Validity of Derived Measurements of Leg-Length Differences Obtained by Use of a Tape Measure Paul Beattie, Kale Isaacson, Dan L Riddle

and Jules M Rothstein PHYS THER. 1990; 70:150-157.

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Validity of Derived Measurements of Leg-Length Differences Obtained by Use of a Tape Measure

Determining the dzference in the length of an individual's legs is often an important component of a musculoskeIetal emmination. Although measurements are easily obtuined with a tape measure, the valdity of these measurements is not known. 7 3 e p u q a e of this study was to emmine the validity of determinations of leg-lengthdzferences (LLDsj obtained by use of a specified tape measure method (TMM).Leg-length dz$eences using the T M and a radiographic technique were M determimd for 10 subjects who were candidatesfor clinical leg-length measurements and for 9 healthy control subjects. Validi41 the TMM measurements was of determined by messing the degree of agreement between TMM-obtained LLDs and those obtained by the radiographic method. Validity estimates as determined by inh-acluss cowelation coeficients (ICG) were ,770for patients, ,359for healthy subjects, and ,683for all subjects. W e n the means of the two values obtained by use of the TMM were compared with the radiographic measurements, the ICCs w e .85;?for the patient group, ,637for the healthy subjecrs, and ,793for all subjects. Thk study suggests that TMM-derivedLLD measurements are tlalid indicators of leg-length inequality and that the estimates of validity are improtled by using the average of two determinations rather than a single determination.[Beattk P, Isaaaon f( Riddle DL, et al: Validity of derived measurements of leg-length d z m ences obtained by use of a tape measure. Phys Ther 70:150-157, 19901
Key Words: Lower extremity, general; Musculoskeletal system; Radiography; Tests and measurements,functional.

Paul Beattie Kale lsaacson Dan L Riddle Jules M Rothstein

Leg-length differences (LLDs) are thought to contribute to the occurrence or severity of many clinical syndromes.l.2Among these conditions low back pain,+' saare sc0liosis,3~4 croiliac painF.9 and a variety of running injuries.lOJ1 However, the degree

of LLD that is clinically significant remains controversial. Subotnick has reported that a dfierence of as little as 3 mm is significant,"J whereas Anderson has stated that a difference of less than 19 mm is acceptable.12 Summaries of various authors' opin-

P Beattie, kIS, PT, is Instructor, Division of Physical Therapy, Department of Orthopedics, School of Medicme, University of New Mexico, Albuquerque, N 87131 (USA). M
K Isaacson, PT, is Staff Physical Therapist, Sports Physical Therapy and Rehabilitation, 2607 Wyoming, Albuquerque, N 87112. At the time this study was conducted, he was a student in the DiviM sion of Physical Therapy, University of New Mexico.

D Riddle, hlS, PT, is Assistant Professor, Department of Physical Therapy, School of Allied Health Professions, Medical College of Virginia, Virginia Commonwealth University, PO Box 224, MCV Station, Richmond, V 23298 A
J Rothstein, PhD, PT, is Associate Professor, Department of Physical Therapy, School of Allied

ions regarding clinically significant LLDs are shown in Table 1. The opinion of what constitutes a "significant LLD" appears to be diagnosis specific. For example, Subotnick considers a difference of 3 mm significant enough to warrant a shoe lift for the treatment of running-related injuries.10 Giles suggests that an LLD of greater than 9 mm could cause enough of a change in the angle of the lumbar facet joints to contribute to the development of back pain.13 Papaioannou et a1 report that an LLD of greater than 22 mm causes significant compensatory scoliosis.3 The association of LLD with many clinical syndromes has made determination of LLDs an important pan of musculoskeletal examinations. There 1501 13

Health Prof'essions, Medical College of Virginia, Virginia Commonwealth University. Thir article was s~rbtnitted April 12, 1989; was with the authon fot. revisionfor 11 week; and was accepted N~vember 1989. 3,

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Table 1 . Leg-Length~ ~ e r e n c(LLDs) Considered Clinically SigniJicant es

LLD (mm)

block-method measurements differed from the radiographic measurements in the determination of which leg was shoner. Other techniques have been described for the clinical measurement of LLD. Among these techniques is the use of a measurement screen.21 The use of a level with moveable arms to approximate the level of the iliac crests" or the level of the anterior superior iliac spines (ASISs)'3 has also been described. There is, however, no evidence supporting the validity and reliability of U D measurements obtained by use of these methods. An additional drawback to using these methods is that they are impractical because they require instruments that are not usually readily available to physical therapists.
A frequently described method for

Comment
According to Subotnick,lo LLD of 3 mm or greater can cause injury to runners. According to Friberg,s LLD of 5 mm or greater leads to biomechanical compensations in the spine. According to Brody,ll LLD of 6 mm or greater can cause injuries to runners. According to Corrigan and Maitland,' LLD of less than 7 mm rarely causes symptoms. According to Giles,l3 LLD of 9 mm or greater causes changes in the angle of lumbar facets. According to Cyriax,s LLD of 10 mm or greater contributes to the development of back pain. According to Gibson et al,4 LLD of 15 mm or greater can cause compensatory scoliosis in the standing person. According to Vogel,l LLD of greater than 20 mm requires lower extremity compensation. According to Papaioannou et a1,3 LLD of greater than 22 rnm causes significant scoliosis. According to Ingram14 LLD of greater than 40 mm often requires surgical correction.

is, however, no universally accepted clinical method for measuring LLD.I4 Determining leg lengths by taking measurements from radiographs and then calculating the difference is generally considered to be the most accurate method for determining leglength inequality.l5-l7Because of their cost, however, radiographs are impractical for determining UD, and radiography exposes the subject to the adverse effects of radiation.17 Therefore, other methods are more often used clinically. Therapists often use simultaneous palpation of both iliac crests of a standing subject to determine LLD. The relative heights in the frontal plane of each crest are then 0bserved.8~~~~~9 this method Although is easy to perform, intratester and intenester agreement has been shown to be lacking.15.18A modified version of this method requires placing narrow blocks (block method) under the observed shoner leg until the iliac Woercrest heights are le~el.1~10~~9~2~ man and Binder-Macleod studied the usefulness of the block method on a 14/151

sample of five subjects.20 They compared radiographic and block-method measurements using an F test and a t test to determine whether the mean measurements obtained with both methods differed significantly. Tests of dfierences such as the t test or F test do not indicate the degree of agreement between repeated measurements. Therefore, conclusions regarding the degree of agreement of the measurements taken in the Woerman and Binder-Macleod study cannot be made. Friberg et a1 used the block method to determine the presence and degree of LLD in 21 patients with low back pain." The authors compared measurements obtained with the block method with those obtained from radiographs. They used only descriptive statistics to repon the degree of agreement between radiographic and block-method measurements. The average intratester error when comparing radiographic with block-method measurements was 5.8 mm. The authors also reported that, approximately 13% of the time, the

assessing LLD requires the use of a tape measure (TMM) to determine the distances from the ASISs to the aloil-71.0'' medial m l e l . 5 l . 9 2 . P 7 Subjects are usually measured while they are positioned supine. Eichler described several potential sources of error when measurements are obtained using the TMM.'6 Differences in the circumferences of the two legs could contribute to distance differences, as could unilateral deviations along the long axis of the leg (eg, genu valgum, genu varum). In addition, Eichler suggested that pelvic asymmetries and difficulty identifying bony prominences by palpation could contribute error to these measurements. Beattie and colleagues conducted a preliminary study using an operationally defined TMM identical to that used in this study to examine the reliability of TMM meas~rements.~7 They were attempting to eliminate error attributable to the sources identified by Eichler. Two examiners obtained repeated measurements of UD on 50 subjects, 38 of whom were patients who were considered clinical candidates for leg-length measurement (eg, they complained of low back or lower

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extremity dysfunction). The authors observed good intrarater reliability (ICC[1,1] = .807) and fair interrater reliability (ICC[l,I.] = ,668) when comparing the first measurements obtained by each examiner. When they compared the mean values of paired measurements, the interrater reliability rose considerably (ICC = .910). These results agree with those of other researchers who found that reliability of TMM-obtained measurements improved when the means of reoeated measurements were

Subject Number
1 2 3 4 5

Table 2. Characteristics of Patient Group (n = 10)

Age (Yr)
34 60 36 28 50 26 27 28 25 27

Sex
F

Height (cm)
168 170 168 203 183 180 175 193 178 178

Welght (kg)
61 68 77 100 86 95 70 86 79 69

Dlagnosls
tibia1 plateau fracture low back pain, osteoarthritis slipped epiphysis of femoral head tibia1 dysplasia femoral fracture distal tibia-fibula fracture low back pain low back pain, sacralization femoral fracture low back pain

F F
M M M

Encouraged by the results of the preliminary study, we conducted this study to determine the validity of LLD measurements obtained with the TMM as compared with LLD measurements obtained radiographically. In addition, we wanted to determine whether the mean values of paired measurements obtained by the TMM are a more valid indicator of LLD than are single measurements.

6 8 9 7

M
M M F

Table 3. Characteristics of ~ o m t a Group (n = 9) l

Subject Number Age (Yr) Helght (cm) Weight (kg)

Sex

Method
Subjects
Ten subjects, ranging in age from 25 to 60 years (X = 34.1, s = 11.2), participated in this study as the "Patient" Group. Each of these subjects had a history of LLD or a recent history of lower extremity, pelvic girdle, or spinal dysfunction that required medical care. These subjects, therefore, were considered candidates for the clinical assessment of LLD. A description of the Patient Group appears in Table 2.
A second group consisting of nine

validity of measurements obtained with use of TMM on healthy subjects, therefore, would be of value. If a subject in either group was known to be pregnant or was late menstruating, she was excluded from the study because of the potential risk of exposure to radiation. All subjects were instructed in the risks and benefits of participating in this study and signed a written consent statement approved by the Human Research Review Committee of the School of Medicine, University of New Mexico.

Procedures Radiographic measurements. Our radiographic leg-length measurement technique was based on use of the mini-scanogram.*8Subjects were positioned supine on standard radiographic tables with a large radioopaque ruler placed under their right lower extremity. An x-ray tube was centered perpendicularly over the subject's right hip, and the first x-ray film was exposed. The tube was then centered over the subject's knee and finally over the subject's ankle while the second and third x-ray films were exposed (Fig. 1). The ruler was then moved under the subject's left lower
152/15

healthy subjects, ranging in age from 22 to 34 years (X = 26.5, s = 3.7), also panicipated in this study, as the "Normal" Group. None of these subjects had a history of known LLD or lower extremity, pelvic girdle, or spinal dyshriction that required medical care. A description of the Normal Group appears in Table 3. These subjects were included because asymptomatic individuals are often evaluated for LLD during preemployment or preathletic screening examinations. The

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track

Exposure 1 (hip)

Exposure 2 (knee)
8)\

' L 7

'--

7
\1

Exposure 3 (ankle)
'y-

bone length.20z2e Therefore, we believe that the measurements obtained from the mini-scanograms were appropriate to use as criteria to examine the validity of measurements obtained with the TMM.

' e
- ' a

,/? ,e
lead-marked ruler

Measurements with the tape measure. All TMM measurements were obtained by one person (PB). During each measurement session, subjects wore a pair of shorts or a hospital gown. The subjects' lower extremities were exposed from the level of the midthigh to their feet. Subjects were positioned supine on a plinth. The examiner positioned the subject's lower extremities in neutral hip rotation as determined by observation. The examiner then placed the subject's medial malleoli together so that they met in a plane that approximated the midsagittal line of the body. The subject's hip and knees were, therefore, in a position that closely approximated the anatomical position.
The examiner stood on the same side of the plinth as the limb he was measuring. The examiner held a blank tape measure between the thumb and the first finger of his hand nearest the subject's pelvis. With the same hand, he used his thumb to palpate the subject's ASIS. One end of the tape measure was placed on the ASIS at the site where the examiner believed he could palpate the origin of the sanorius muscle on the inferior portion of the ASIS. With the hand opposite to that holding the tape measure on the ASIS, the examiner gradually guided the tape down the anteromedial aspect of the subject's thigh, patella, and lower leg until he made contact with the point where the subject's medial malleolus sloped inferiorly and laterally (Fig. 3). The examiner then held the tape taut and lifted it away from the subject. Another person recorded the value from the opposite surface of the tape. The examiner then repeated the same procedure on the subject's opposite lower extremity. Following this procedure, the subject was asked to stand and to move about for approximately one minute in whatever manner was

Fig. 1. Illustration of three radiographic exposures wed in mini-scanogram.X-ray

tube i s on moveable track that allous exposures to be obtained with tube positioned

above hip, knee, and ankle of supine subject.

extremity, and the procedure was repeated for that extremity. A licensed, boardcertified radiologist supervised this portion of the study and examined all radiographs for pathology. The mini-scanograms when placed together show the hip, knee, and ankle with the ruler clearly visible, which allowed for measurements of leg length (Fig. 2). Leg length (U) was calculated by subtracting the value visible on the ruler at the superior margin of the head of the femur from the value seen at the midportion of the joint space between the distal tibia and the superior margin of the talus. (For example, the marking at the tibiotalar joint space was 101 cm and the marking at the head of femur was 16 cm; therefore, U = 101 - 16 = 85 cm.) The preliminaq study indicated we could reliably measure LLD with a tape measure. However, because we did not know whether we could

obtain reliable measurements from the mini-scanograms, we examined reliability of these measurements as part of our method. Unless these measurements were reliable, it would not be reasonable to use the miniscanogram measurements as criteria in a validity study. Interrater reliability for measurements from the mini-scanograms was determined from the measurements taken by two of the authors (PB and KI). They independently measured the leg lengths and calculated the LLDs. Intraclass correlation coefficients (ICC[l,l]) were used to estimate agreement between the LLD meas~rements.~9 The ICC for the 19 paired measurements taken by the two observers from all subjects was ,993. The ICCs revealed that the measurements of UD obtained from the miniscanograrns were highly reliable between the two examiners. The measurements obtained from miniscanograms are commonly accepted as valid indicators of lower extremity

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repeated measurements. We did not use random pairs of testers to take measurements in this study. However, this ICC formula does not exclude error attributable to the testers, whereas other forms of the ICC do factor out error attributable to different examiners. Based on our clinical experience, dltferent clinicians may measure LLD in the same patient; therefore, differences between examiners may be a potential source of error. By using this formula (1,l) for calculation of the ICC, we did not exclude error attributable to the testers. We believe this version of the statistic provides the most clinically meaningful estimate of the amount of error associated with LLD measurements. The ICC was used to estimate agreement between LLD measurements obtained with the mini-scanograms and the TMM. Although the absolute values of the leg lengths obtained using the two techniques would be dserent, the calculated (derived) LLDs would be in agreement if the TMM measurements were valid for determining the LLD. The criterion-referenced validity of measurements obtained with the TMM was calculated in two ways. The first measurements of LLD using the TMM were compared with the measurements of LLD calculated from the mini-scanograms. The means of the paired measurements of LLD obtained by using the TMM were also compared with the measurements of LLD obtained from the mini-scanograms. Separate ICCs were calculated for the Patient Group, the Normal Group, and the pooled data from both groups. Results The values calculated for LLD from measurements obtained by the T M M and by the mini-scanogram method are presented in Table 4. The ICC values obtained by comparing the first measurements of LLD obtained by the TMM with the measurements of LLD obtained using the mini-scanogram method were ,770 for the Patient Group, .359 for the Normal Group,

Fig. 2. Mini-scanogram showing radio -opaque markings on ruler placed under subject's lower limb. comfortable and then to return to the supine position on the plinth. The same examiner then repeated the entire procedure to obtain a second pair of mt:asurements.
A positive value, therefore, indicated

that the left leg wa5 longer than the right leg. A negative value indicated that the right leg was longer than the left leg. We used the ICC (formula 1 , l ) to examine the degree of agreement for measurements taken in this study.29 This form of the ICC is typically used when random pairs of testers take

Data Analysis
The LLD was calculated by subtracting the right leg-length measurement from the left leg-length measurement.

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and .683 for the entire sample (Tab. 5). The ICC values obtained by comparing the mean values of two measurements of LLD obtained by the TMM with the measurements of LLD obtained using the mini-scanogram were ,852 for the Patient Group, ,637 for the Normal Group, and ,793 for all subjects (Tab. 5).

medial malleolus

blank tape measure

Discussion Validity of Tape Measure Method Values of Leg-Length Difference

In all cases, the second measurements obtained using the TMM demonstrated considerably greater agreement with the values from the miniscanogram than did the first TMM measurements. For example, the ICC for the first TMM measurements of the Normal Group subjects compared with the mini-scanogram measurements was ,359, whereas the ICC for the second TMM measurements compared with the mini-scanogram measurements was ,786 (Tab. 5). The reason for the difference in validity coefficients between the first and second measurements is unclear. The best validity estimate (ICC = ,852) for the Patient Group, however, was obtained by use of the mean of the TMM measurements. The finding that the mean of two measurements of LLD obtained with the TMM was the most valid measure should have been anticipated because previously we demonstrated that reliability of these measurements was enhanced by use of mean values.2' Validity is dependent o n reliability; therefore, clinicians are advised to use the mean of two TMM-obtained LLD measurements. The TMM is an indirect method for measuring leg length and then determining LLD. The starting point of measurement from the ASIS allows iilclusion of a portion of the bony pelvis Factors such as bony asymmetry of the pelvis o r pelvic obliquity, which may not actually cause an LLD, could influence the measurements obtained by using the TMM. Asymme-

Fig. 3 Illmtration of tape measure method.for obtaining leg-length measurements . of supine subject. Both legs are placed as closelv as possihle to the anatomical position. Leg-length difference i calculated ly subtracting length of left 1eg.from length of right s leg. (ASIS = anterior superior iliac spine.)

Subject Numberb

Table 4. ~eg-Length Ijifferences

Calculated from Mlnl-scanograms (cm)

Calculated by Use of TMMa (cm) First Measurement Second Measurement

"TMM = tape measure nletllod.

"~ubjects through 10 were the Patient Group, subjects 11 through 19 were the Normal Group. 1

tries in the surface contours of the thigh, knee, and lower leg (eg, asymmetries caused by swelling, muscular atrophy, or obesity) could also signifi-

cantly alter the position of the tape, leading to meawrements that would not reflect leg length.

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Table 5. Intraclass Correlatiom? for Comparisons of Leg-Length D e e n c e Alemurements Obtained by Use of Tape Measure Method (TMM) and by Use of Mini-scnnogrnnls
Flrst TMM Measurement Second TMM Measurement Mean of TMM Measurements

Group
Normal (n
=

Patient (n := 10) 9)

,770 ,359 ,683

,803 ,786 ,790

,852 ,637 ,793

All subjects (N = 19)

"Intraclass correlation coeficients were calculated using equation 1 , l of Shrout and FIeiss.j9

not be representative of many clinicians who may use this technique infrequently. We believe, however, based on the preliminary study, that clinicians can derive fairly reliable LLD measurements by using the TMM defined in this article. Future research can help clinicians by examining the reliability and validity of LiD measurements obtained on a larger sample with a larger number of therapists obtaining the measurements. In addition, studies examining inferential uses of TMM-derived measurements would be helpful.

'The results of the preliminary study

and of this study indicate that LLD measurernents obtained by use of a TMM are relatively valid when the means of paired measurements are used. These measurements, however, like all measurements, have a degree of error associated with them. In using me:aurements in the clinical setting, this error must be considered. The error associated with the measurements can only be meaningful when clinicians consider the magnitude of LI,D that they believe warrants treatment. Clinicians should know whether they are able to correctly determine which leg is shorter in patients requiring assessment of LLD. Examination of our data suggests that the error associated with LLD measurements may be highly consequential when small LLDs are noted. When TMM-derived measurements of LLD were 5 mm or less, the examiner erred in the determination of which leg was the shorter on four out of nine subjects. This error was determined by use of the data from the radiographic measurements. When TMM-derived measurements of LLD were greater than 5 mm, the examiner never made an error when determining which leg was shorter. Based on these data, therapists should be cautious when making cllinical decisions based on TMM-obtained LLD measurements of 5 mm or less. The TMM provides data relative to LLD in the supine subject. These data do not define the degree of functional

impairment created by the LLD. Our validity study showed relatively strong agreement with a criterion measure (measurements obtained by use of the mini-scanograms); we did not validate any other inferential use of the TMM measurements. Our results indicate that measurements of LLD obtained using the TMM appear to represent the same anatomical relationships that can be documented by use of the mini-scanograms. Because we examined LLDs with both the TMM method and our radiographic method in supine subjects, we cannot be sure that our measurements reflect functional LLD measurements. For example, this method does not assess structural or biomechanical asymmetries of the foot and ankle that could create an LLD during such activities as standing, walking, and running. We suggest that in addition to using TMM measurements, clinicians evaluate the effect of LLD on patients by analyzing specific functional activities (eg, walking, running, stair climbing). Therefore, although the TMM may be considered to provide valid measurements of LLD on patients, our data represent only a portion of the information necessary to make appropriate clinical decisions. The generalizability of our conclusions has some limitations. The sample size was small. Perhaps most importantly, the examiner (PB) has used the TMM technique on many occasions during the preparation for this study and in previous studies. The skill of the examiner in our study may

The measurements obtained with the TMM appear to be valid for assessing LLDs in patients when the mean of two measurements is used. Measurements are less valid when healthy subjects are measured. Given the indirect nature of this technique and the unresolved issue of what constitutes a clinically significant LLD, we believe that clinicians should not depend solely on TMM measurements for clinical decisions.
Acknowledgments

We thank James R Stevenson, MD, and Gloria Gilreath, KT, for their assistance with the radiographic part of the study and Barbara Arnstadt for her assistance in preparing this manuscript. We would also like to express our appreciation to the late Fred Rutan, MS, PT, for his assistance with this study.
References
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Validity of Derived Measurements of Leg-Length Differences Obtained by Use of a Tape Measure Paul Beattie, Kale Isaacson, Dan L Riddle and Jules M Rothstein PHYS THER. 1990; 70:150-157.

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