Assessment Notes Describing Classic SRLS

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Assessing relative leg lengths of all clients since 2014, virtually all have a structurally short right leg. This cannot be corrected by Chiropractic or Osteopathic adjustment. The bones of one leg are longer than the bones of the other. However, lying on the treatment table, their ankles are usually aligned. This is not so unbelievable considering we stand on flat ground. If there is a leg length discrepancy the ground does not move to accommodate it...look higher up the body. Permanent distortion occurs at the pelvis affecting the upper body through mild Scoliosis and the lower limbs through Lumbro-Sacral and Hip dysfunction. There are several common patterns within which the condition can escalate and develop acute symptomatic effects.

 

The most common pattern looks like this:

 

•  A structurally short right leg typically in the range of 15mm to 20mm;

•  Right leaning pelvic tilt;

•  Left hip in high range rotation sagittally about the SIJ with a short and tight iliacus;

•  Prominent Left Lower Limb Mechanism that varies from subtle thickening and tightening to acute pain, dysfunction and injury under loading and other influences;

•  Rigidity about the right iliac crest and hip with a tight adductor magnus; and

•  Mild Scoliosis with right convexity through lumbar and thoracic spine, elevating the right shoulder, incrementally tipping the head to the left loading right vertebral extensors from lower thoracic through to the sub-occipitals.

 

Explanatory Notes

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A.  Signature Trait of an Elevated Shoulder tipping the head slightly due to mild scoliosis with convexity through thoracic. Most commonly right sided encouraged by the right leaning pelvic tilt. For the common right sided cases, we carry our bag over the right shoulder. The off the shoulder look is to the left. The left bra strap falls off. The head is slightly tipped to the left loading vertebral extensors down the right side from sub-occipitals to the lower thoracic. There are exceptions to this where the spine will flop to the left at the juncture of the lumbar and thoracic elevating the left shoulder. This complication has the potential for dysfunction and injury at the nodal point where direction changes. I have sighted more complex cases where there are multiple nodes as spinal direction changes from right to left, then left to right as it progresses upwards.

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B.  Signature Trait of an Elevated Left Hip observed both standing and supine at ASIS and greater trochanter. The right leaning pelvic tilt is generally between 3mm and 10mm higher at the ASIS of the left hip when standing. Whereas, in supine it will be greater and typically appears to be between 15mm and 25mm. This is not necessarily an accurate reflection of actual leg length discrepancy due to each hip being aligned differently in the sagittal plane. It is an indication only. A more accurate estimate is gained by observing the discrepancy at the greater trochanter.

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C.  Second Cardinal Sign of SRLS, rigidity at right hip observed tractioning ankle in supine. The right hip being wooden and stiff whereas the left hip is soft and giving. Caused largely by gait issues associated with the short leg not confidently finding the ground with each step taken. The momentary hesitation setting up unconscious holding patterns through the iliac crest. Lumbar spine and hip. Other factors are at play here too and should they escalate, the Right Lower Limb Mechanism becomes prominent and presentation becomes more right sided.

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D.  Comparing relative positions of lower limbs at the malleolus in supine…most commonly this is level or very close to it. We stand on flat ground. In the presence of a structural leg length discrepancy look to the pelvis for permanent distortion accommodating the difference. Acute conditions through the spine and torso will functionally pull one hip up creating a discrepancy at the ankles. 

 

This might seem basic but it is a common mistake. Looking at alignment of the ankles alone does not reveal structural leg length. Determining the length of anything cannot be done examining one end only. The position of both ends must be considered. Comparing leg lengths can be done examining relative positions at malleolus and greater trochanter of both legs side by side in supine or measuring each individually in standing from ground to greater trochanter.

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E.  First Cardinal Sign of SRLS, high range anterior rotation of the left hip about the SIJ in the sagittal plane, the ASIS will be 50mm to 60mm inferior to the iliac crest in the standing position. This is so common I call it “normal” despite actually being poor posture that in the long term damages the SIJ. It is an unconscious anatomic adjustment pulling up the longer leg, reducing but not eliminating pelvic tilt, to make us feel more comfortable and protect the spine to some degree. I classify this anomaly from Low to Very High Range in four stages.

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F.  Right hip will be level, the line through the ASIS and posterior aspect of the Iliac Crest is horizontal to the floor in the standing position.

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G.  Third Cardinal Sign of SRLS, mild scoliosis with right convexity. Shifting the centre of gravity in the torso to the right causing the pelvis to make a counterbalancing move to the left. The elevated and jutting left hip becomes the perfect perch for baby freeing the strong right hand for work and defence. This was a survival trait in prehistoric times. It was the most successful model. Hence, through evolutionary adaptation a structurally short right leg is a dominant genetic trait today. It is living proof that back at the time early hominid species began to walk on two legs they were predominantly right handed.

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H.  Scoliosis with right convexity is accompanied by greater development and tightness of the spinal erectors on the right side. Generates discomfort and tightness issues in the upper right quadrant of the thoracic behind the scapula and up into the sub-occipitals. 

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I.  Tightness and tenderness through the right QL’s is a function, in part, of right leaning pelvic tilt dropping the right hip and elevating the left hip. It’s a geometric thing. Incrementally opening disk spacing on the right and closing it on the left encouraging disk bulging to the right. There is more to the story. It is part of the Right Lower Limb Mechanism which is complex but in this example is not prominent. The most common presentation being a prominent Left Lower Limb Mechanism.

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J.  The left SIJ held in chronic anterior rotation in the Sagittal plane tightens and strains the ligamental structure, compresses the joint through the Spanish windlass effect. May or may not be painful or tender to palpate. In the short term blocks energetic Qi flow down back line of the lower limb. Primary contribution to the Left Lower Limb Mechanism. In the longer term (decades) causes instability and injury to the SIJ.

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K.  Left Lower Limb Mechanism is the outcome of thickening and tightening down backline of left lower limb from gluteals and piriformis through to the plantar fascia resulting from energetic Qi flow blockage at left SIJ tightly bound by anterior hip rotation. Under loading it can morph into pain, dysfunction and injury at any point along this line. The condition may waft and wane as activity levels and other contributing factors vary day to day or month to month. Readily palpable comparing left to right limb. In low level cases almost undetectable by the client but noticeable to a practitioner with good palpation skills. Often mistaken for inflammation but unlike inflammation, can be rapidly resolved by eliminating strain at the SIJ and lumbro-sacral region. Responsible for the most common unforced injury in AFL football of the torn left hamstring. Every second or third player on the pro-tennis circuit has Rock Tape down the back of their left hamstrings for the same reason. Symptoms such as Piriformis Syndrome and Sciatic pain result, hamstring calf and achilles issues, Compartment Syndrome and Plantar Fasciitis individually. I have had much success treating these cases by normalising hip position to eliminate binding of the SIJ. Chronic Plantar Fasciitis can be resolved within days/weeks of doing so.

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Nett Effect at the Pelvis

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The postural response at the pelvis and lumbro-sacral region to the leg length discrepancy from a short right leg places the structure under constant strain generating mild Scoliosis with Right Convexity and a prominent Left Lower Limb Mechanism. Specifically this looks like:

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•  Tight left Hip Flexors;

•  Bound left SIJ with compressed cartilage and tight ligamental structure;
•  Spasm in the left Glutes and Piriformis;

•  Tight right Adductor Magnus;

•  Rigidity about the Iliac Crest and TFL of the right hip;

•  Limited rotation at the right Femoro-acetabular joint;

•  Right QL's tight and tender;

•  Rigid right SIJ, and;

•  All sorts of strain about Sacrum and Lumbar vertebrae being loaded by scoliotic strain from pelvic tilt and Lumbar vertebral disks being encouraged to bulge to the right.

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General Discussion

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This presentation is similar to the Osteopathic view purported by Tom Bowen. However, rather than attributing the effects from a leg length discrepancy working through the pelvis and up the spine, he did not assess structural leg length. Sighting the effects of an elevated left hip, right leaning pelvic tilt, mild scoliosis with right convexity that causes slight head tilt affecting cervical vertebrae and loading the right TMJ with chronic low level strain, he chose to view this dysfunction at neck and jaw as the primary cause for “Dural Drag” working down the spine, straining torso, lifting the left hip. Overlooking the structural leg length discrepancy elevating the hip in the first place, this Osteopathic interpretation is inaccurate and not the full story. I am inclined to view the Dural Drag explanation as a fiction concocted in the absence of the full facts.

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With a practice that was largely sports based in my early years, the Left Lower LImb Mechanism was the first aspect of this condition to come to my attention. While aware of the hip rotation’s effect on the SIJ blocking energetic Qi flow and generating backline symptoms, I did not know why this postural anomaly occurred. It was a mystery to me. The adhoc hip rotation seemed to be random and would defy treatment. It was not until I learned of the common structural leg length discrepancy did full understanding come. That is, the underlying impact of the short right leg generating an unconscious anatomic adjustment pulling the longer left leg up. Hip rotation resists responding to rehab and treatment until an adjusting heel lift is placed under the short leg.

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Many minds quickly go to questioning exactly what the structural leg length discrepancy is in millimetres. 5mm is low range. The medium or average is in the order of 10mm. I consider high range to be anything from 15mm and above. 20mm is not uncommon. 25mm or greater is rare. The largest I have seen I would estimate to have been 35mm. At 62yrs of age that one had never been told he had a short leg despite much consultation with Medical Doctors and Specialists.

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In some respects, it is not too important exactly how large or small the leg length discrepancy is. Every case is different and the degree of impact on the individual can vary greatly. A lower range discrepancy can be affecting one person more than a high range is another. Two vastly different discrepancies may have the same adjusting heel lift size.

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In clinical practice, knowing the actual leg length discrepancy to the accuracy of a millimetre is not required. The Cardinal Signs indicate a discrepancy exists. A comparative examination of structural leg length confirms there is a discrepancy and it can be classified as low, medium, high or very high range. That is sufficient information to commence treatment where acute symptoms are present. Treatment is a trial and error approach basically determining what amount of heel lift adjustment the body will accept.

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There is no expectation of realigning the body into a fully symmetrical state. The bony structure and joints have been permanently altered. There is no formula for calculating adjustment size based on leg length discrepancy. It is a matter of determining what amount of adjustment the body will accept. This is typically between 3mm and 5mm which may be no more than one quarter to one third of the actual discrepancy. Permanent distortion becomes ingrained through the pelvis which has been accommodating the discrepancy for decades. This limits how much adjustment it will accept initially. In time, it is possible to increase adjustment in response to symptomatic effects as flexibility through the pelvis improves.

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Because full symmetry is not achieved, a partial leg length discrepancy still exists and heel lift treatment alone may not be adequate to fully treat the condition. Dramatic enduring change can result for pelvis, spine and lower limb mobility. Internal health function can improve. However, gait will still be affected and supplementary exercise and massage treatment may be necessary. Particularly for the Second Cardinal Sign at the right hip. Lumbar tightness, fascial binding about the sacrum, and tightness through the hip and iliac crest blocks energetic Qi flow in the bladder meridian. I describe these as primary bladder meridian choke points. The bladder meridian feeds the kidney meridian energetically. Where the bladder meridian is blocked, the kidneys are starved energetically and kidney deficiency symptoms develop. The right side is affected more in this way than the left but both sides are susceptible to this blocking effect on the bladder meridian. A Chi Gong Master sensitive to these energies can distinguish the energetic vitality of the right versus left kidney. This is supported by Traditional Chinese Medical theory and known to a few TCM practitioners. It is not taught in their university training. 

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Based on personal experience of being assessed and treated by six TCM doctors over a period of 45 years, the common theme has been the presence of kidney deficiency. I now know the First Cardinal Sign made itself known to me at age fifteen and symptoms demonstrating I was afflicted by kidney deficiency began in the late teens. These TCM practitioners have been diagnosing and treating the kidney deficiency with acupuncture and herbal treatment all my adult life. However, treatment outcomes were only ever partial and temporary. Should I cease treatment, the symptoms would quickly reappear. It was presumed I either had a congenital weakness or my lifestyle habits were bad. It was not until addressing and eliminating chronic muscular spasm and tightness through the right hip from the Second Cardinal Sign and clearing the blocked bladder meridian, were kidney deficiency symptoms dramatically alleviated. It is the bladder that feeds the kidneys energetically. Should the bladder meridian be blocked, the kidneys are starved energetically. On clearing the blockage, for the first time the TCM doctor doing pulse diagnosis stated "Your pulse is normal" and "Pulse is good." They have never said that in 45 years.​

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Following lumbro-sacral injury suffered at age 60 from leg length discrepancy and a high athletic training load, my lower limb mobility progressively deteriorated and internal health suffered. Pelvic tilt and distortion now compounded by lumbro-sacral injury, energetic blocking effects at the pelvis escalated. This became what I now call an advanced case of Short Right Leg Syndrome. I am Case 4 in the Notes section. Advanced cases are rarely seen in my practice. Should I visit a retirement home, I suspect many would be found.

 

Much ineffective treatment was received from medico's and therapists over a five year period. While suffering low back and lower limb symptoms, none examined structural leg length. Their treatment yielding no more than limited temporary outcomes. It was not until faced with the prospect of forced retirement from active life that I began self treatment. Insertion of a small adjusting wedge under the short leg brought about dramatic enduring change.

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I describe specific patterns of effect from the postural strain placed on the pelvis and lumbro-sacral region from structural leg length discrepancy. While the biomechanical effects on gait and through the spine are easy to see, making a connection to lower limb symptoms is not. This is because they are due predominantly to blocked energetic Qi flow. This is unknown to conventional practitioners and not considered in their examination.

 

The impact of blocked energetic Qi flow through the pelvis is not restricted to mobility issues. Many clients being treated for structural leg lengthy discrepancy report coincidental beneficial side effects to their internal health. I eventually came to realise there is a condition I describe as the Pelvic Block. In TCM medical theory, fourteen organ channels and acupuncture meridians passing through the pelvis to the lower limbs. Chronic soft tissue strain through the pelvis inhibits energetic Qi flow through these channels, directly impacting internal health. Digestive and reproductive organs and kidneys are affected. This aspect of the condition might be considered a greater concern than mobility issues. Health, well being, vitality and lifespan potentially being impacted in the longer term. The effects from Short Right Leg Syndrome increase as we gain weight, lose flexibility and become more sedentary with age. Research into the extent of the Pelvic Block's effects should be conducted.