腿长不等的评估、临床意义和神经调控康复治疗

《绝地大师疼痛康复专题课程系列1.0》

第二十五讲 腿长不等的评估、临床意义和神经调控康复治疗

Assessment and clinical significance of leg length discrepancy

1. Facts about leg length discrepancy (LLD) 腿长不等(LLD)的事实

90% of population has some variance of LLD due to bony variance with 20% with a LLD of > 9mm – Chiropractic Osteopathy 2005 90%的人群由于骨骼变异而有一定的腿长差异，20%的LLD为>9mm——脊骨神经整骨学，2005年

Two types of LLD: structural and functional 两种类型的LLD：结构性和功能性

Average LLD is about 11 mm 平均LLD约为11毫米

Shorter limbs carry an increased risk of knee osteoarthritis 较短侧腿会增加膝骨关节炎的风险

Longer limbs can carry a greater incidence of stress fractures 较长侧腿可能有较大的应力骨折发生率

2. Clinical key to remember 要记住的临床关键

LLD may not matter at all LLD可能不重要

Most people adapt and even in significant LLD this may not be a problem 大多数人适应，甚至在明显腿长差异中，这可能也不是一个问题

However it is key to understand the possible cascade effects of LLD in along the kinetic chain and in the MSK system itself 然而，了解LLD在沿动力学链和肌骨系统本身中可能的级联效应是关键的

LLD is most commonly recognized during postural or gait assessment 在姿势或步态评估中，LLD最常被识别

3. Types of leg length discrepancy 腿长不等的类型

Structural: congenital, post-trauma, post-surgery 结构性：先天性、创伤后、手术后

Functional: due to joint or muscle contractures 功能性：由于关节或肌肉挛缩（疼痛跛行）

4. Structural LLD 结构性腿长不等

右侧腓骨缺失，左侧应力性骨折。

5. Structural leg length – spinal effects 结构性腿长 – 脊柱影响

左侧骨盆下降，鞋垫上推使骨盆水平。

6. Structural LLD causes DJD, fracture 结构性LLD导致退行性关节病变、骨折

7. LLD after hip replacement 髋关节置换术后LLD

Journal of Bone and Joint Surgery reported 18% of THA patients had an increase of leg length of 18% of more than 1.5cm. 骨与关节外科杂志报道，18%的THA患者腿部长度增加，18%超过1.5cm。

LLD of up to 10mm is well tolerated by patients according to the clinical orthop related res. 根据临床骨科学相关研究，患者LLD达到10mm可很好耐受。

Most LLD after surgery result from improper equipment selection before surgery. 大多数LLD手术后LLD的原因是手术前植入物选择不当。

8. Functional LLD 功能性LLD

Causes of functional LLD 功能性LLD的原因：

Nerve injury – foot drop 神经损伤-足下垂

Knee contracture following ligament injury going untreated. 韧带损伤（ACL）未治疗后的膝关节挛缩。

Type 2 diabetes due to proprioceptive effects 2型糖尿病影响本体感觉

Chronic muscle tightness due to injury 因损伤引起的慢性肌肉紧张

Pain: antalgic adaptations ie. Limping 疼痛：避痛适应，即跛行

9. Consequences of pathomechanics 病理力学的结果

Maladaptions to LLD LLD的适应不良：

Muscle adaptation, inhibition, taut bands, trigger points etc 肌肉适应、抑制、紧绷带、激痛点等

Joint degeneration in the shorter limb 较短腿关节退变

Scoliotic curves 脊柱侧凸曲度

Risk of falling 跌倒风险

10. NORMAL GAIT 正常步态

EACH STEP IS A UNIQUE EVENT IN TIME 每一步都是一个独特的事件

FORCES ARE ABSORBED DIFFERENTLY EACH AND EVERYTIME 每次力量被吸收都不一样

THIS PRESERVES JOINTS AND SURROUNDING SOFT TISSUE 这样可以保护关节和周围软组织

NORMAL GAIT IS CHAOTIC 正常步态是混乱的。

11. COMPENSATORY GAIT 代偿步态
LIMPING IS PREDICTABLE 跛行是可预测的。

EACH STEP FOLLOWS THE SAME PATTERN 每一步都遵循相同的模式。（足跟着地时中足锁定）

OVER TIME THE JOINTS AND SURROUNDING TISSUES ARE UNABLE TO ADAPT TO THE REPEATED FORCES AND THE TISSUE BEGINS TO CHANGE. 随着时间，关节和周围组织无法适应重复力量，组织开始改变。

IE. CONTRACTION OF FASCIA, REDUCTION OF BLOOD FLOW, ADDITION OF NEUROGENIC INFLAMMATION – ALL RESTRICT ACCESSORY MOVEMENTS 例如，筋膜收缩、血流减少，加上神经源性炎症-所有这些都限制附属运动。（运动链向上膝髋腰）

12. Joint variability 关节可变性

（1）Optimal 最佳:

Chaotic structure, healthy State of movement. Forces are absorbed and dispersed correctly.混乱性结构，健康的运动状态。力被正确吸收和分散。

（2）Rigid 僵硬:

Stiff, repetitive, unchanging ie. Limpling. 僵硬、反复、不变的，即跛行。（退变、融合关节）

（3）Greater than optimal 大于最佳

Unpredictable, an injured ankle that provides incorrect proprioceptive info after trauma. 不可预测，受伤踝在创伤后提供不正确的本体感觉信息。

13. Entry points of energy 能量进入点

Direction of movement that joints encounter during a primary movement. Ie: during shoulder flexion the joint slides slightly before going into flexion. 关节在一个主要运动中的运动方向。即：在肩关节屈曲时，关节轻微滑动，然后进入屈曲。

This slide is referred to as an accessory movement 这里指附属运动。

As entry joint points become injured they reduce their ability to use accessory movement – resulting in the abnormal absorption and dispersement of energy along the kinetic chain. 当进入关节点受损伤时，它们降低了它们使用附属运动的能力——导致沿动力学链的能量异常吸收和分散。

Under normal circumstances, walking should be a unique and different movement with every step 在正常情况下，走路的每一步应该是一种独特而不同的运动。

14. Assessment of LLD 腿长不等的评估

（1）How to measure structural LLD 如何测量结构性LLD

Length of leg: from ASIS to medial malleolus 腿长：从ASIS到内踝

Determine if femur is longer from positioning yourself on the side of the table 确定股骨是否较长，自己在床侧

Determine if the tibia is longer from positioning yourself at the foot of the table 确定胫骨是否较长，自己在足侧

（2）Measuring true LLD 测量真正的LLD

腿长：ASIS，内踝中点

（3）Comparing femur to tibia in LLD 在LLD中比较股骨到胫骨

Side view 侧面观

股骨：立膝，双足平，站床侧，尺放膝前，股骨长侧伸出

Foot table view 床尾观

胫骨：站足侧，双足平，尺放膝上，高侧胫骨长

15. Gait in leg length discrepancy 在腿长不等中的步态

（1）GAIT ASSESSMENT 步态评估：

1. GENERAL SYMMETRY/ASYMMETRY 全身对称性/非对称性（一侧肩低，跛行）

2. ARM SWING/STRIDE Length 手臂摆动/步幅（平衡/本体感觉下降，手臂摆动/步幅下降）

3. FLOW/RHYTHM OF GAIT 步态的流畅/节律（特别治疗后）

（2）Observing the effects of uneven gait 观察不均匀步态的影响

Changes in posture due to adaptation 因适应而改变姿势

Increased forces on joints in the shorter leg 在短腿的关节上增加力量

Adaptive gait in the frontal 在额状面的适应性步态

Alternation of stride length and arm swing 跨步长度和手臂摆动的替代

（3）演示

手臂摆动下降。

短腿：1英寸

增加手臂摆动，改善平衡；步幅增加；旋转代偿。

后筋膜链与后斜向筋膜链交汇。

右短腿引起左ST抑制或功能障碍。

（短腿对步态的影响）

16. lower extremity – stability 下肢-稳定性

Hip flexors 髋屈肌群：Psoas 腰大肌（紧张，腿长变短）；Iliacus 髂肌；Pectineus 耻骨肌

Abductors 外展肌群（抑制：适应性，足跟垫）：TFL 阔筋膜张肌；Glut med 臀中肌；Glut min 臀小肌

Adductors 内收肌群：Longus / brevis (5°) 长/短肌；Magus (30°) 大收肌

Extensors伸肌: Glut max 臀大肌

Obliques: IO/EO 腹斜肌：内斜/外斜

（如何快速评估下半身功能（活动性和稳定性）？）

17. ACCESSORY MOVEMENTS = JOINT GLIDE 附属运动=关节滑动（骨间运动，运动前滑动）

Sagittal 矢状面：前后

Transverse 横断面：侧向

Frontal 额状面：上下

18. ASSESSMENT GUIDE OF ACCESSORY GLIDE 附属滑动的评估指南

FLEXION/EXTENSION & INVERSION/EVERSION 屈曲/伸展和内翻/外翻

FRONTAL PLAY 额状面滑动

TORSIONAL PLAY 扭转滑动（踝至中足）

19. GAIT: LOCKED & UNLOCKED 步态:锁定和解锁
HEEL STRIKE: THE FOOT/ANKLE EVERT WHICH LOCK THE SUBTALAR JOINT (BLUE) AND UNLOCKS THE MIDFOOT (RED) 脚跟着地：足/踝关节外翻，锁定距下关节(蓝色，稳定)，解锁中足(红色，准备吸收力量)（本体感觉缺失踝扭伤，足跟着地时距下关节不及时锁定，足内翻扭伤）

SWING PHASE: AS THE FOOT AND ANKLE SWING THROUGH THE AIR THE SUBTALAR JOINT (BLUE) INVERTS WHICH UNLOCKS THE JOINT AND CAUSES THE MIDFOOT (RED) TO LOCK 摆动相：当足和踝在空中摆动时，距下关节(蓝色)内翻，解锁关节，并导致中足(红色，跗横关节)锁定（帮助推进）

20. Treatment options for LLD LLD的治疗选项

（1）Correcting motor inhibitions 纠正运动抑制

Lower extremity scan determines inhibitions 下肢筛查确定抑制

Upper extremity scan may be prudent because posterior torsional line adaptation is in play. Ie. Right short leg will affect left shoulder girdle 上肢筛查可能是明智的，因为后扭转线适应正在发挥作用。即，右短腿会影响左侧肩带

In general the muscles involved are the psoas, gluteus maximus, medius, serratus anterior, quadratus lumborum 一般来说，涉及的肌肉是腰大肌、臀大肌、臀中肌、前锯肌、腰方肌

（2）Psoas pecking: lumbar plexus neuromodulation 腰大肌轻啄：腰丛神经调控

Lumbar plexus 腰丛：T12-L5；LFCN, lateral femoral cutaneous nerve 股外侧皮神经：F, femoral 股神经；O, obturator (anterior / posterior) 闭孔神经（前/后）

通过腹直肌筋膜。

（深部筋膜链（1）-腰大肌轻啄）

（3）EPE technique: when to use it and why? 能量进入点技术：何时和为何使用？

After we restore motor activation, after we address the trophic changes in tissue due to maladaption, and after we restore local soft tissue mechanics – we must keep in mind the incoming forces at the entry points of energy. 在我们恢复运动激活，处理了由于适应不良引起的组织营养性改变，并且恢复局部软组织力学后——我们必须记住能量进入点的传入力（附属运动）。

Learning to address the foot/ankle in the lower extremity and the wrist/hand will be necessary to remove maladaptations. 学习处理下肢的足踝和手腕将是必要的，以消除适应不良。

I use it whenever the patient presenting to me has had the problem for 3 months or greater. 每当患者出现问题超过3个月时，我就使用它。

（参见《足踝功能障碍的附属运动和康复治疗》）

（4）When to add a lift 何时增加足垫

Runners with greater than 3mm LLD should use a lift. 跑步者LLD大于3mm应使用足垫。

Martens et al, recommend a lift in anything over 6mm Martens等，建议在任何超过6mm中使用足垫

Large discrepancies of one inch (25.4mm) or more should be added gradually. ¼ inch (6mm) every four weeks until symptoms abase 差异大于一英寸(25.4mm)应逐渐增加。每四周¼英寸（6mm），直到症状减轻。

（5）Lift caveats 足垫说明

Ideally lift should cover entire length of foot 理想情况下，足垫应该覆盖整个足长（不只足跟）。

A calcaneal lift will decrease activation of the gastrocnemius and tibialis anterior muscles. 跟骨足垫会降低腓肠肌和胫前肌的激活。

The greater the lift, the greater the inhibition of these muscles over time 垫高越多，随着时间的推移，这些肌肉的抑制越大。

If lifts are added, make sure to address the motor points of these muscles on each visit 如果增加了足垫，确保在每次就诊时处理这些肌肉的运动点。

21. 总结

1. 不要认为有长短腿就是问题，纠正长短腿不是唯一解决方案。

2. 长短腿会发生，会影响肌骨系统。

3. 始终要做功能性评估并治疗患者以改善功能，未必需要足跟垫。