for tibial shaft fractures.
While ITBS pain can be acute, the iliotibial band can be rested, iced, compressed and elevated (RICE) to reduce pain and inflammation, followed by stretching. Massage therapy, and many of its modalities, can offer relief if symptoms arise.
Two systems of fracture classification are commonly used to aid diagnosis and management of tibia shaft fractures:
- Oestern and Tscherne Classification
- Gustilo-Anderson Classification
Management is dependent on the determination of whether the fracture is open or closed.