Shoe Lifts for Leg Length Discrepancy in Adults With Common Painful Musculoskeletal Conditions: A Systematic Review of the Literature

Published:December 08, 2017DOI:



      To determine whether shoe lifts effectively treat leg length discrepancy (LLD)–associated morbidities in adults with common painful musculoskeletal conditions.

      Data Sources

      Trip database, Cochrane Central Register of Controlled Trials database, PubMed database, Physiotherapy Evidence Database, and National Guideline Clearinghouse database. The search was performed in September 2017, was limited to English only, and had no time constraints.

      Study Selection

      Two reviewers independently determined study eligibility. Inclusion criteria were (1) participants ≥18 years old with musculoskeletal-related complaints and LLD; (2) a shoe lift intervention was used; and (3) the study reported on pain, function, range of motion, patient satisfaction, quality of life, or adverse events. Randomized controlled trials (RCTs) and controlled intervention, cohort, before-and-after, case series, and case report studies were included. Three-hundred and nineteen articles were screened, and 9 guidelines were reviewed.

      Data Extraction

      We extracted data pertaining to participant demographic characteristics, study setting, recruitment, randomization, method of LLD measurement, shoe lift characteristics, treatment duration, and outcome measures. We included 10 studies, including 1 RCT.

      Data Synthesis

      LLD was associated with low back pain, scoliosis, and osteoarthritis of the hip and knee. Description of LLD correction strategy was often inadequate. Study quality was very low or poor. In non-RCT studies reporting on the proportion of participants who improved with a shoe lift, 88%±3% of 349 participants treated had partial or complete pain relief (effect size range, 66.7%–100%). All 22 RCT participants receiving treatment experienced pain relief (mean pain reduction, 27±9mm on a 150-mm visual analog scale). Two of 9 guidelines recommended shoe lift use based on consensus and were of moderate-to-high quality.


      There is low-quality evidence that shoe lifts reduce pain and improve function in patients with LLD and common painful musculoskeletal conditions. High-quality research evaluating a threshold LLD to correct and a strategy to do so is necessary. Developing an appropriate comparison group to test clinically relevant outcome measures would make a valuable contribution in this regard.


      List of abbreviations:

      GRADE (Grading of Recommendation, Assessment, Development and Evaluation), LBP (low back pain), LLD (leg length discrepancy), OA (osteoarthritis), RCT (randomized controlled trial), ROM (range of motion), THA (total hip arthroplasty), VAS (visual analog scale)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Murray K.J.
        • Azari M.F.
        Leg length discrepancy and osteoarthritis in the knee, hip and lumbar spine.
        J Can Chiropr Assoc. 2015; 59: 226-237
        • Gurney B.
        Leg length discrepancy.
        Gait Posture. 2002; 15: 195-206
        • Brady R.J.
        • Dean J.B.
        • Skinner T.M.
        • et al.
        Limb length inequality: clinical implications for assessment and intervention.
        J Orthop Sports Phys Ther. 2003; 33: 221-234
        • Defrin R.
        • Ben Benyamin S.
        • Aldubi R.D.
        • et al.
        Conservative correction of leg-length discrepancies of 10mm or less for the relief of chronic low back pain.
        Arch Phys Med Rehabil. 2005; 86: 2075-2080
        • Golightly Y.M.
        • Allen K.D.
        • Helmick C.G.
        • et al.
        Symptoms of the knee and hip in individuals with and without limb length inequality.
        Osteoarthritis Cartilage. 2009; 17: 596-600
        • Harvey W.F.
        • Yang M.
        • Cooke T.D.
        • et al.
        Association of leg-length inequality with knee osteoarthritis: a cohort study.
        Ann Intern Med. 2010; 152: 287-295
        • Mahmood S.S.
        • Mukka S.S.
        • Crnalic S.
        • et al.
        The influence of leg length discrepancy after total hip arthroplasty on function and quality of life: a prospective cohort study.
        J Arthroplasty. 2015; 30: 1638-1642
        • Vaidya S.V.
        • Patel M.R.
        • Panghate A.N.
        • et al.
        Total knee arthroplasty: limb length discrepancy and functional outcome.
        Indian J Orthop. 2010; 44: 300-307
        • Bhave A.
        • Mont M.
        • Tennis S.
        • et al.
        Functional problems and treatment solutions after total hip and knee joint arthroplasty.
        J Bone Joint Surg Am. 2005; 87: 9-21
        • McCaw S.T.
        Leg length inequality. Implications for running injury prevention.
        Sports Med. 1992; 14: 422-429
        • Veterans Affairs Canada
        Leg length inequality.
        (Available at:)
        • McCaw S.T.
        • Bates B.T.
        Biomechanical implications of mild leg length inequality.
        Br J Sports Med. 1991; 25: 10-13
        • Knutson G.A.
        Anatomic and functional leg-length inequality: a review and recommendation for clinical decision-making. Part I, anatomic leg-length inequality: prevalence, magnitude, effects and clinical significance.
        Chiropr Osteopat. 2005; 13: 11
        • Reid D.C.
        • Smith B.
        Leg length inequality: a review of etiology and management.
        Physiother Can. 1984; 36: 177-182
        • Knutson G.A.
        Anatomic and functional leg-length inequality: a review and recommendation for clinical decision-making. Part II. The functional or unloaded leg-length asymmetry.
        Chiropr Osteopat. 2005; 13: 12
        • AmeriHealth Caritas District of Columbia
        Treatment of leg-length discrepancy.
        (Available at:)
        • Golightly Y.M.
        • Tate J.J.
        • Burns C.B.
        • et al.
        Changes in pain and disability secondary to shoe lift intervention in subjects with limb length inequality and chronic low back pain: a preliminary report.
        J Orthop Sports Phys Ther. 2007; 37: 380-388
        • Thakral R.
        • Johnson A.J.
        • Specht S.C.
        • et al.
        Limb-length discrepancy after total hip arthroplasty: novel treatment and proposed algorithm for care.
        Orthopedics. 2014; 37: 101-106
        • Stanitski D.F.
        Limb-length inequality: assessment and treatment options.
        J Am Acad Orthop Surg. 1999; 7: 143-153
        • Woolf S.H.
        • Grol R.
        • Hutchinson A.
        • et al.
        Clinical guidelines: potential benefits, limitations, and harms of clinical guidelines.
        BMJ. 1999; 318: 527-530
        • Bellamy N.
        • Buchanan W.W.
        • Goldsmith C.H.
        • et al.
        Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee.
        J Rheumatol. 1988; 15: 1833-1840
        • Weigl M.
        • Cieza A.
        • Harder M.
        • et al.
        Linking osteoarthritis-specific health-status measures to the International Classification of Functioning, Disability, and Health (ICF).
        Osteoarthritis Cartilage. 2003; 11: 519-523
        • Roos E.M.
        • Roos H.P.
        • Lohmander L.S.
        • et al.
        Knee Injury and Osteoarthritis Outcome Score (KOOS)–development of a self-administered outcome measure.
        J Orthop Sports Phys Ther. 1998; 28: 88-96
        • Schuit D.
        • Adrian M.
        • Pidcoe P.
        Effect of heel lifts on ground reaction force patterns in subjects with structural leg-length discrepancies.
        Phys Ther. 1989; 69: 663-670
        • Lopez R.G.
        • Jung H.G.
        Achilles tendinosis: treatment options.
        Clin Orthop Surg. 2015; 7: 1-7
        • Hennessey W.J.
        • Uustal K.
        Lower limb orthoses.
        in: Cifu D.X. Braddom's Physical Medicine and Rehabilitation. Elsevier, Philadelphia2016: 249-274
        • Hochberg M.C.
        • Altman R.D.
        • April K.T.
        • et al.
        American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee.
        Arthritis Care Res (Hoboken). 2012; 64: 465-474
        • McAlindon T.E.
        • Bannuru R.R.
        • Sullivan M.C.
        • et al.
        OARSI guidelines for the non-surgical management of knee osteoarthritis.
        Osteoarthritis Cartilage. 2014; 22: 363-388
        • Zhang W.
        • Nuki G.
        • Moskowitz R.W.
        • et al.
        OARSI recommendations for the management of hip and knee osteoarthritis: part III: changes in evidence following systematic cumulative update of research published through January 2009.
        Osteoarthritis Cartilage. 2010; 18: 476-499
        • Fernandes L.
        • Hagen K.B.
        • Bijlsma J.W.
        • et al.
        EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis.
        Ann Rheum Dis. 2013; 72: 1125-1135
      1. National Institute for Health and Care Excellence. Osteoarthritis: care and management. Clinical guideline GC177 2014.

        • Toward Optimized Practice
        Guideline for the evidence-informed primary care management of low back pain.
        Toward Optimized Practice, Edmonton2011
        • American College of Occupational and Environmental Medicine
        Hip and groin disorders.
        in: Hegmann K.T. Occupational medicine practice guidelines. American College of Occupational and Environmental Medicine, Elk Grove Village (IL)2011: 1-440
        • American College of Occupational and Environmental Medicine
        Low back disorders.
        in: Hegmann K.T. Occupational medicine practice guidelines. American College of Occupational and Environmental Medicine, Elk Grove Village (IL)2011: 333-796
        • The American College of Foot & Ankle Orthopedics & Medicine
        Prescription custom foot orthoses practice guidelines.
        The American College of Foot & Ankle Orthopedics & Medicine, Bethesda, MD2006
        • Higgins J.P.T.
        • Green S.
        Cochrane handbook for systematic reviews of interventions version 5.1.0.
        The Cochrane Collaboration, 2011 (Published online at
        • National Heart Lung and Blood Institute
        Quality assessment tool for case series studies.
        National Institutes of Health, 2014 (Published online at
        • National Heart Lung and Blood Institute
        Quality assessment tool for observational cohort and cross-sectional studies.
        (Available at:)
        • Brouwers M.C.
        • Kho M.E.
        • Browman G.P.
        • et al.
        Development of the AGREE II, part 2: assessment of validity of items and tools to support application.
        CMAJ. 2010; 182: E472-E478
        • Balshem H.
        • Helfand M.
        • Schünemann H.J.
        • et al.
        GRADE guidelines: 3. Rating the quality of evidence.
        J Clin Epidemiol. 2011; 64: 401-406
        • Liberati A.
        • Altman D.G.
        • Tetzlaff J.
        • et al.
        The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration.
        BMJ. 2009; 339: b2700
        • Sharpe C.R.
        Leg length inequality.
        Can Fam Physician. 1983; 29: 332-336
        • Bhave A.
        • Marker D.R.
        • Seyler T.M.
        • et al.
        Functional problems and treatment solutions after total hip arthroplasty.
        J Arthroplasty. 2007; 22: 116-124
        • Vekaria R.
        • Bhatt R.
        • Ellard D.R.
        • et al.
        Intra-articular facet joint injections for low back pain: a systematic review.
        Eur Spine J. 2016; 25: 1266-1281
        • Boone T.
        Metabolic cost of walking with and without a shoe lift on the contralateral foot of an immobilised extended knee.
        Aust J Physiother. 2001; 47: 141-145
        • Abdulhadi H.M.
        • Kerrigan D.C.
        • LaRaia P.J.
        Contralateral shoe-lift: effect on oxygen cost of walking with an immobilized knee.
        Arch Phys Med Rehabil. 1996; 77: 670-672
        • Kerrigan D.C.
        • Abdulhadi H.M.
        • Ribaudo T.A.
        • et al.
        Biomechanic effects of a contralateral shoe-lift on walking with an immobilized knee.
        Arch Phys Med Rehabil. 1997; 78: 1085-1091
        • Beaudoin L.
        • Zabjek K.F.
        • Leroux M.A.
        • et al.
        Acute systematic and variable postural adaptations induced by an orthopaedic shoe lift in control subjects.
        Eur Spine J. 1999; 8: 40-45
        • Vogt L.
        • Brettmann K.
        • Pfeifer K.
        • et al.
        Gait disorders - assessment and rehabilitation supported by movement analysis.
        Z Orthop Ihre Grenzgeb. 2002; 140: 561-567
        • Goel A.
        • Loudon J.
        • Nazare A.
        • et al.
        Joint moments in minor limb length discrepancy: a pilot study.
        Am J Orthop (Belle Mead NJ). 1997; 26: 852-856
        • Raczkowski J.W.
        • Daniszewska B.
        • Zolynski K.
        Functional scoliosis caused by leg length discrepancy.
        Arch Med Sci. 2010; 6: 393-398
        • Zabjek K.F.
        • Leroux M.A.
        • Coillard C.
        • et al.
        Acute postural adaptations induced by a shoe lift in idiopathic scoliosis patients.
        Eur Spine J. 2001; 10: 107-113
        • Kipp D.
        • Village D.
        • Edwards K.J.
        Effectiveness of evenup shoe-lift use among individuals prescribed a walking boot.
        J Allied Health. 2017; 46: 104-110
        • Giles L.G.
        • Taylor J.R.
        Low-back pain associated with leg length inequality.
        Spine (Phila Pa 1976). 1981; 6: 510-521
        • Friberg O.
        Clinical symptoms and biomechanics of lumbar spine and hip joint in leg length inequality.
        Spine (Phila Pa 1976). 1983; 8: 643-651
        • Helliwell M.
        Leg length inequality and low back pain.
        Practitioner. 1985; 229: 483-485
        • Gofton J.P.
        Persistent low back pain and leg length disparity.
        J Rheumatol. 1985; 12: 747-750
        • Rothenberg R.J.
        Rheumatic disease aspects of leg length inequality.
        Semin Arthritis Rheum. 1988; 17: 196-205
        • Nellensteijn J.M.
        • Nellensteijn D.R.
        • De Jong T.
        Case report: painless chronic liner dissociation of a total hip arthroplasty.
        Clin Orthop Relat Res. 2013; 471: 1769-1772
        • Delacerda F.G.
        • Wikoff O.D.
        Effect of lower extremity asymmetry on the kinematics of gait.
        J Orthop Sports Phys Ther. 1982; 3: 105-107
        • Delacerda F.G.
        • McCrory M.L.
        A case report: effect of a leg length differential on oxygen consumption.
        J Orthop Sports Phys Ther. 1981; 3: 17-20
        • Carrasco-Labra A.
        • Brignardello-Petersen R.
        • Santesso N.
        • et al.
        Improving GRADE evidence tables part 1: a randomized trial shows improved understanding of content in summary of findings tables with a new format.
        J Clin Epidemiol. 2015; 74: 7-18
        • McCarthy J.J.
        • MacEwen G.D.
        Management of leg length inequality.
        J South Orthop Assoc. 2001; 10: 73-85
        • Bettoni E.
        • Ferriero G.
        • Bakhsh H.
        • et al.
        A systematic review of questionnaires to assess patient satisfaction with limb orthoses.
        Prosthet Orthot Int. 2016; 40: 158-169
        • Squillaro T.
        • Peluso G.
        • Galderisi U.
        Clinical trials with mesenchymal stem cells: an update.
        Cell Transplant. 2016; 25: 829-848
        • Steinert A.F.
        • Rackwitz L.
        • Gilbert F.
        • et al.
        Concise review: the clinical application of mesenchymal stem cells for musculoskeletal regeneration: current status and perspectives.
        Stem Cells Transl Med. 2012; 1: 237-247