MedicalContinuing Education Orthotics Biomechanics&

Goals and Objectives

After reading this article, the physician should be able to:

1) Understand the various etiologies of leg-length asym- Evaluation and metry 2) Recognize the present- ing clinical symptoms that Management may be caused by a leg- length discrepancy

3) Differentiate between an of Leg-length anatomical and functional leg-length discrepancy Discrepancy 4) Determine the amount of leg-length difference pre- sent in a patient

Here’s a comprehensive look at the 5) Select an appropriate diagnosis and treatment of this condition. heel lift or shoe modification for the management of a leg- length problem

Welcome to Podiatry Management’s CME Instructional program. Our journal has been approved as a sponsor of Contin- uing Medical Education by the Council on Podiatric Medical Education. You may enroll: 1) on a per issue basis (at $20.00 per topic) or 2) per year, for the special introductory rate of $129 (you save $71). You may submit the answer sheet, along with the other information requested, via mail, fax, or phone. In the near future, you may be able to submit via the Internet. If you correctly answer seventy (70%) of the questions correctly, you will receive a certificate attesting to your earned cred- its. You will also receive a record of any incorrectly answered questions. If you score less than 70%, you can retake the test at no additional cost. A list of states currently honoring CPME approved credits is listed on pg. 154. Other than those entities cur- rently accepting CPME-approved credit, Podiatry Management cannot guarantee that these CME credits will be acceptable by any state licensing agency, hospital, managed care organization or other entity. PM will, however, use its best efforts to ensure the widest acceptance of this program possible. This instructional CME program is designed to supplement, NOT replace, existing CME seminars. The goal of this program is to advance the knowledge of practicing podiatrists. We will endeavor to publish high quality manuscripts by noted authors and researchers. If you have any questions or comments about this program, you can write or call us at: Podiatry Management, P.O. Box 490, East Islip, NY 11730, (631) 563-1604 or e-mail us at [email protected]. Following this article, an answer sheet and full set of instructions are provided (p. 154).—Editor

By Mark A. Caselli, DPM tremity asymmetry varies from 60 the body. One shoe heel will usual- per cent to 95 percent in the gener- ly wear away more than the other. hronic overuse problems al population. A high index of sus- One foot, ankle, knee, and hip will that persist despite appropri- picion for the presence of leg- be under more stress, and there will Cate care are the hallmarks of length asymmetry should always be eventually be compensatory the presence of a leg-length differ- considered in the athlete with back changes that take place above the ence. The symptoms associated or lower extremity complaints. pelvis as the balance of the spine is with leg-length discrepancies are di- With a leg-length discrepancy, altered. Scoliosis can develop with verse and at times vague and con- the center of gravity changes as premature joint degeneration on fusing. The incidence of lower ex- weight is transferred to one side of Continued on page 148 www.podiatrym.com SEPTEMBER 2006 • PODIATRY MANAGEMENT 147 Discrepancy... compensated for during normal associates, in a study of 100 stu- ambulation. dents, found that a combined struc- Continuingone side of the spine. When excessive load and stress, tural-functional deformity occurred Leg-length asymmetries appear however, are placed on an asym- 87.5 per cent of the time and both Medical Education to be the third most common metrical lower extremity during conditions must be addressed in a cause of running injuries. For skat- many sports activities, symptoms treatment plan. ing, it is a common cause of knee, may occur. The excessive overload Environmental factors such as hip, and foot pain. It is also a major that runners subject themselves to, drainage crowns built into road- contributor to a skater’s loss of for example, amplifies the stresses ways, banked running surfaces, and power, loss of balance, and loss of by a factor of three; lower extremity excessive wear of shoes can create a control. Minor asymmetry that is asymmetry as little as an eighth situation mimicking a leg-length inch may become symptomatic. difference. These environmental factors can also either accentuate or Etiology of Leg-Length correct structural and functional Asymmetry length differences depending how There are three categories in the athlete is running on a given the classification of limb-length surface. asymmetry. The two major cate- gories are structural and function- Anatomical Compensation al. The one minor category is envi- The spine, pelvis, and lower ex- ronmental. It is important to be tremity are all involved in the com- able to differentiate between struc- pensation of leg-length asymmetry. tural, functional, and environmen- Leg-length asymmetry causes the tal leg-length asymmetry because center of gravity to be shifted to the Figure 1: A hip replacement can result in the treatment for each is different. short leg side. Most commonly, the a leg-length discrepancy Structural discrepancies compensations associated with leg- result from an actual length asymmetry include shoulder anatomic shortening of drop (to the long side), pelvic tilt one or more of the bones (to the short side), lumbar scoliosis of the lower extremity. (convex to the short side), knee This can occur from a flexion (increased on the long side), growth plate injury dur- genu recurvatum (on the short ing childhood or adoles- side), subtalar joint pronation (on cence, fractures, or genetic the long side), and ankle plantar and acquired conditions flexion and foot supination (on the that affect bone growth. short side). Surgical procedures such The function of the compensa- as total hip and knee re- tion associated with leg-length placements can also lead asymmetry is to functionally short- to limb-length differences en the long leg, functionally presentFigure 2: mayDirect be clinical considered method normal. for measuring leg- (Figure 1). lengthen the short leg, level the Thislength minor asymmetry can be well Structural leg-length dif- sacral base, and thereby shift the ferences can also result center of gravity away from the from spinal abnormalities such as short leg. scoliosis. Structural limb-length dis- crepancies appear to be present in Symptoms Associated with about 6 to 12 per cent of the ath- Leg-length Discrepancies letes presenting with apparent leg- The most common symptom length discrepancies. Functional associated with leg-length asymme- leg-length differences are far more try is backache. Other symptoms af- common than structural patholo- fecting the lower extremity with a gies. They are present in three out structural discrepancy usually ap- of five athletes examined, and usu- pear first on the long leg side and ally occur as a result of muscular include flank pain, arthritis of the weakness or inflexibility at the knee, psoasitis, arthritis of the hip, pelvis or foot and ankle complex. patellar tendinitis, patellofemoral Conditions that result in func- pain syndrome, plantar fasciitis, tional leg-length differences in- medial tibial stress syndrome, and clude pelvic obliquity, adduction or metatarsalgia. Symptoms affecting flexion contractures of the hip, the short extremity include iliotib- genu varum, valgum or recurva- ial band syndrome with lateral Figure 3: Indirect method of determin- tum, calcaneovalgus, equinovarus, knee pain, trochanteric bursitis, ing leg-length discrepancy and rearfoot pronation. Okun and Continued on page 149

148 PODIATRY MANAGEMENT • SEPTEMBER 2006 www.podiatrym.com MedicalContinuing Education Discrepancy... cardinal body planes (frontal, sagit- the iliac crest is low on tal, and transverse) while looking at the same side and becomes sacroiliac discomfort, Achilles ten- each body segment. The head and level by placing the subtalar dinitis, and cuboid syndrome. neck should be analyzed for any tilt joint in neutral position. If just a functional leg-length to one side or the other (most com- asymmetry is present, the symp- monly tilts to the short side). The Testing For Pronation toms will usually appear on the shoulders should be evaluated for The effect of pronation in con- short side first and include plantar any tilt that might be present (most tributing to the leg-length asymme- fasciitis, medial tibial stress syn- commonly tilts to the long leg side try is determined by the pronation drome, patellofemoral pain syn- for balance). test. With the patient standing drome, illiotibial band syndrome, Arm swing should be noted for with the knees extended and the ipsilateral sacroiliac discomfort symmetry of motion. The spine can feet in the angle and base of stance, with contralateral low back pain, also be evaluated for any curvatures the subtalar joint is placed in the and secondary psoasitis. or deviations. The hips should be neutral position. The iliac crests are evaluated for any asymmetries in palpated and any discrepancies are Making the Diagnosis of Leg- motion (hip will drop to the short recorded. The patient is then al- length Discrepancy side). The knees should be evaluat- lowed to pronate and the iliac When attempting to diagnose ed for any varum, valgum, flexion, crests are reevaluated as to their po- leg-length asymmetry in a patient, or recurvatum. The position the sition, and any changes are noted. the examiner must determine three heel makes to the ground at con- The pronation test is used to deter- things. First, is there a leg-length tact and midstance should be noted mine whether orthoses or heel lifts asymmetry present, and on which (there is usually an increase in heel are indicated in the treatment of side of the body is it located? Sec- eversion on the long side). the leg-length discrepancy. ond, if a leg-length asymmetry is By performing the pronation present, is it due to a functional or test, the examiner determines one anatomic deformity? Finally, what of three things: (1) pronation has is the amount of leg-length asym- Chronic overuse no effect on leg-length; (2) prona- metry? problems that persist tion is causing a functional short leg; or (3) pronation is compensat- Examination despite appropriate ing for the long leg. If subtalar joint The examination to rule out a pronation has no effect on leg- limb-length inequality must be orga- care are the hallmarks length, there will be no change be- nized and systematic so that any of the presence of a tween the iliac crests with neutral clues that are suggestive and are con- and pronated subtalar joint posi- sistent with a short leg will not be leg-length difference. tions. If the iliac crest on the ipsi- overlooked. The patient should be lateral side is lower in pronation positioned in bare or stocking feet than in neutral subtalar joint posi- with the feet about 7 to 8 inches tion, then the subtalar joint prona- apart. S/he should be instructed to Because a limb-length discrep- tion is causing a functional leg- stand in a normal, relaxed position, ancy produces an asymmetry, the length asymmetry. with knees extended. While the pa- timing of the gait parameters will In this situation, an orthosis tient is standing, the iliac crests are also be deviated. An early heel-off with appropriate posting would be palpated and assessed for asymmetry. may be seen on the short side. The indicated to correct the leg-length The presence of a pelvic side long side will have a shortened asymmetry. If the iliac crest be- shift, lateral spine curvature (noting swing phase, while the short side comes more level when examined the convexity), fontal plane leg de- will have a longer swing phase. The in the pronated position, then sub- viation (genu varum and valgum), long side will have a longer stance talar joint pronation is compensat- sagittal plane leg deviation (knee phase, while the short side will ing for a structural leg-length asym- flexion, hamstring and/or ankle have a shorter stance phase of gait. metry. The use of a heel lift on the equinus), transverse plane leg devi- opposite extremity is indicated in ation (excessive femoral medial ro- Structural Vs. Functional this instance to correct the anatom- tation, demonstrated by “squinting Asymmetry ic asymmetry along with decreasing patella”), along with unilateral foot Once the identification of a the amount of compensatory long pronation should be determined limb-length asymmetry is made, the leg subtalar joint pronation. and its body side recorded. next step is to categorize the asym- metry as a structural or functional Determining the Amount of Gait Analysis problem. A structural short leg man- the Leg-length Discrepancy An analysis of the patient’s gait ifests as a pelvic obliquity in which Once the diagnosis and classifi- should be performed to evaluate for the iliac crest is low on the same cation of leg-length asymmetry is asymmetries during ambulation. side and becomes level with the use made, the discrepancy can then be Dynamic gait findings should sup- of a heel lift. A functional short leg quantified by either a direct or indi- port static measurements. An evalu- secondary to foot pronation mani- rect method of measurement. The ation should be made on the three fests as a pelvic obliquity in which Continued on page 150 www.podiatrym.com SEPTEMBER 2006 • PODIATRY MANAGEMENT 149 Discrepancy... method is difficult to reproduce gear or canted running surfaces is and fails to take into account func- easily treated with the use of new Continuingindirect method of evaluating tional limb-length discrepancies. or appropriate foot wear or a leg-length is superior to the di- The indirect method of limb- change in the running surface. The Medical Education rect method. The direct method in- length evaluation involves reduc- structural limb asymmetry is treat- volves measuring the distance be- tion of the pelvic tilt and leveling ed with a heel lift. tween two points, the anterior su- of the sacral base by placing a ma- perior iliac spine and the medial terial of a known thickness under Manual Muscle Testing malleolus (Figure 2). The direct the short leg while the patient is Manual muscle testing should be a standing in subtalar joint neutral routine procedure within the static position (Figure 3). examination. All muscles that are Another method involves plac- tight secondarily to a limb-length ing a carpenter’s level across the pa- discrepancy must be stretched dur- tient’s knees while he/she is in a sit- ing the heel lift and orthotic thera- ting position. Both feet should be in py. Muscles commonly affected are subtalar neutral position (Figure 4). those that abduct the thigh. A lift can be placed under the short leg until the bubble in the level is Selecting and Using Heel Lifts centered. This method can be used The purpose of the heel lift is to when the limb-length difference is level off the sacral base and correct suspected to be below the knee. The the compensatory scoliosis caused indirect method is reproducible and by the short leg. It is likely that sev- accurate in quantifying the amount eral different types of heel lifts of leg-length discrepancy. would be used for different shoes and activities. No single heel lift Clinical Measurements works perfectly for every daily need, Clinical measurements are by but the therapeutic effects of using Figure 4: Using a carpenter’s level to de- nature grossly inaccurate when heel lifts are most effective if they termine leg-length symmetry exact measurements of the are used in all the patient’s shoes. femur or tibia are required. Temporary use may require varying More thorough determina- the elevation over time. Long-term tions of their lengths by use requires foot comfort and mini- use of radiographic meth- mum disturbance of shoe fit. ods are essential in the Lifts used for sports activities re- treatment of significant quire firm support to retain control leg-length discrepancy. Al- and prevent injuries. The amount though there are various of elevation can also affect the radiographic methods choice of heel lift or external shoe used, the CT scan is the heel or sole additions. It is general- most accurate (Figure 5). ly accepted that it is unwise and uncomfortable to add more than 12 Treatment mm. (1/2 inch) of heel elevation in- The treatment for leg- side a shoe using inserts, and often length differences often one must use even less. depends on whether or The maximum amount of eleva- Figure 5: A CT scan is the most accurate method of not symptoms are present. tion that will be comfortable in a determining anatomical leg-length If the body is compensat- shoe will depend on the individual ing for a length difference and the style and size of shoe, with without causing biomechanical smaller feet generally able to accom- stress in other areas, correcting the modate less height, and lace-up difference may alter the body me- shoes allowing more than slip-ons or chanics in such a way as to cause loafers. The maximum height that an injury. If the discrepancy is can comfortably be used in a shoe causing symptoms, it needs to be will also be determined by the tight- addressed for full recovery to take ness of the shoe fit, and the amount place. of heel elevation already created by Treatment depends on the clas- the heel of the shoes. Laced shoes sification of the asymmetry. A func- with four or five eyelets can assist in tional asymmetry due to unilateral accommodating a heel lift. foot pronation is corrected with the use of properly posted foot or- Type of Shoe Worn thoses. The environmental asym- The type of shoes that are to be Figure 6: Cork heel lifts metry secondary to improper foot Continued on page 151

150 PODIATRY MANAGEMENT • SEPTEMBER 2006 www.podiatrym.com MedicalContinuing Education Discrepancy... protect the cork from abrasion as are available in a variety well as to increase their life (Figure 6). of sizes and heights, and in worn will also determine the type various firmnesses of plastic. of lift that can be used. Closed-heel Cork Lifts The ideal firmness, or durome- shoes are easier to adapt with a heel Cork lifts can be placed above ter, is 50-60, since softer plastics lift. Sandals or flip-flops may re- or under the insole or heel pad of will result in loss of height and quire an unobtrusive transparent the shoe. Placing a firm lift under cause heel rubbing in the shoe. heel lift for best appearance, or the insole results in the foot resting Solid plastic lifts are designed to be methods which a shoe-repair shop on the same amount of cushioning placed beneath the insole or heel can provide, such as a wedge built as in the unmodified shoe. With pad of a shoe, the lift adding only into the sole. More than 12 mm. of the firm lift placed under the in- height rather than compressibility. elevation should be done at least sole, both shoes will feel alike. Solid plastic lifts are available in partially with external modifica- Cork lifts are also a good choice if several different widths and tions to the shoe. For stability and the user does not wish to lift the heights, commonly 3 mm., 5 mm., minimal disturbance to lower-body insole of a shoe to place the lift be- 7 mm., and 12 mm. Special double- balance, external elevation should faced tape is used to fix these lifts be placed under the entire foot, in place rather than glue. The main rather than just the heel. drawback to plastic lifts is that they Adjustable heel lifts are sometimes difficult to fit per- Heel Lifts are available which fectly in all shoes due to the rela- A well-designed heel lift should tive rigidity of these materials. A be long enough to extend forward allow for the changing firm plastic lift is more difficult to under the arch to avoid “bridging” adapt to different shoes than less between the heel and the ball of the of the height of the lift rigid materials such as cork. foot. If the lift is too short along the by removing and length of the foot or has a “slope” Foam Rubber Lifts that is too steep, it can cause the replacing layers of Foam rubber in-shoe lifts are foot to slip forward in the shoe, es- widely available and are usually pecially when running. The longer materials. supplied with a leather, vinyl, or the heel lift, the better it functions. fabric top surface. These lifts can be A shoe lift should add elevation placed directly under the foot or with minimal compressibility to neath it because the slight resilien- under an insole. They typically pro- avoid creating vertical heel motion cy of cork tends to be more com- vide a maximum of 9 mm. (3/8 and rubbing in the shoe. Firm shoe fortable directly under foot than inch) of height. Caution must be lifts are mandatory for active sports harder materials. used in selecting a foam rubber ma- to avoid loss of control though ex- Cork lifts are easily fit in most terial that is not too spongy. Softer cess motion in the shoe which can shoes since the shape of the materi- foam rubber heel lifts will crush result in injuries, most often ankle al is easily modified and simple to permanently with use and lose sprains. fix permanently in place with con- their original height quickly. Mate- Most heel lifts are made of tact adhesives or double-faced tape. rials that are too soft can also cause cork, foam rubbers, or various plas- The primary shortcoming of cork increased heel motion resulting in tics. Cork is a good material for heel lifts is that they are not partic- uncomfortable heel rubbing and many types of in-shoe lifts as it is ularly durable. calluses as well as instability when inexpensive, light-weight, and walking or running, leading to minimally compressible. Cork lifts Molded Plastic Lifts ankle sprains and falls. are available in a wide range of Cast or molded plastic shoe lifts sizes and heights, and are usually are often used for leg-length com- Adjustable Heel Lifts covered with leather or vinyl to pensation since they are more Adjustable heel lifts are available durable than cork or foam rubber which allow for the changing of the for extended heavy use. These lifts Continued on page 152

Figure 7: Rubber adjustable heel lifts Figure 8: Multi-layered transparent Figure 9: Height of lift should be mea- with leather top covers heel lift from Clearly Adjustable sured at calcaneal contact point www.podiatrym.com SEPTEMBER 2006 • PODIATRY MANAGEMENT 151 Discrepancy... shortage. This is ac- of limb-length discrep- complished by hav- ancies include osseous Continuingheight of the lift by removing ing the patient epiphyseodosis, phy- and replacing layers of materials. stand with the sub- seal stapling, bone- Medical Education Adjustable heel lifts are available in talar joint in neu- lengthening by dis- two varieties: those composed of tral. Then a material traction (Figure 12), three layers of rubber or plastic foam of known thickness distraction epiphyseol- (Figure 7), and a multi-layered lift, is placed under the ysis, and physeal stim- which is made of many thin layers short limb until the ulation. ■ of firm plastic (Figure 8). iliac crests are level. The thick- References ness of the Batchelor D: Short- heel lift leg syndrome in run- under the ners. Dynamic Chiro- short leg is practic 20(18), 2002. Baylis WJ, Rzonca the amount EC: Functional and of limb- structural limb-length length in- discrepancies: evalua- equality tion and treatment. present. Clin Podiatr Med Surg When 5(3), 1988. Figure 12: Bone lengthening dis- Caborn DNM, Figure 10: Athletic shoe modification for leg-length using a heel lift, the traction procedure for congenital- Armsey TD II, Groll- discrepancy ly short femur heel lift man L, et al: Running. Three-layer lifts are made of height should be measured at the In Fu FH, Stone DA (eds) Sports Injuries. Philadelphia, Lip- three layers of 3mm foam rubber, point where the calcaneus rests pincott Williams & Wilkins, 2001. cork, or soft plastic and have upon it, not at the back end of the Cole L: Leg-length discrepancy. leather, vinyl, or fabric top covers. lift (Figure 9). Skates.com http://www.skates.com/Ar- The layers can be removed or re- The amount of heel lift that is ticles.asp?ID=135 placed to choose a height in 3 mm. used initially is about half of the Fields KB, Craib M: Biomechanics of increments. These lifts are intended anatomic discrepancy. This amount is running and gait. In Sallis RE, Massimi- for use directly underfoot, rather used to realign the superstructure in a no F (eds) Essentials of Sports Medicine. than beneath the insole. This gradual manner. The clinician, with St. Louis, Mosby, 1996. makes them particularly desirable feedback from the patient, will deter- Julien PH: Sure Footing. Atlanta for sandals and shoes where the in- mine the final amount of lift that will Foot & Ankle Center, 1998. Okun SJ, Morgan JW, et al: Limb- sole cannot easily be produce the best re- length discrepancy. A new method of lifted. sults for the underly- measurement and its clinical signifi- The Clearly ing symptoms. Ap- cance. J Am Pod Assoc 72:595, 1982. Adjustable lift is de- proximately a quarter Schamberger W: The Malalignment signed to be used to three-eighths inch Syndrome: Implications for Medicine under the insole or heel lift can fit into the and Sports. Edinburgh, Churchill Liv- footbed. It is not com- average adult shoe. If ingstone, 2002. pressible, so both more correction is re- Tachdjian TO: Pediatric Orthope- shoes feel alike and no quired, an addition dics. Philadelphia, W.B. Saunders Com- additional cushioning may need to be added pany, 1990. Zehr RW: Heel Lifts and Shoe Lifts - or heel rubbing is in- to the outside of the a Product Selection Guide ©2005 troduced in the shoe. shoe (Figure 10). http://www.clearlyadjustable.com This type of heel lift consists of fourteen 1 Surgical mm layers of firm Management plastic material which Surgical manage- Dr. Caselli is allow for peel-and-re- ment might be consid- Staff Podiatrist place adjustment of ered as an alternative at the VA Hud- son Valley the heel height in in- for severe or significant Health Care Sys- crements of 1 mm. to deformities (Figure 11). tem in Mon- about 1/2 inch. Most orthopedic sur- trose, NY and is geons do not consider Adjunct Profes- Amount of Heel Lift an operative procedure sor in the De- The amount of indicated for discrepan- partment of Or- Figure 11: Young patient with a thopedic Sci- heel lift needed is de- 6cm leg-length difference, war- cies less than approxi- ences at the New termined by the indi- ranting surgical consideration mately 2.5 cm. in an York College of Podiatric Medicine. Dr. rect method of evalu- for leg-lengthening surgical adult. Surgical proce- Caselli is a Fellow of the American Col- ating a structural procedure dures for the treatment lege of Sports Medicine.

152 PODIATRY MANAGEMENT • SEPTEMBER 2006 www.podiatrym.com MedicalContinuing Education EXAMINATION

See answer sheet on page 155.

1) A high index of suspicion of B) Pelvic tilt to short side 11) A leg-length asymmetry in the presence of a leg-length dis- C) Knee flexion on short side which the obliquity of the iliac crepancy should be considered D) Foot pronation on short crest becomes level with the when an athlete presents com- side use of a heel lift alone would plaining of: be categorized as: A) Back pain 7) Which one of the following is A) A structural leg-length B) Asymmetric shoe heel not a function of the compensa- discrepancy wear tion associated with leg-length B) A functional leg-length C) Unilateral arch pain asymmetry? discrepancy D) All of the above A) Functionally shorten the C) An environmental leg- long leg length discrepancy 2) Which one of the following is B) Functionally lengthen the D) None of the above not one of the categories in the short leg classification of leg-length C) Level the sacral base 12) Which one of the following discrepancy? D) Shift center of gravity to- is not necessary in determining A) Structural wards the short leg the amount of leg-length dis- B) Functional crepancy by the indirect C) Habitual 8) Which one of the following is method? D) Environmental the most common symptom of A) Patient must be stand- leg-length asymmetry? ing 3) Which one of the following A) Plantar fasciitis B) Subtalar joints must be conditions can result in a struc- B) Shin splints in neutral position tural leg-length discrepancy? C) Backache C) Material of known thick- A) Growth plate injury D) Calcaneal bursitis ness is placed under appar- B) Flexion contracture of hip ently short leg C) Unilateral pronation 9) Which one of the following is D) Patients must wear their D) Genu recurvatum not consistent with the diagno- normal shoes sis of a structural leg-length dis- 4) What is the incidence of func- crepancy? 13) The most accurate radio- tional limb-length discrepancy A) Symptoms usually appear graphic method of determin- among athletes? first on the short side ing the true anatomical length A) 12 percent B) Symptoms are more com- of a limb is: B) 30 percent mon during high levels of A) Teleoroentgenography C) 60 percent sports activities B) Slit scanography D) 87 percent C) Conditions such as arthri- C) Orthoroentgenography tis of the hip and knee can D) CT scan 5) Which one of the following occur on the long side would be considered an envi- D) Iliotibial band syndrome 14) Under what condition ronmental factor that could re- and Achilles tendinitis are should you consider not sult in a leg-length discrepancy? common on the short side correcting a limb-length A) Steep hills discrepancy? B) Drainage crown in 10) Which one of the following A) When symptoms occur roadway is not a common gait observa- only during rigorous activi- C) Platform shoes tion when evaluating a patient ties D) Sandy beach with leg-length asymmetry? B) When there are no A) Hip drop to the short side symptoms 6) Body compensations associat- B) Early heel lift off on the C) When there is only uni- ed with a leg-length discrepancy long side lateral pronation include which one of the follow- C) Shorter stance phase on D) When the difference ing? the short side in limb-length is under A) Shoulder drop on short D) Increased heel eversion 2.5 cm side on the long side Continued on page 154 www.podiatrym.com SEPTEMBER 2006 • PODIATRY MANAGEMENT 153 EXAMINATION PM’s Continuing (cont’d) Medical Education CPME Program 15) A functional leg-length discrepancy due to Welcome to the innovative Continuing Education unilateral foot pronation is best treated by: Program brought to you by Podiatry Management A) A change of running surface Magazine. Our journal has been approved as a B) A new pair of shoes sponsor of Continuing Medical Education by the C) Properly posted foot orthoses D) A heel lift Council on Podiatric Medical Education.

16) It is unwise to add an in-shoe heel lift of Now it’s even easier and more convenient more than: to enroll in PM’s CE program! A) 1/8 to 1/4 inch You can now enroll at any time during the year B) 3/8 to 1/2 inch and submit eligible exams at any time during your C) 3/4 to 1 inch D) 1 to 1 1/2 inches enrollment period. PM enrollees are entitled to submit ten exams 17) The type of shoe that can best accommo- published during their consecutive, twelve–month date a heel lift is: enrollment period. Your enrollment period begins A) Loafer with the month payment is received. For example, B) Flip-flop if your payment is received on September 1, 2003, C) Open heel (backless) D) Laced your enrollment is valid through August 31, 2004. If you’re not enrolled, you may also submit any 18) Which of the following is not a desirable exam(s) published in PM magazine within the past characteristic of a heel lift? twelve months. CME articles and examination A) Minimal compressibility questions from past issues of Podiatry Man- B) Extend to the medial tuberosity of the agement can be found on the Internet at calcaneus C) Made of cork, rubber, or plastic http://www.podiatrym.com/cme. All lessons D) Capable of being adjustable in height are approved for 1.5 hours of CE credit. Please read the testing, grading and payment instructions to de- 19) Which one of the following is not a com- cide which method of participation is best for you. mon practice in using a heel lift in the manage- Please call (631) 563-1604 if you have any ques- ment of a leg-length discrepancy? tions. A personal operator will be happy to assist you. A) The initial height of the lift is about half of the anatomic discrepancy Each of the 10 lessons will count as 1.5 credits; B) It is most desirable to place a heel lift thus a maximum of 15 CME credits may be under the insole of the shoe earned during any 12-month period. You may se- C) The height of the heel lift is determined lect any 10 in a 24-month period. with the patient standing in resting subtalar joint position The Podiatry Management Magazine CME D) The heel lift height should be measured at the point where the calcaneus rests up program is approved by the Council on Podiatric on it Education in all states where credits in instruction- al media are accepted. This article is approved for 20) Operative procedures may be considered 1.5 Continuing Education Contact Hours (or 0.15 for a leg-length discrepancy greater than at CEU’s) for each examination successfully completed. least: A) 1 cm B) 2.5 cm C) 4 cm D) 6 cm Home Study CME credits now See answer sheet on page 155. accepted in Pennsylvania

154 PODIATRY MANAGEMENT www.podiatrym.com ✄ MedicalContinuing Education Enrollment/Testing Information and Answer Sheet Note: If you are mailing your answer sheet, you must complete exam during your current enrollment period. If you are not en- all info. on the front and back of this page and mail with your rolled, please send $20.00 per exam, or $129 to cover all 10 exams credit card information to: Podiatry Management, P.O. Box (thus saving $71* over the cost of 10 individual exam fees). 490, East Islip, NY 11730. Facsimile Grading To receive your CPME certificate, complete all information and TESTING, GRADING AND PAYMENT INSTRUCTIONS fax 24 hours a day to 1-631-563-1907. Your CPME certificate will (1) Each participant achieving a passing grade of 70% or be dated and mailed within 48 hours. This service is available for higher on any examination will receive an official computer form $2.50 per exam if you are currently enrolled in the annual 10-exam stating the number of CE credits earned. This form should be safe- CPME program (and this exam falls within your enrollment period), guarded and may be used as documentation of credits earned. and can be charged to your Visa, MasterCard, or American Express. (2) Participants receiving a failing grade on any exam will be If you are not enrolled in the annual 10-exam CPME pro- notified and permitted to take one re-examination at no extra cost. gram, the fee is $20 per exam. (3) All answers should be recorded on the answer form below. For each question, decide which choice is the best an- Phone-In Grading swer, and circle the letter representing your choice. You may also complete your exam by using the toll-free ser- (4) Complete all other information on the front and back of vice. Call 1-800-232-4422 from 10 a.m. to 5 p.m. EST, Monday this page. through Friday. Your CPME certificate will be dated the same day (5) Choose one out of the 3 options for testgrading: mail-in, you call and mailed within 48 hours. There is a $2.50 charge for fax, or phone. To select the type of service that best suits your this service if you are currently enrolled in the annual 10-exam needs, please read the following section, “Test Grading Options”. CPME program (and this exam falls within your enrollment peri- od), and this fee can be charged to your Visa, Mastercard, Ameri- TEST GRADING OPTIONS can Express, or Discover. If you are not currently enrolled, the fee Mail-In Grading is $20 per exam. When you call, please have ready: To receive your CME certificate, complete all information 1. Program number (Month and Year) and mail with your credit card information to: 2. The answers to the test Podiatry Management 3. Your social security number P.O. Box 490, East Islip, NY 11730 4. Credit card information There is no charge for the mail-in service if you have already In the event you require additional CPME information, enrolled in the annual exam CPME program, and we receive this please contact PMS, Inc., at 1-631-563-1604.

ENROLLMENT FORM & ANSWER SHEET

Please print clearly...Certificate will be issued from information below.

Name ______Soc. Sec. #______Please Print: FIRST MI LAST Address______City______State______Zip______Charge to: _____Visa _____ MasterCard _____ American Express Card #______Exp. Date______Note: Credit card is the only method of payment. Checks are no longer accepted. Signature______Soc. Sec.#______Daytime Phone______State License(s)______Is this a new address? Yes______No______

Check one: ______I am currently enrolled. (If faxing or phoning in your answer form please note that $2.50 will be charged to your credit card.) ______I am not enrolled. Enclosed is my credit card information. Please charge my credit card $20.00 for each exam submitted. (plus $2.50 for each exam if submitting by fax or phone). ______I am not enrolled and I wish to enroll for 10 courses at $129.00 (thus saving me $71 over the cost of 10 individual exam fees). I understand there will be an additional fee of $2.50 for any exam I wish to submit via fax or phone. Over, please 155 ✄ (cont’d) www.podiatrym.com 11. A12. B A13. C B A14. D C B A15. D C B A16. D C B A17. D C B A18. D C B A19. D C B A20. D C B A D C B D C D (Caselli) EXAM #7/06 of Leg-length Discrepancy Evaluation and Management and Management Evaluation 1. A2. B A3. C B A4. D C B A5. D C B A6. D C B A7. D C B A8. D C B A9. D C B A D C B D C D 10. A B C D LESSON EVALUATION exam Please indicate the date you completed this ______the lesson? How much time did it take you to complete ______hours ______minutes How well did this lesson achieve its educational objectives? ______Very well ______Well all ______Somewhat ______Not at lesson? What overall grade would you assign this A B C D Degree______Additional comments and suggestions for future exams: ______Circle: ENROLLMENT FORM & ANSWER SHEET & ANSWER FORM ENROLLMENT PODIATRY MANAGEMENT • SEPTEMBER 2006

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