Leg Lenght Test, Trendelenburg and Adam's Test

 

Based on the pre-screening postural assessment and the gait analysis, it has been noticed possible area of concern regarding mobility, muscle tightness and imbalances around the pelvis region. The client observational gait analysis shown a pelvic lateral tilt to the right which could be caused by a Trendelenburg gait, scoliosis or leg length discrepancy. Therefore, different tests will be performed to identify the possible causes. These tests will be the Leg-length test, Trendelengurg test and Adams test .

1. Leg Lenght Test

Leg discrepancy (LLD) is a common condition with a prevalence of 90% in general population and 40% in sport individuals (Gordon and David, 2010), and it is the result of as an anatomical unequal extremity limb length, caused by a shortening or lengthening of the bony structure (from  head of the femur to the malleolus, in the ankle); or by abnormal function in the pelvis  (Rotated pelvis) (Gordon and David, 2010). Severity of LDD will depend on the cm of difference, and discrepancies greater than 20 mm are considered mild, causing alterations in  biomechanics and loading patterns, altering posture and inducing abnormal locomotion and musculoskeletal disorders. (Applebaum et al., 2021; Shailam et al., 2013). Most common disorders are gait abnormities, scoliosis, osteoarthritis (Raczkowsk et al., 2010; Rannisto et al., 2015). Furthermore, LLD has been associated to LBP, but the literature is contradictory. Haryono et al., (2019) examined the correlation between LBP and LLD in 70 students and found LBP in 48% of the cases and LDD in 41.3%; of which 16 students had LLD. In contrast, Noormohammadpour et al., (2016) examined 28 football players and found no correlation between LLD and LBP.   

The LLD is a valid and reliable test. In a systematic review of 11 studies, Farahmand et al., (2019) reported high (ICC=0.7) to very high (ICC=0.9) interrater and intra-rater reliability. Depending on the subjects, the validity of the methodologies ranged from low to very high. The authors reported this test is valid and reliable when is not tested on obese population. Client’s length legs were measured in a lying rested supine position, from the umbilicus to the medial malleolus, and from the superior iliac spine/ASIS to the malleolus (Asim et al., 2013). The client LLD test resulted in a leg discrepancy of 0.5 cm, left-leg length was 107cm and L-length-length 107.5cm from the umbilicus to the malleolus, whirlst from the iliac spine the results obtained were R-leg 99.5cm and L-leg 99 cm.

Figure 1. Visual illustration of leg length test.

2. Trendelenburg Test 

A Trendelenburg gait is an abnormal gait characterized by a hip abductor weakness, gluteus medius and gluteus minimus weakness on the ipsilateral side of the stance leg causing a drop in the contralateral hip (Gandbhir et al., 2022; Stastny et al., 2015) (Figure 1). The Trendelenburg test allows to  assess different hip dysfunction but the interpretation of findings is controversial to establish a standardisation of a positive test (Gogu and Gandbhir, 2020). Asayama et al., (2002) defined a positive Trendelenburg test result as a pelvic tilt angle of greater than 2°, whereas Westhoff et al. (2005) defined positive as a pelvic drop in of more than 4°degrees and/or a maximum pelvic drop higher of 8°on the non-stance limb during the single-stance phase (Bailey et al., 2016).

Test is performed with the client single limb stance. A positive test will result when the pelvis on the non-stance leg drops below the stance side. Contrary, a negative test result occurs with neutral pelvic alignment  (Stevens et al., 2020). It can be observed that client drops both contralateral sides to the non-stance leg, therefore the Trendelenburg test resulted positive. This could mean that client has hip abductor, gluteus minimus and medius weakness. However, interpretation of the results must be cautelous due to false positive could be as result of possible scoliosis (Gogu and Gandbhir, 2020).

 

                                            

   Figure 2. Client performing bilateral Trendelenburg test.

3. Adam's Test

This test has been decided to be carried out due during the postural assessment the client shown a lateral pelvic tilt to the right side and the right arm is elevated which could be caused by a mild scoliosis. Furthermore, as mentioned in the Leg length test, the client R-leg was 0.5 cm longer. Therefore, Adam’s test will be performed to identify possible causes.

The Adams forward bend test (FBT) is the simplest test to screen possible scoliosis (Karpier et al., 2021; Oetgen et al., 2021). The test consists of patient bending forward until the spine is horizontal to the ground, hands facing to the client body and the practitioner stands behind seeking for back abnormalities of the spinal curve, ribs or shoulder asymmetries and determine if trunk rotates (Farhaan, et al., 2013;Karpier et al., 2021; Oetgen et al., 2021).

FBT has been subject to numerous studies that assess its reliability and validity. In a meta analysis on 5,128 students by the School Scoliosis Screening (SSS), it was found that relying on a single test is not advisable for diagnosing scoliosis. The analysis revealed an odds ratio (OR) of 2.91 and lower positive predictive values (PPV) for curves greater than 10° (OR=0.40) 23.2% vs. 38.0%), and curves greater than 20° (OR=0.34)(3.5% vs. 11.0% (Fong, 2010).

 

During the FBT in Figure 3, the client demonstrates a leftward bend, which suggests the presence of mild scoliosis. Nevertheless, to avoid false positive results, it is advisable to conduct a follow-up test in a few weeks. Based on the initial test, it is possible that the client's lateral pelvic tilt and leg length discrepancy are due to the mild scoliosis. Confirmatory identification of the asymmetry is recommended through an X-ray examination.

  References:

Applebaum, A., Nessim, A. and Cho, W. (2021) ‘Overview and spinal implications of leg length discrepancy: Narrative review.’ Clinics in Orthopaedic Surgery, 13(2), p. 127.

Asayama, I., Naito, M., Fujisawa, M. and Kambe, T. (2002) ‘Relationship between radiographic measurements of reconstructed hip joint position and the Trendelenburg sign.’ The Journal of Arthroplasty, 17(6), pp. 747–751.

Asim, H.M., Qayyum, A., and Hashim, J.A., (2013) ‘Leg length discrepancy; the reliability of tape measure method.’ Professional Medical Journal, 20 (6), pp. 995-998.

Bailey, R.W., Richards, J., and Selfe, J. (2016) ‘A Biomechanical Investigation of Selected Lumbopelvic Hip Tests: Implications for the Examination of Walking.’ Journal Manipulative Physiology Therapy, 39(6), pp. 411-419.

Farahmand, B., Ebrahimi Takamjani, E., Yazdi, H.R., Saeedi, H., Kamali, M., and Bagherzadeh Cham, M. (2019) ‘A systematic review on the validity and reliability of tape measurement method in leg length discrepancy.’ Medical Journal Islam Republic of Iran, 26, pp. 33:46.

Fong, D.Y.T., Lee, C.F., Cheung, K.M.C., Cheng, J.C.Y., Ng, B.K.W., Lam, T.P., Mak, K.H., Yip, P.S.F. and Luk, K.D.K., 2010. A meta-analysis of the clinical effectiveness of school scoliosis screening. Spine, 35(10), pp.1061-1071.

Gordon, J. E. and Davis, L. E. (2019) ‘Leg length discrepancy: The natural history (and what do we really know).’ Journal of Pediatric Orthopaedics, 39(Supplement 1). 

Haryono, I. R., Kawilarang, M. and Prastowo, N. A. (2019) ‘Leg length discrepancy in college students and its association with low back pain: A preliminary study.’ Journal of Anthropology of Sport and Physical Education, 3(2), pp. 15–18.

Healey, K. C., Hatfield, D. L., Blanpied, P., Dorfman, L. R. and Riebe, D. (2014) “The effects of myofascial release with foam rolling on performance.” Journal of Strength and Conditioning Research, 28(1) pp. 61–68.

Karpiel, I., Ziębiński, A., Kluszczyński, M.,and Feige, D.(2021). A Survey of Methods and Technologies Used for Diagnosis of Scoliosis. Sensors, 21(24), pp. 8410. 

Macdonald, G.Z., Button, D.C., Drinkwater, E. J., & Behm, D.G. (2014). Foam rolling as a recovery tool after an intense bout of physical activity. Medicine and Science in Sport and Exercise, 46(1), 131-142.

Noormohammadpour, P., Khezri, A. H., Linek, P., Mansournia, M. A., Hassannejad, A., Younesian, A., Farahbakhsh, F., and Kordi R. (2016) ‘Comparison of lateral abdominal muscle thickness and cross-sectional area of multifidus in adolescent soccer players with and without low back pain: A case control study.’ Asian Journal of Sports Medicine, 7(4), pp.e38318.

Oetgen, M.E., Heyer, J.H. and Kelly, S.M., 2021. Scoliosis screening. JAAOS-Journal of the American Academy of Orthopaedic Surgeons, 29(9), pp.370-379.

Raczkowski, J.W., Daniszewska, B., and Zolynski, K. (2010) ‘Functional scoliosis caused by leg length discrepancy’. Archives of Medical Science, 6(3), pp. 393–398. 

Rannisto, S., Okuloff, A., Uitti. J., Paananen, M., Rannisto, P.H., Malmivaara, A., and  Karppinen, J. (2015).  Leg-length discrepancy is associated with low back pain among those who must stand while working. BMC Musculoskeletal Disorders, 7;16, pp.110.

Stastny, P., Tufano, J. J., Lehnert, M., Golas, A., Zaatar, A., Xaverova, Z. and Maszczyk, A. (2015) ‘Hip abductors and thigh muscles strength ratios and their relation to electromyography amplitude during split squat and walking lunge exercises.’ Acta Gymnica, 45(2), pp. 51–59.

Stevens, W. R., Jo, C.-H., and Tulchin-Francis, K. (2020). ‘Clinically derived biomechanical criteria for the Trendelenburg test.’ Clinical Biomechanics, pp.105066.