Heel Lifts: how to determine if you need them

Arthur B. Gross, DC

Hardly a day goes by that I don't talk with healthcare professionals across the country who are seeking more information on the use of heel lifts. They are aware that there is a need for them, but they aren't quite sure how to approach the problem. I hope this article helps practitioners better understand why, when and how to recommend heel lifts to their patients.

But first, lets look at why we need to even consider the use of heel lifts.

Frieberg1 has determined that about 50% of the population have uneven leg length, but found that of the low back pain patients, 75% had leg length inequality of 5mm or more. Giles2 has demonstrated that there can be a 75% reduction of low back, hip, and sciatic pain in the short leg cases of less than 10 millimeters by placing a lift under the short leg.

Kakushima3 found that patients who have leg anisomelia due to disorders in the lower extremities are at greater risk of developing disabling spinal disorders due to exaggerated degenerative change. Therefore, treatment for leg length discrepancy may be helpful in preventing degenerative spinal changes.

In the United States there are approximately 300 million people. Nachemson4 states that 88% of the population are back pain patients at one time or another. Of that 248 million people only 60% will seek professional help.

Consequentially, there are about 148.8 million back pain patients that will look for professional help, be it from the general practitioner, orthopedic specialist, osteopath, chiropractor, physical therapist, acupuncturist, etc. By using Nachemson's reasoning, one could assume that approximately 111 million people with lower back pain could possibly receive a great deal of relief if not total elimination of their back pain just by placing a heel lift of a predetermined thickness under the heel on the side of the short leg.

Unfortunately, there are very few practitioners in the healing arts who treat back pain, that fully understand the use and application of heel lifts. It is projected that approximately 3 million heel lifts were dispensed to the healing arts in 2005. Heel lifts are usually given to patients in multiples of 4.

Therefore, about 750,000 back pain patients, or .0005% of the back pain population received heel lifts as part of their regimen of care.

But according to Friberg, in his study, there probably should have been 111 million people receive a heel lift as part of the treatment of their lower back pain.

What is a Heel Lift?

A heel lift is a mechanical device which lengthens the shorter leg by a prescribed amount, thereby creating a more level platform or base for the spine to rest on.

Heel Lifts will:
  • Tend to level an inferior pelvis or sacrum due to an anatomical short leg that has initiated a scoliosis.
  • Support a rotatory scoliosis of the lumbar spine and inhibit further rotatory degradation.
  • Force a spinal change.
  • Reduce the shortening or lengthening effect of hip or knee prosthesis.
  • Improve spinal balance.
  • Improve oxygen consumption.
  • Improve gait.

When heel lifts are used effectively, the result is quicker restoration of normal contour, muscle tone, and better systemic function.

The application of heel lift therapy is a safe, non-invasive, and an inexpensive alternative to methods of treatment that have already proven unsatisfactory.

Understand that Heel Lifts are used in an effort to correct the influences of an "anatomical short leg."

Orthotics are used in an effort to correct the influences of a "functional short leg." They should be differentiated only in the weight-bearing posture.

Definitions Anatomical short leg is the difference in the length of the structures (femur, tibia & fibula, or femoral neck) from the ground to the femur head compared between the left and right leg. The causes of anatomical short leg could be from trauma, polio, birth defect, surgery, or asymmetrical growth.

Functional short leg is the difference in the alignment of the structures from the ground to the femur head compared between the left and right leg. The cause of functional short leg is usually excessive unilateral pronation of the foot or ankle, but it can also be caused by a valgus or varus unilateral knee.

History In determining when to use heel lifts it is important to take a good history and postural examination of the patient.
  • In the history phase, determine if the patients back pain is of chronic nature.
  • Have there been frequent exacerbations?
  • Has there been surgery or trauma to the hips or lower extremities?
  • What about fractures to the legs, ankles, or feet?
  • Did they have any serious falls while growing up?
  • Have they been treated for this back pain before?
  • Did the previous treatment help, but after a while the pain returned?

Patients have told me that they feel they have a short leg, or someone has told them they walk funny or with a limp. It is very important to listen to the patient then ask questions to get more detail.

Examination We have discussed why heel lifts might be needed in patient care, and that a large segment of the population has leg length inequality but only a small sampling are being properly evaluated and treated. Also it is evident that the use of heel lifts is an inexpensive, alternative type of treatment in some conditions that are brought on by anatomical leg deficiency. We now understand that Anatomical short leg is the difference in length of the lower extremity and is corrected by the use of heellifts and that functional short leg is the difference in alignment of the lower extremity and is corrected by the use of Orthotics. In order to make the differentiation you must do a standing postural examination.

Standing Weight-bearing Examination:
  • Position the patient in bare or stocking feet with their feet about 7-8 inches apart.
  • Instruct them to stand in a normal, relaxed position, with knees locked in extension.
  • Visually examine the feet and ankles to determine any excessive unilateral pronation.
  • Palpate under the arches of both left and right foot to determine any drop of the longitudinal arch or marked tenderness under the arch.
  • Look at the back of the knees and determine if there is a valgus deformity. Is there a knee flex? Any unilateral medial rotation of the knee.
  • Place your hands across the top of the iliac crest and determine if there is unleveling of the pelvis.
  • Look at the sacral dimples (over the ala of the sacrum) for unleveling.
  • Is there a flank fold? (Just above the iliac crest there may be a fold or indentation of the flank on the long leg side.)
  • Can you visualize any lumbar curvature?
  • Check lumbar range of motion. Is there more lateral bending on one side than the other? On flexion, are the lumbar erectors more pronounced on one side than the other? Also, is there a rib hump?
  • Is there an elevated scapula, is one shoulder higher than the other?
  • Is there deviation of the head or neck to one side?

If there is unleveling of the pelvis or sacral dimples, simply stand behind the patient, put your hands on the tops of the iliac crests and have the patient rock up on the lateral aspect of both feet (Fully suppinate the feet). If the pelvis levels out or the sacral dimples level out in this position then you are looking at a functional short leg and an orthotic is indicated. If the pelvis remains unleveled in that position, then an anatomical short leg is present and a heel lift is needed.

If the pelvis tends to level out, but not completely, then there is a combination of a functional and anatomical short leg. This would be an indicator for both orthotic and heel lift. If you have ruled out a functional short leg, and have determined that there is an anatomical short leg. The next step in your examination is a radiographic examination of the lumbar spine and pelvis in the weight bearing position.

Radiographic Procedure Next we will review x-ray techniques which help determine the presence of anatomical leg deficiency as well as other pelvic or spinal deficiencies. First, there are some things that need to be considered in your x-ray department.

  • Bucky or Grid should be plumb and the sides to be perpendicular to the floor.
  • Central ray to be perpendicular to the bucky or grid.
  • X-ray room floor where the patient is positioned should be level.
  • Pre-marked area for the placement of the patients heels.
  • View boxes should be plumb and perpendicular to the floor.

Radiographic examination has been determined to be the best method of determining leg length inequality. LLI can be determined by a standing film with the primary ray at the level of the femur heads to determine femur head height, or by a scanogram in which the bones of the leg are actually measured in length.

However, when evaluating a patient for a heel lift, we need to determine more than just anisomelia. We need to see the level of the pelvis, the level of the sacrum, the level of L5, the shape of L5, and the lateral deviation of the lumbar spine. The film needs to become a "blueprint" and the best methods to evaluate those areas are the following films.

Views that are needed to determine the use of heel lifts.

  1. A-P Lumbar View Positioning Foot separation - feet 7-8 inches apart Position of the knees - locked in extension Central ray- on the umbilicus at 40 inch FFD, or the xyphond process on the 72 inch FFD. Collimation should be a full 14 x 17 or 14 x 36 based upon the FFD.
  2. The A-P view will reveal femur head heights, pelvic heights, pelvic obliquity, the level of L5, and lateral deviation of the lumbar spine.
  3. Tilt up view of the sacral base. Do this view immediately after the A-P view. Tilt tube head up 30 degrees primary ray midway between the pubes and umbilicus Use an 8 x 10 inch cassette Increase kvp by 10. The tilt up view will visualize both SI joints, plateau of the sacrum, L5 disc space, and the configuration of the body of L5.
  4. Lateral Lumbar. This view shows you disc height, facet positioning, vertebral body positioning, sacral angle, and lumbar spine center of gravity.

When you evaluate these films for the purpose of using heel lifts, look at them from a structural point of view. Will a lift give the spine better balance and take the stresses off of the L4-L5, L5-S1 vertebral motor units? What is the dominant inferiority? Is it unleveling of the femur heads, unleveling of the sacrum, or unleveling of L5 that makes the spine deviate left or right? Will a lift help shift and support this patients lumbar spine back toward the mid-line? Ask yourself these questions, then you will be able to determine the approximate amount of lift to use as well as what side to use it on.

Heel lifts are not just for anatomical leg deficiency, use them if you have unleveling of the sacrum, or if the body of L5 is wedged, or there is a deficient plateau of the sacrum. These are all anatomical deficiencies and need to be addressed by some means of supporting the deficient side.

Remember, a heel lift is a mechanical device used to balance and support anatomical deficiencies. If a heel lift is applied and helps it is helping to restructure and stabilize the lumbar spine and pelvis, then it needs to remain in position.

Lifts should be increased in 2mm increments every two weeks until optimum stabilization has occurred. Post films should be taken in 4 to 6 weeks to evaluate treatment results.

In my clinical experience I have found that heel lifts from 3mm to 9mm can be used in the heels of most conventional shoes without discomfort, but higher heel lifts require a higher backed shoe, boot, or high top athletic shoe. If the patient requires more lift than 12mm it is necessary to have the sole and heel of the shoe built up. Usually half the amount of heel lift required is placed on the sole of the shoe.

1Friberg, Ora. "Clinical symptoms and biomechanics of lumbar spine and hip joint in leg length inequality"  Spine 1983
2Giles, L.G.F. Leg Length Inequality Spine 1981: Sept. 6 (5): 510-518
3Kakushima M, Miyamoto K, Shimizu K. Departments of Orthopaedic Surgery,Hirano General Hospital, Gifu, Japan. 2003
4Nachemson AL; Low Back Pain -its Etiology and Treatment Clin Med 78:18-24, 1971 Sept. 8(6):643-651