What is the treatment for leg length discrepancy and enthesopathy along the greater trochanters of the femur?

Management of Leg Length Discrepancy with Enthesopathy Along the Greater Trochanters

For leg length discrepancy with enthesopathy along the greater trochanters of the femur, treatment should include a shoe lift on the shorter limb to equalize leg lengths, combined with targeted hip and knee strengthening exercises to address the enthesopathy.

Assessment of Leg Length Discrepancy

Radiographic Evaluation

• Weight-bearing radiographs with a calibration rule are essential for precise measurement of leg length discrepancy 1
• Include anteroposterior (AP) projections of the hip, knee, and ankle to evaluate the complete mechanical axis 1
• MRI may be necessary in selected cases when radiographs and physical examination don't provide sufficient diagnostic information about the enthesopathy 1

Classification of Leg Length Discrepancy

• Mild: 0-2 cm discrepancy
• Moderate: 2-5 cm discrepancy
• Severe: >5 cm discrepancy 1

Treatment Algorithm Based on Severity

For Mild LLD (0-2 cm) with Enthesopathy

1. Shoe lift or orthotic insole for the shorter limb

   • Even discrepancies less than 1 cm should be addressed to prevent compensatory mechanisms 2
   • 3D printed orthotic insoles have shown improvement in joint pain and gait parameters 3
   • Shoe modifications help equalize leg lengths and improve biomechanics 1

2. Hip and knee-targeted exercise therapy

   • Strengthening exercises for the quadriceps and hip muscles 4
   • Progressive loading in both open and closed chain exercises 4
   • Focus on strengthening the entire leg to improve biomechanical function 4

3. Manual therapy for the lower quadrant

   • Addresses soft tissue restrictions and joint mobility 4
   • Helps reduce pain associated with enthesopathy

For Moderate LLD (2-5 cm) with Enthesopathy

1. Consider referral to orthopedic specialist for evaluation of surgical options 1
2. For growing children: epiphysiodesis of the longer limb may be recommended 1
3. For skeletally mature patients: shortening procedure or limb lengthening may be considered 1
4. Continue conservative management with shoe lifts and exercise therapy while awaiting surgical intervention

For Severe LLD (>5 cm) with Enthesopathy

1. Referral to orthopedic surgeon for limb lengthening procedures 1
2. May require multiple surgical interventions 1

Specific Management of Enthesopathy Along Greater Trochanters

1. Hip-targeted strengthening exercises

   • Focus on hip abductors and external rotators
   • Progressive loading to improve muscle function around the greater trochanter 4

2. Soft tissue stretching

   • Particularly for the iliotibial band and hip flexors
   • Helps reduce tension on the entheses at the greater trochanter 4

3. Activity modification

   • Temporary reduction in activities that aggravate symptoms
   • Gradual return to activities as symptoms improve

Importance of Addressing Leg Length Discrepancy

• Even small discrepancies (>5 mm) can lead to long-term pathology 5
• Hip pathology is more common in the longer limb 5
• Knee pathology has been reported in both the longer and shorter limbs 5
• Back problems tend to be more common on the shorter side 5

Monitoring and Follow-up

• Regular clinical and radiographic follow-up until symptoms resolve 1
• Monitor for improvement in pain, function, and gait
• Adjust treatment plan based on response to interventions

Potential Complications if Left Untreated

• Progressive joint pain and dysfunction
• Premature osteoarthritis in the hip and knee joints 5
• Compensatory lumbar scoliosis 2
• Gait abnormalities and increased energy expenditure during walking 3

Caution and Pitfalls

• Avoid using ankle-high devices alone for significant leg length discrepancies, as they don't provide adequate correction 4
• When using a knee-high or ankle-high device on one limb, always consider adding a shoe lift to the contralateral limb to improve comfort and balance 4
• Don't ignore even small leg length discrepancies, as they can lead to significant long-term musculoskeletal problems 5

Remember that treatment decisions should be based on the degree of leg length discrepancy, skeletal maturity, and severity of symptoms from the enthesopathy, with the goal of improving function and preventing long-term complications.