ChiroACCESS Article



Leg Length and Osteoarthritis



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March 3, 2010

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Knee PainTwo recent publications examining the possible relationship between leg length inequality and osteoarthritis have resulted from the Multicenter Osteoarthritis Study (MOST).  The data was collected using a cohort of 3,069 adults age 50 to 79. The subjects either had knee pain or risk factors for knee pain which included obesity and previous knee injury.  The most recent study published this month (March 2010) strongly links leg length inequality with osteoarthritic changes in the knee.  Baseline assessments were made with experienced technicians using full limb anteriorposterior radiographs.  Subjects were followed up after 30 months and reassessed for joint space narrowing.  The significant change was in individuals with a leg length difference of over one centimeter. The authors concluded that “Radiographic leg-length inequality was associated with prevalent, incident symptomatic, and progressive knee osteoarthritis. Leg-length inequality is a potentially modifiable risk factor for knee osteoarthritis.”  This provides another opportunity for chiropractors to engage in the prevention of knee osteoarthritis as part of their wellness program.
 
A 2009 study, using the same cohort failed to identify a relationship between leg length inequality and greater trochanteric pain.

Association of leg-length inequality with knee osteoarthritis: a cohort study.

Ann Intern Med. 2010 Mar 2;152(5):287-95.

Harvey WF, Yang M, Cooke TD, Segal NA, Lane N, Lewis CE, Felson DT.
Boston University School of Medicine and Tufts Medical Center, Boston, Massachusetts; Queen's University, Kingston, Ontario, Canada; University of Iowa, Iowa City, Iowa; University of California at Davis, Davis, California; and University of Alabama, Birmingham, Alabama.

Background: Leg-length inequality is common in the general population and may accelerate development of knee osteoarthritis.

Objective: To determine whether leg-length inequality is associated with prevalent, incident, and progressive knee osteoarthritis.

Design: Prospective observational cohort study.

Setting: Population samples from Birmingham, Alabama, and Iowa City, Iowa.

Patients: 3026 participants aged 50 to 79 years with or at high risk for knee osteoarthritis.

Measurements: The exposure was leg-length inequality, measured by full-limb radiography. The outcomes were prevalent, incident, and progressive knee osteoarthritis. Radiographic osteoarthritis was defined as Kellgren and Lawrence grade 2 or greater, and symptomatic osteoarthritis was defined as radiographic disease in a consistently painful knee.

Results: Compared with leg-length inequality less than 1 cm, leg-length inequality of 1 cm or more was associated with prevalent radiographic (53% vs. 36%; odds ratio [OR], 1.9 [95% CI, 1.5 to 2.4]) and symptomatic (30% vs. 17%; OR, 2.0 [CI, 1.6 to 2.6]) osteoarthritis in the shorter leg, incident symptomatic osteoarthritis in the shorter leg (15% vs. 9%; OR, 1.7 [CI, 1.2 to 2.4]) and the longer leg (13% vs. 9%; OR, 1.5 [CI, 1.0 to 2.1]), and increased odds of progressive osteoarthritis in the shorter leg (29% vs. 24%; OR, 1.3 [CI, 1.0 to 1.7]).

Limitations: Duration of follow-up may not be long enough to adequately identify cases of incidence and progression. Measurements of leg length, including radiography, are subject to measurement error, which could result in misclassification.

Conclusion: Radiographic leg-length inequality was associated with prevalent, incident symptomatic, and progressive knee osteoarthritis. Leg-length inequality is a potentially modifiable risk factor for knee osteoarthritis. Primary Funding Source: National Institute on Aging.

Symptoms of the knee and hip in individuals with and without limb length inequality.

Osteoarthritis Cartilage. 2009 May;17(5):596-600. Epub 2008 Nov 19.

Golightly YM, Allen KD, Helmick CG, Renner JB, Jordan JM.
Department of Epidemiology, School of Public Health, University of North Carolina, Chapel Hill, NC 27599, USA.

OBJECTIVE: This cross-sectional study examined the association of limb length inequality (LLI) with chronic joint symptoms at the hip and knee in a large, community-based sample, adjusting for the presence of radiographic osteoarthritis (OA) and other confounders.

METHODS: The total study group comprised 3012 participants with complete knee symptoms data, 3007 participants with complete hip symptoms data, and 206 with LLI>or=2 cm. Presence of chronic knee symptoms was defined as report of pain, aching, or stiffness (symptoms) of the knee on most days. Presence of chronic hip symptoms was defined as hip pain, aching, or stiffness on most days or groin pain. Multiple logistic regression models were used to examine the relationship of LLI with knee and hip symptoms, while adjusting for demographic and clinical factors, radiographic knee or hip OA and history of knee or hip problems (joint injury, fracture, surgery, or congenital anomalies).

RESULTS: Participants with LLI were more likely than those without LLI to have knee symptoms (56.8% vs 43.0%, P<0.001), and hip symptoms (49.5% vs 40.0%, P=0.09). In adjusted models, knee symptoms were significantly associated with presence of LLI (adjusted odds ratio [aOR]=1.41, 95% confidence interval, [95% CI] 1.02-1.97), but the relationship between hip symptoms and LLI (aOR=1.20, 95% CI 0.87-1.67) was not statistically significant.

CONCLUSION: LLI was moderately associated with chronic knee symptoms and less strongly associated with hip symptoms. LLI may be a new modifiable risk factor for therapy of people with knee or hip symptoms.

Leg-length inequality is not associated with greater trochanteric pain syndrome.

Arthritis Res Ther. 2008;10(3):R62. Epub 2008 May 29.

Segal NA, Harvey W, Felson DT, Yang M, Torner JC, Curtis JR, Nevitt MC; Multicenter Osteoarthritis Study Group.
Department of Orthopedics & Rehabilitation, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, 0728 JPP, Iowa City, IA 52242-1088, USA. neil-segal@uiowa.edu

INTRODUCTION: Greater trochanteric pain syndrome (GTPS) is a common condition, the pathogenesis of which is incompletely understood. Although leg-length inequality has been suggested as a potential risk factor for GTPS, this widely held assumption has not been tested.

METHODS: A cross-sectional analysis of greater trochanteric tenderness to palpation was performed in subjects with complaints of hip pain and no signs of hip osteoarthritis or generalized myofascial tenderness. Subjects were recruited from one clinical center of the Multicenter Osteoarthritis Study, a multicenter population-based study of community-dwelling adults aged 50 to 79 years. Diagnosis of GTPS was based on a standardized physical examination performed by trained examiners, and technicians measured leg length on full-limb anteroposterior radiographs.

RESULTS: A total of 1,482 subjects were eligible for analysis of GTPS and leg length. Subjects' mean +/- standard deviation age was 62.4 +/- 8.2 years, and 59.8% were female. A total of 372 lower limbs from 271 subjects met the definition for having GTPS. Leg-length inequality (difference > or = 1 cm) was present in 37 subjects with GTPS and in 163 subjects without GTPS (P = 0.86). Using a variety of definitions of leg-length inequality, including categorical and continuous measures, there was no association of this parameter with the occurrence of GTPS (for example, for > or = 1 cm leg-length inequality, odds ratio = 1.17 (95% confidence interval = 0.79 to 1.73)). In adjusted analyses, female sex was significantly associated with the presence of GTPS, with an adjusted odds ratio of 3.04 (95% confidence interval = 2.07 to 4.47). CONCLUSION: The present study found no evidence to support an association between leg-length inequality and greater trochanteric pain syndrome.

Leg length discrepancy.

Gait Posture. 2002 Apr;15(2):195-206.

Gurney B.
Division of Physical Therapy, School of Medicine, University of New Mexico, Health Sciences and Services, Boulevard 204, Albuquerque, NM 87131-5661, USA. bgurney@salud.unm.edu

The role of leg length discrepancy (LLD) both as a biomechanical impediment and a predisposing factor for associated musculoskeletal disorders has been a source of controversy for some time. LLD has been implicated in affecting gait and running mechanics and economy, standing posture, postural sway, as well as increased incidence of scoliosis, low back pain, osteoarthritis of the hip and spine, aseptic loosening of hip prosthesis, and lower extremity stress fractures. Authors disagree on the extent (if any) to which LLD causes these problems, and what magnitude of LLD is necessary to generate these problems. This paper represents an overview of the classification and etiology of LLD, the controversy of several measurement and treatment protocols, and a consolidation of research addressing the role of LLD on standing posture, standing balance, gait, running, and various pathological conditions. Finally, this paper will attempt to generalize findings regarding indications of treatment for specific populations.
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