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O&P Pioneer: Ivan Long, CP(E) Horse Trainer Turned Prosthetist
By Sherry Metzger, MS Recognized as a legendary pioneer, Ivan Long, CP(E)
began his distinguished career in the orthotics and prosthetics
field in a saddle shop. The leatherwork he did as a horse trainer
led to an interest in orthotics manufacturing. An interest
heightened, perhaps, by a personal desire for a better gait, since
a polio affliction at the age of two resulted in a weak left leg
and a first-hand appreciation of the challenges and benefits of the
field.
 During the 1950s, Long developed braces and
orthotics in Minneapolis, Minnesota, then moved to Denver,
Colorado, in 1957 to begin prosthetic work. He traveled across the
country during this time, taking every available course in the
field at the University of California-Los Angeles (UCLA), New York
University (NYU) and Northwestern University, Chicago,
Illinois.
Revolutionary Discovery
Then, in 1974, Long made a discovery that led to his best-known
contribution, a revolutionary socket design. While working with
transfemoral amputees who were Vietnam veterans at Fitzsimmons Army
Hospital near Denver, Long requested a full-length X-ray of a
prosthetic patient standing in his prosthesis. What he saw was
something completely unexpected. He found that the femur in the
quadrilateral socket, the socket most widely used at the time, was
at nearly 20 degrees of abduction. He proceeded to X-ray 100
amputees fitted with the quadrilateral socket from hip to floor.
His findings were astonishing: 94 of those patients presented with
abducted femurs. "I began taking X-rays of patients standing in
prostheses, and that was the turning point of my life," Long
remembers. He published his findings in the December 1975 issue of
Orthotics and Prosthetics, and since that time, his career
has focused on remedying the problem of femoral abduction in
transfemoral amputees.
Long discovered that current socket design offered little
support for the amputated femur. Unsupported, the femur is abducted
by the gluteus medius muscle, one of 12 muscles unaffected by
transfemoral amputation. The gluteus medius and gluteus maximus
muscles' normal function is to adduct the femur when walking.
Therefore, Long found that an improper socket resulted in healthy
muscles working opposite of what they should do. "When the femur of
the amputated limb is pointed away (abducted) from the midline of
the body, it has the same effect on the gluteus medius as
paralysis." Long explained in a 2004 issue of inMotion
magazine, "When this muscle is functioning properly, it helps
support the upper body, and the head moves forward without shifting
to the side when an individual walks. Without gluteus medius
support, however, the entire upper body moves over to the side for
balance." This causes the amputee to walk with a wide base and a
"lurch" to the amputated side.
Long's lifelong goal has been to help amputees improve their
gait. "It's a tremendous feeling when you can change the way a
person walks and take away that lurch to the side." To this end,
Long developed what he termed the Normal Shape, Normal Alignment
(NSNA) method. The first step was to design a socket that would
support the femur in place and reduce the abduction problem. "In
order to support the femur," Long explained, "it is necessary to
narrow the M-L dimension of the socket."
Ischial Containment Socket
Long noted that in the quadrilateral socket, the ischial
tuberosity rested on the posterior wall of the socket, which
allowed the patient's socket to move laterally during weight
bearing. His solution was to create a socket that contained the
ischial tuberosity, now known as the ischial containment
socket.
Long's Line
"Ischial containment alone is not the complete answer," Long
stresses. "There definitely needs to be proper alignment to go with
it, and that is where Long's Line comes in." Long's Line is a
straight line starting at the center of the hip joint, passing down
through the distal femur, through the center of the heel of the
prosthetic foot. To this day, one of Long's greatest
disappointments has been that, though the ischial containment
socket is widely used, the crucial alignment process is often
ignored. In his opinion, the best way to achieve the proper
alignment is by X-raying the patient in his/her prosthesis. His
hope is clearly stated on the back of his "Above Knee Prosthetic
Consultant" business card: "Wish for the day when a prescription
for an above-knee prosthesis will be accompanied with an X-ray of
the pelvis and both femurs. The X-ray would show the ability of the
amputee to adduct the amputated femur to a normal angle. Another
X-ray would be taken of the amputee standing in the finished
prosthesis to demonstrate normal adduction."
Fitting Success
 After his article in inMotion magazine
was published, Long received e-mails from amputees around the
country asking if he could help them "walk better." He corresponds
with both the patient and their prosthetists in an effort to assist
with proper alignment. Is it possible for this sort of
"long-distance" patient care to occur? In fact, one of Long's
career highlights occurred when he demonstrated the incredible
fitting of a prosthesis to a patient he had never met. Long
presented the prosthesis he had created in advance from the
measurements and cast of the residual limb mailed to him by a
transfemoral amputee at the 1985 American Orthotic & Prosthetic
Association (AOPA) meeting in Pittsburgh, Pennsylvania. He
successfully fit the patient with the new limb in front of 140
prosthetists, and the amputee incredibly walked better than he had
since his amputation, declaring that for the first time he was free
from the pain of his distal femur pressing against the wall of the
socket.
Because actually seeing an amputee's gait change in this way is
worth a thousand words, Long videotaped his patients walking down a
hallway with their "old" prosthetic limb and then with a new one
Long fitted using the NSNA method. Patient after patient appeared
on the tape, and the results were all the same: the side-to-side
motion, lurching to the amputated side, and discomfort were all
remedied by the new limb. One patient remarked, "Wow, that feels
better!"
Honored for Work
In 1991, the American Academy of Orthotists and Prosthetists
(the Academy) honored Long's work with transfemoral amputees by
awarding him the Distinguished Practitioner Award. "I was quite
excited to be the first prosthetist to receive the award," Long
said. Students and colleagues alike respect him. "Mr. Long is a
shining example of the best of the O&P pioneers," commented
John Michael, CPO, FAAOP, who began his career in 1976. "He never
lost his patient focus. He mastered the state-of-the-art of his
era, then he had the courage and insight to violate the "norms" to
take state-of-the- art to another level." Michael continued, "When
I was a student prosthetist in the 1970s, Gunter Gehl, CP, told our
graduating class at Northwestern University that Ivan Long had
written an article about a new type of socket. He said we should
all read it because if Ivan says it's better, then it is." This
year, Long was honored with a Lifetime Achievement Award at the
Hanger Orthopedic Group Education Fair in Reno, Nevada. Yet, Long
said, "The greatest reward comes from helping people walk straight.
That's what keeps me going to this day."
Sherry Metzger, MS, is a freelance writer with degrees in anatomy and neurobiology. She is based in Westminster, Colorado, and may be reached at metzgerfive@hotmail.com 
Table Of Contents - October 2005
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