Cellulitis is a bacterial infection of the skin, most likely to affect the lower legs.

Bacteria that normally live on your skin, most commonly Streptococcus, Staphylococcus (Staphylococcus aureus) enter your body through a cut, burn, scrape, or through skin conditions like eczema or fungal infection of the foot; or another open sore. Once your skin is infected, the bacteria can spread to your lymph nodes and bloodstream, where they can cause a life-threatening infection called sepsis.

A person is more likely to develop this infection if one has one or more of the following conditions:

  • a weakened immune system from a disease or from medical treatment (ex. Chemotherapy)
  • chronic illnesses such as diabetes
  • skin conditions such as eczema or shingles
  • obesity

Symptoms of Cellulitis

  • Swelling and Redness over a large area
  • Pain and Tenderness
  • Fever
  • Blisters over the skin
  • Dimples on the Skin (Pitting oedema)

Diagnosing Cellulitis

Take the patient to the doctor right away, if you observe a large area of red swollen skin and fever, especially if you have diabetes or a weakened immune system. Cellulitis is a potentially serious condition that needs to be treated as soon as possible.

Treating Cellulitis

Cellulitis is treated with an oral antibiotic for 10 to 14 days. Symptoms should improve within one to two days but ensure that the patient completes the entire course of medicines. Stopping the medication too soon allows the most potent bacteria to survive, contributing to the development of antibiotic-resistant superbugs and setting up the possibility that your infection will come roaring back. If the patient doesn’t feel better or if the symptoms get worse while on oral antibiotics, the doctor may stronger intravenous (IV) antibiotics in a hospital. Severe cases may be treated with IV antibiotics from the start.

When cellulitis is treated early, it usually clears up completely without causing any long-term complications. However, once a person has had cellulitis, he/she is more likely to develop it again.

To prevent a future occurrence, keep your skin clean, and, if you have any wounds, be sure to disinfect and cover them properly

Evaluation and Management of Limb Length Discrepancy

Limb length difference or discrepancy (LLD), occurs when one leg is noticeably shorter than the opposite. The prevalence rates of LLD range anywhere between 40 to 90 per cent of the population.

The effects of limb length differences are related to many painful orthopaedic concerns. In the literature, researchers have noted a correlation with LLD either causing or exacerbating foot, knee, hip and back issues. There also are significant kinematic and kinetic ramifications of LLD on, how it contributes to both static stance and dynamic gait asymmetry.

Some orthopaedic texts claim that any limb length discrepancy of less than one-half cm up to 2 cm is inconsequential. However, there’s quite a bit of literature to support the likelihood that an LLD of even less than five mm can indeed cause or exacerbate many musculoskeletal issues. During pressure mapping analysis, LLDs as little as three mm affect gait symmetry. Therefore, LLD should be one of the first conditions podiatrists look for when performing a comprehensive biomechanical examination.

Structural And Functional LLDs’

Limb length discrepancies are usually classified as either being structural or functional. Structural LLDs are due to bony abnormalities or asymmetry somewhere between the talus and therefore the lumbar spine. These structural issues may be congenital but may also result in a childhood growth plate injury, other trauma or result from joint replacement surgery later in life. Functional LLDs usually result from physiologic changes in the body or biomechanical compensatory changes that occur anywhere from the foot to the lumbar spine.

Scoliosis, an abnormal lateral curvature of the spine, may be an explanation for structural or functional LLD, depending on the kind of deformity. Some patients can functionally compensate for a scoliotic LLD, which would then qualify as a functional LLD in most cases. Those patients who are unable to compensate for their scoliosis usually have a structural LLD.

Causes of LLD

  • Congenital
  • Infection
  • Post-traumatic
  • Neoplasms
  • Irradiation
  • Skeletal Dysplasia’s
  • Others

Diagnosing Limb Length Discrepancy

There are two ways to see if a patient has an LLD. one way is via clinical or physical examination. The second way is via radiographic imaging. One may accomplish this with a conventional full-length lower body standing X-ray, a three-part standing scanogram X-ray, magnetic resonance imaging (MRI) or computed tomography (CT). The latter two modalities require the patient to be in a very supine position.

Radiographic imaging is the most numerically reliable method for assessing LLD in line with the literature. The suggestion here is that the clinician should perform a clinical assessment irrespective of what the radiology report suggests about the scale of a patient’s deformity.

Clinical Examination

Clinical examination for LLD can involve two different methods: direct and indirect. For the direct way, one utilizes a tape measure to determine the distance between the anterior superior iliac spine (ASIS) and the fibular malleolus. The clinician performs this measurement with the patient supine but may do so with the patient standing. Patient body structure, weight and issues with unilateral muscle atrophy yet clinician error can all impact the outcome of direct method measurement of LLD.

Indirect method clinical measures occur with patients standing. The clinician will assess either the anterior superior iliac spine, the posterior superior iliac spine (PSIS) or both still at the level of the pelvis to determine which leg is long and which leg is short. Studies have shown that the indirect clinical LLD measure is more accurate and reproducible between clinical users than the direct measure. The indirect method also often incorporates the utilization of various thickness blocks of wood, felt or ethylene-vinyl acetate (EVA) foam to help in determining what proportion of a measurable difference, in centimetres or inches, there is between the short and long limbs.

While one usually performs this method of measure statically, combine the utilization of adhesive felt in three mm thicknesses and connect the felt to the patient’s heel(s) for a dynamic evaluation as the patient walks or runs. This process may determine if there is a mitigation of the usual clinical signs of LLD.

Clinical Signs

The other clinical signs of LLD the clinician should regularly assess beyond the methods mentioned above. for instance, one should compare shoulder height to pelvic level during gait. The high shoulder and low hip are to be on the short limb as opposed to the low shoulder and high hip on the longer limb. Checking for unilateral early heel-off during gait, even though it is not always easy to see in patients with more subtle LLDs, may be helpful. Standing hip hike testing is when the patient attempts to hike one leg and hip at a time up into their body without leaning medially or laterally away from the respective limb. The limb that he or she “feels” lifts higher towards their torso is on the short-sided limb.]

The real issue is LLDs’ create the potential for multi-level compensation throughout the upper and lower extremities. Limb length discrepancies create asymmetrical structure and performance throughout the kinetic chain. These issues can minimally or significantly affect static stance and/or dynamic gait and might result in or exacerbate the pain issues. LLDs’ and the other functional or structural conditions, of the lower extremity, are that regardless of where the primary deforming force may originate, the resulting pain will not always be in that same location. I hope that the reasons for the multi-level effects of LLD below will help clarify why this may be the case.

  • Spine

Examination of the spine is crucial during the physical exam and when the patient is in ‘stance’. Merely tracing the vertebral column as the patient faces away from you and as he or she begins to flex forward can provide you with a cursory but usually accurate idea if there are any scoliotic curvatures to take into account regarding a possible LLD.

  • Pelvis

One of the primary areas that most clinicians will seek to examine in patients whom they suspect of having an LLD is the hips or pelvic plateau. Pelvic obliquity, a tilting of the pelvis up toward the long side limb and down toward the short side limb, is characteristic for clinicians to see when examining for LLD.

  • Innominate bones

Single-sided sagittal plane rotation of the bilateral innominate bones (anterior superior iliac spine or posterior superior iliac spine) often occurs in patients with LLD. In most instances, the anterior superior iliac spine and the posterior superior iliac spine will be short on the short limb side and higher on the long limb side, causing the sacral base to become unlevel and cause functional scoliosis.

  • Hips

There can be significantly increased pressure and forces through the acetabulum of the long-sided hip joint, due to the foot and limb compensations, usually external rotation. These compensations, can uncover the head of the femur in the acetabulum and lead to a much more concentrated area of force or pressure on the smaller functioning area of the femoral head cartilage.

  • Knee

The knee on the long side may flex easily or hyperextend as compensation for LLD. The short-sided limb will usually be fully extended in ‘stance’ and can tend to flex less in ‘stance’ phase gait than the long-sided knee. Often in older patients, the knee that tends to flex easily is associated with weak quadriceps. Some older patients with knee osteoarthritis may present to the clinic with fixed knee flexion. In these circumstances, the patient has developed a structural LLD. Therefore, one should treat this deformity as the short limb in this instance.

  • Ankle

The ankle on the short limb side tends to plantarflex early to seek contact with the ground during the swing phase and into the first stance phase of gait. The chronic swing phase plantarflexion can cause weakness of the tibialis anterior, resulting in a functional restriction of dorsiflexion on the short limb side ankle.

  • Foot

The foot also pronates on the long-sided limb while the short-sided limb’s foot will tend to stay more rectus or at times be more supinated. Blake states about 80 per cent of his participants with an LLD had more calcaneal valgus on the long limb side, but 20 per cent had more calcaneal valgus on the short limb side.

  • External rotation

The foot and lower leg on the long leg side often externally rotate and exhibit a valgus heel both in ‘stance’ and in dynamic gait. during a caveat to the current, Subotnick says the short limb and foot will at times externally rotate and have a valgus heel as much or more so than the typical long sided foot or leg.

When one sees abnormal signs of LLD, sort of a high anterior superior iliac spine and low posterior superior iliac spine on the identical side, or increased rearfoot valgus on the short limb foot, the clinician will often see that other expected signs of traditional LLD aren’t in alignment either.

  • Early Heel-Off During Gait: Sign Of LLD?

Using pressure mapping to assess gait, the observation of an early unilateral heel-off isn’t always indicative of LLD. There are many other factors in a patient’s biomechanics which will mimic an early heel-off during gait. In general, during gait, patients with LLD tend to “step down” onto the short limb and “vault” over the long-sided leg. One will often see decreased stance times, step length and an increased cadence on the short-sided leg. When examining pressure mapping data, the accelerations on the short-sided limb are usually faster along with an early heel off and shorted stance phase.

One of the primary causes of an early heel-off not always associated with a short limb is a limitation of dorsiflexion range of motion of the ankle joint. Once the ankle joint has hit its functional or structural limit of dorsiflexion, then the foot rarely has the other option but to begin to off-weight the heel. the foremost reliable test for assessing ankle joint dorsiflexion range of motion is the ankle joint lunge test. Testing LLD on the table is extremely unreliable between testers. However, we should understand that repeatability of tests does matter.

  • Ankle Range of Motions causing Early Heel-Off

Van Gheluwe, Dananberg and colleagues reference functional hallux limitus causing midfoot collapse, which can also cause an early heel-off. The functional restriction of the first MPJ’s ability to dorsiflex promptly can cause a retrograde midfoot collapse, resulting in an early heel off. Clinicians regularly see this deformity with the use of pressure mapping devices. Adding modifications to a foot orthotic and an accompanying initial heel lift to alleviate the functional hallux limitus will usually also reduce this midfoot collapse.

Another potential cause of early heel-off observed in pressure mapping data is when the patient has a chronically flexed knee position or weak quadriceps that will result in the knee giving out early in the stance phase of gait.

All of those conditions can show differing degrees of heel-off during gait. they can also occur with or without a unilateral functional or structural LLD. Many foot and ankle practitioners automatically assume that any detectable LLD is related to functional LLD and that this is a result of the patient having more pronation in one foot than the other. They also wrongfully assume that merely correcting for the forefoot and rearfoot pronation via a custom orthotic prescription will make sure of this issue. Subotnick has discussed this, but there are no empirical studies to show that this approach works for all patients.

A study by Cornwall and McPoil showed that a “slight to moderate limitation of ankle passive dorsiflexion range of motion significantly alters the timing, but not the magnitude, of frontal plane rearfoot motion during walking.” I feel that one should use heel lifts to treat the ankle equinus or ankle dorsiflexion range of motion restriction to change the impaired timing. Then treat the heel position separately with varus posting. do not assume that one will always affect the other as the studies don’t necessarily show that they will every time.

Customised Orthotics In Treating LLDs

Many studies on LLD discuss the primary use of heel lifts inside shoes. In general, heel lifts alone don’t fulfil their potential for the patient. it’s probably best in most instances to use a heel lift in conjunction with a foot orthotic, AFO and/or directly add it to a shoe to maximize treatment of the LLD and overall foot function during gait.

In a 2018 article in Podiatry Today, Richie discussed the utilisation of heel lifts. one of Dr Richie’s conclusions was that the literature strongly points to the combined use of heel raise with a custom-moulded, prescription foot orthotic for issues that require the use of a heel lift.

Ultimately, using heel lifts with custom foot orthotics won’t change the actual measurable range of motion of any of the affected joints in the kinetic chain. However, the use of the custom foot orthotic with a heel lift will nearly always cause an increase in a joints’ functional range of motion, especially at the ankle joint, and to a more symmetrical functioning gait.


Limb length discrepancies are related to many different types of orthopaedic pain issues from the foot to the low back. Accordingly, clinicians must regularly assess patients for LLD during their comprehensive biomechanical examination. Using the indirect method of clinical assessment has proven to be the most reliable approach, short of radiographic studies.

Once you diagnose what variety of LLD a patient is probably going to experience, you may then often have a greater appreciation for why he or she could also be compensating up and down his or her entire kinetic chain. The kinetic and kinematic compensations can also explain other orthopaedic complaints that your patients could also be experiencing.

Finally, it’s best to treat these issues with a heel lift in conjunction with a custom-moulded prescriptive foot orthotic device and/or directly add it onto a shoe. This method of treatment is the most likely to lead to the desired outcome for your patients.


  1. Article in Podiatry Today by Dr Williams 
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  3. Woerman AL, Binder-Macleod SA. Leg length discrepancy assessment: accuracy and precision in five clinical methods of evaluation. J Ortho Sports Phys Ther. 1984;5(5):230-239. 
  4. Friberg O. Clinical symptoms and biomechanics of lumbar spine and hip joint in leg length inequality. Spine. 1983;8(6):643-651.
  5. Gordon JE, Davis LE. Leg length discrepancy: the natural history (and what do we really know). J Pediatr Orthop. 2019;39(6): S10-13.
  6. Azar FM, Canale ST, Beaty JH. Campbell’s Operative Orthopedics. Amsterdam: Elsevier;2016.
  7. Raczkowski JW, Daniszewska B, Zolynski K. Functional scoliosis caused by leg length discrepancy. Arch Med Sci. 2010;6(3):393-398. 
  8. Ploumis A, Trivedi V, Shin JH, Wood KB, Grottkau BE. Progression of idiopathic thoracic or thoracolumbar scoliosis and pelvic obliquity in adolescent patients with and without limb length discrepancy. Scoliosis Spinal Disord. 2018;13:18. 
  9. Walsh M, Connolly P, Jenkinson A, O’Brien T. Leg length discrepancy – an experimental study of compensatory changes in three dimensions using gait analysis. Gait Posture. 2000;12(2):156-161.
  10. Subotnick SI. The short leg syndrome. J Am Podiatr Assoc. 1976;66(9):720-723.
  11. Blake RL, Ferguson HJ. Correlation between limb length discrepancy and asymmetrical rearfoot position. J Am Podiatr Med Assoc. 1993;83(11):625-633.
  12. Williams B. What pressure mapping can reveal about limb length discrepancy in a patient’s gait. Podiatry Today. Available at: https://www.podiatrytoday.com/blogged/what-pressure-mapping-can-reveal-about-limb-length-discrepancy-patients-gait. Published November 18, 2019. Accessed June 29, 2020.
  13. O’Toole GC, Makwana NK, Lunn J, Harty J, Stephens MM. The effect of leg length discrepancy on foot loading patterns and contact times. Foot Ankle Int. 2003;24(3):256-259.
  14. D’Amico JC, Dinowitz HD, Polcaninoff M. Limb length discrepancy: an electrodynographic analysis. J Am Podiatr Med Assoc. 1985;75(12):639-643. 
  15. Konor MM, Morton S, Eckerson JM, Grindstaff TL. Reliability of three measures of ankle dorsiflexion range of motion. Int J Sports Phys Ther. 2012;7(3):279-287. 
  16. Van Gheluwe B, Dananberg H, Hagman F, Vanstaen K. Effects of hallux limitus on plantar foot pressure and foot kinematics during walking. J Am Podiatr Med Assoc. 2006;96(5):428-436. 
  17. Cornwall MW, McPoil TG. Effect of ankle dorsiflexion range of motion on rearfoot motion during walking. J Am Podiatr Med Assoc. 1999;9(6):272-277. 
  18. Aruin AS, Hanke T, Chaudhuri G, Harvey R, Rao N. Compelled weight-bearing in persons with hemiparesis following stroke: the effect of a lift insert and goal-directed balance exercise. J Rehab Res Dev. 2000;37(1)65-72. 
  19. Kiapour A, Abdelgawad AA, Goel VK, Souccar A, Terai T, Ebraheim NA. Relationship between limb length discrepancy and load distribution across the sacroiliac joint—a finite element study. J Orthop Res. 2012;30(10):1577-1580.
  20. Richie DR. Heel elevation in the shoe: what the literature reveals. Podiatry Today. 2018;31(11):30-41.

Role of Custom Orthotics & Footwear in Diabetic Foot Conditions

People who have diabetes can have various complications due to diabetes, and one of them is Diabetic Foot Disease (DFD). A combination of various conditions of the foot, including the problems with circulation, nerves, immunity, and deformity of the foot, is seen in DFD. Occasionally one or more of these may exist as an isolated issue, but often people suffer from more than one at the same time.

  • Circulation: People with circulation problems don’t have as much oxygenated blood supplying their feet as other individuals and therefore have difficulty healing any wounds. Many times, their veins also have difficulty taking the blood back to the heart.
  • Nerves: Those who have nerve problems will have either negative symptoms – they don’t feel anything in the foot, either touch, heat or cold, or vibration, and positive symptoms – pain, tingling sensation, burning sensation, etc. They may also have balance issues.
  • Immunity: Some individuals with diabetes have a diminished response to their immune system. Because of this, they can get an infection from a cut or wound more efficiently and have more difficulty treating it.
  • Deformity:  The muscles in the foot get weaker, and the persons can have a collapse of the arch of their foot or increased arches, hammertoes, or other deformities, causing pain or high pressures in certain areas of the foot.

Proper footwear is, therefore, essential for people with diabetes. Your Podiatric Specialist at FootSecure can help you choose proper footwear and recommend shoe modifications to protect your feet.

How does special footwear work?

The footwear often is prescribed by podiatry specialists and fitted by a group of professionals called orthotists. The footwear may be designed to have a very stiff sole (more commonly people feel that the softer the soles, the better the footwear is, but that is a myth, what is required is an insole, which is hard enough to correct the foot and the gait and withstand the body weight) and rocker bottom foot to decrease the forces sent to the ball of the foot.

They also may have a bar or wedge applied to the sole to even out the weight distribution on foot. Footwear will be designed to prevent any seams that are inside the shoe from rubbing against the foot. 

There can be several benefits to wearing custom footwear:

  • Relieve areas of increased pressure. Any area where there is too much pressure on the foot can lead to skin breakdown. Footwear should help relieve these high-pressure areas and reduce the occurrence of related problems, like calluses, wounds, blisters, etc.
  • Reduce shock and shear. The footwear would decrease both the amount of vertical pressure or shock, on the bottom of the foot, and reduce the impact of horizontal movement of the foot within the shoe.
  • Accommodate, stabilize and support deformities. Deformities resulting from conditions such as the arch’s collapse, loss of fatty tissue, hammertoes, and amputations must be accommodated. Many deformities need to be stabilized to relieve pain and decrease the risk of progression of the deformity.
  • Limit motion of joints. Limiting certain joints’ motion in the foot can often decrease inflammation, relieve pain, and result in a more stable and functional foot. 

How will I know if I need a special shoe?

If the shape of your foot has begun to change, you have callouses in your foot, or you’ve noticed skin breakdown, redness, or swelling, you should make an appointment with our podiatry specialists for evaluation.

That being said, custom footwear is just one area of potential benefit, and this evaluation would take into account your other medical problems and available treatment options.

Depending on the findings, shoe inserts, wedges, custom arch supports, or special footwear may be recommended. When there is a concern for ulceration and infection, your podiatric surgeon may recommend other treatments first, including particular types of casts and skincare and possibly even surgery. 

What are the special shoe options?

Many people with diabetes need special footwear prescribed by a podiatrist. Prescription footwear includes:

  • Therapeutic footwear. Immediately following surgery or as part of an ulcer’s treatment, some type of shoe may be necessary before a regular shoe can be worn.
  • Custom footwear. Custom footwear is the basis for most footwear prescriptions. It is generally an oxford-type or athletic shoe with an additional 1/4- to 1/2-inch of depth throughout the shoe, allowing the extra volume to accommodate any needed inserts or orthoses, as well as deformities commonly associated with a diabetic foot. In-depth footwear also tends to be light in weight, have shock-absorbing soles, and come in a wide range of shapes and sizes to accommodate virtually any foot.
  • External shoe modifications. This involves modifying the outside of the shoe somehow, such as modifying the shape of the sole or adding shock-absorbing or stabilizing materials.
  • An orthosis or Custom Insoles. An orthosis is a removable insole that provides pressure relief and shock absorption. Both off-the-shelf and custom-made orthoses are commonly prescribed for patients with diabetes, including a special total contact orthosis, which is made from a model of your foot and offers a high level of comfort and pressure relief.
  • Custom-made footwear. A foot with deformities or amputations, a custom-made shoe can be constructed from a cast or model of the patient’s foot. With extensive modifications in the footwear, even the most severe deformities can usually be accommodated.

How long does special footwear typically last?

Like the regular footwear that you have worn in the past, except that occasionally the upper portion of the shoe may be made from a type of leather that stretches better such as deer hide. This softer leather can be stretched or will stretch as you continue to wear it, and it adjusts itself to the shape of your foot. Unfortunately, this comes at a cost since this type of leather is less durable. Independent of the type of leather used, if the shoe is beginning to break down, it should again be evaluated by the orthotist.

Similarly, the inserts also last a certain period based on your usage. Typically, if you see a concavity in your insoles, then it’s time to change them.   

When should I wear this footwear?

In general, this footwear is designed to be worn daily whenever you are on your feet. That being said, if your foot does not have significant deformity or loss of sensation, brief periods of time in a different type of shoe may not be so risky that it cannot be considered.

Are special footwear heavier than normal footwear?

There are many styles of special footwear. They may look different than regular footwear and sneakers, but usually aren’t heavier.

Something doesn’t feel right about my special footwear. What should I do?

Usually, it takes about a week or two, to get used to the new footwear or inserts. If it is mild discomfort, you should give some time for the body to adjust. If you have severe pain, skin discoloration, or blisters, please stop wearing the footwear and immediately call your orthotist.

By Dr. Sanjay Sharma 

Sourced and Modified from the original article by James Jastifer, MD