Leg Length Discrepancy and Short Right Leg Syndrome
in the context of Remedial Therapy
Discussion of Short Right Leg Syndrome Assessment in the Context of Remedial Therapy
The effects of SRLS first came to my attention treating tightness, injury and pain in the back line of the lower limbs. Correlating forward rotation of the hip with tightness in the soft tissue of the SIJ, in turn blocking energy flow down the backline of the lower limb, causing thickening and tightening through the fascia and connective tissue. This was long before I was aware of the short leg condition. I simply assumed it had to do with loading and activity patterns beyond my understanding. The first success came clearing a chronic Plantar Fasciitis condition by normalising the hip posture through stretching chronically tight hip flexors. Why the left hip was pushed into anterior rotation remained a mystery until I learned of SRLS and realised hip rotation is an anatomic adjustment to reduce pelvic tilt. This is not to say a subject having legs of equal or near equal length cannot have a rotated hip and suffer the same fascial tightening down the backline but that is a hypothetical scenario that I really do not sight in practice. Interestingly, the most common unforced injury in AFL football is the torn left hamstring and every second or third player on the pro-tennis circuit has Rock tape down the back of their left hamstring.
The most common pattern sighted is pelvic tilt in the frontal plane with the left hip elevated and sloping down to the right. The left hip is in high range anterior rotation in the Sagittal plane. The right hip is level. The backline of the left lower limb will be subtly thick and tight from the glutes through to the plantar fascia. The left glutes will be noticeably tighter and in spasm relative to the right side. The left SIJ being chronically rotated to full range of motion is often tender to palpate. The right QL's are tight and may be tender to palpate. Right leaning scoliosis in the Lumbar spine with right convexity evident through the Thoracic evidenced by bulging costals to the right. The right shoulder will be elevated over the left.
Exception cases with left convexity through the Thoracic in lieu of right convexity are sighted. My observation is these are low range leg length discrepancies. The spine is not so convincingly encouraged to the right as it will be with higher range cases. Flopping to the left at the juncture of the Lumbar and Thoracic causing them to have an elevated left shoulder, carry a shoulder bag on the left shoulder but still carry baby on left hip freeing right dominant arm for work and defence.
Lower limb symptoms of thickening and tightening down the backline are not exclusively left sided. Right lower limb instances are sighted too due to an acute state of dysfunction in the Lumbro-Sacral region from the Ride Sided Mechanism. While it is hypothetically possible for bilateral backline dysfunction through the lower limbs, it is not common. Once symptoms become acute causing high degrees of tightness, pain and possible injury, it is almost always clearly a right or left sided issue. Left sided cases being the most common presentation.
Above the pelvis, tilt in the Frontal plane causes the foundation of the spine to lean to the right generating a scoliotic force on the spine. My knowledge and experience of this is rudimentary. It has been studied extensively by physical therapists yet discussion with Chiropractic, Osteopathic and Bowen Therapists indicate the contribution of leg length difference to this mild scoliosis is largely discounted and dismissed. I say this because by and large they do not examine each and every case for the possibility and make the assumption the pelvic tilt is generated from some factor working its way down from the neck or TMJ.
Leg length discrepancies estimated to be between 10mm and 20mm are common. Less than 5mm we will be seeing Cardinal signs but actually detecting the leg length difference without the use of an x-ray scan may be a challenge and I am uncertain. Some studies indicate 10mm is the average leg length discrepancy. 15mm is big, easily observed and normally expect back pain and high degree of rotation at the hip of the longer leg and all that goes with it. 25mm is huge but I have one client with this (determined by a Chiropractor with x-ray) and he is just fine clomping around like a pirate on a peg leg totally unaffected by it...a boxer so enormously fit and strong his torso maintains its integrity...when older, out of shape drinking beer on the couch and watching reruns it may be a different story. Once I have sighted a leg length difference in the order of 35mm aged 62 that was experiencing acute symptoms and dysfunction. Unfortunately, he would not acknowledge the condition nor engage in treatment.
When one leg is longer than the other, standing both legs evenly planted feels uncomfortable...the higher hip throwing an unhealthy tilt into the spine. Unconsciously we make a postural flop, anteriorly rotating the hip in the Sagittal plane on the side of the longer leg. This is an anatomical adjustment pulling the left leg upwards and we feel better. The hip rotating about the SIJ is a cam adjustment for the hip joint at the Acetabulum which rotates about the SIJ posteriorly and superiorly on an arc with a radius of approximately 120-150mm...this has the potential to pull the limb upward by up to 20mm in cases of high range rotation of 30 degrees, adjusting the apparent leg length, levelling the hips to some degree. This is good because it is protecting the spine. It is bad because the left Sacro-Iliac Joint rotated anteriorly is causing chronic tightness in the joint due to the Spanish Windlass effect loading ligaments and compressing cartilage. It is not sufficient to compensate fully for the leg length difference, some pelvic tilt remains and sign of mild scoliosis results. Attempts to normalise this posture at the left hip through rehab exercise and treatment often fail without employing an adjusting shim under the short leg...the hip rapidly defaulting to the rotated position without the most rigorous and frequent rehab which most clients are not prepared or able to undertake.
Due to the leg length difference, weight loading is not evenly distributed between each leg. The longer leg is supporting greater weight and it is part of the mechanism for the hip rotation observed at the left hip. Occasionally, it is the cause of injury in the longer leg...I have seen tibial stress fracture in a young adult athlete and arch collapse (left foot only) in a juvenile which were influenced by the load imbalance and the twisted SIJ adversely affecting musculature.
Where there is a short leg, with every step taken during the course of their life, the right foot stepping through does not immediately find the ground...even after tilting and rotating compensation through the pelvis, the right foot falls short by a mere fraction of a millimetre and there is an infinitesimal hesitation while the leg is held at the hip until contact with the ground. I call this the Pendulum Effect which sets up holding patterns through the musculature of the hip. Rotation in the right Ilio-Femoral joint will be slightly restricted compared to the opposite side. The left foot plants confidently. The right foot fall is lighter and hesitant. The right hip is usually level and Adductor Longus will be tight. The right hip is rigid when tractioning inferiorly from the ankle. The left hip is soft and giving.
Another factor contributing to rigidity through the right side is right leaning pelvic tilt that geometrically opens lumbar disk spacing on the right and closes it on the left. Vertebral surfaces rather than being parallel, become wedge shaped opening to the right. This encourages mild disk bulging to the right causing a tenderness and tightness palpating the right QL's. Rarely catastrophic but frequently encountered it contributes to right sided rigidity through the pelvis. I note SIJ pain and dysfunction correlates with more acute levels of this condition in the lumbar region. This degree of dysfunction will cause tightening and thickening down the back line of the lower limb.
Another factor at the right hip is loss of gluteal stabilisation on the left side. Glute Medius provides a canter-levered downward force on the pelvis when the right foot lifts. ue to energetic blockage at the left SIJ from hip rotation
While the postural position of the right hip in the Sagittal plane is normal, the presentation of pain and dysfunction in the right SIJ had me confounded. I initially hypothesised this may be due to abnormal hip rhythm issues resulting from rigidity at the right hip plus lumbar pain and tightness present in the right QL's. As a result the right SIJ is forced to mobilise through a higher range compensating for the lack of mobility at hip and lumbar region. While this may be a part of the story for right sided cases...I only hypothesise...I am more inclined to think mild lumbar disk bulging described earlier is responsible and the rigidity caused by gait issues described above. The right SIJ is often described as "stuck" and will be mobilised by high velocity thrusts by manipulative therapists. As a Remedial Massage Therapist or Craniosacral Therapist, I encourage mobility through the SIJ by more gentle means with Integrative Fascial Release techniques from the leg and through the hip/pelvis, manual pressure flaring the joint, giving rehab exercises to mobilise the joint and normalise muscle tone about the hip and waist, and consider use of an adjusting heel lift under the short leg should symptoms be sufficiently acute to warrant. Where there are acute symptoms, it is almost like we always have to go to the adjusting shim under the short leg.
Think about this, how many of you find it more comfortable to carry a bag over the right shoulder? It just seems to continually slip off the left shoulder. SRLS causing an elevated left hip and elevated right shoulder encourages mothers to carry their child on the left hip and bag over right shoulder, leaving the dominant right arm free for defence and work. I theorise SRLS is an evolutionary adaptation increasing a mother and child's chances of survival in prehistoric times. It is now a dominant genetic trait in Homo Sapiens. The vast majority of all clients I examine have a short right leg. Even or near even leg length is uncommon. I never see short left legs unless they have suffered an injury in their youth that may have stunted the growth of that leg.
The varying degree of dysfunction or otherwise is wide ranging individually and no one description fits all cases. Some subjects are virtually unaffected, exhibiting no adverse symptoms while at the other end of the spectrum, lives and careers have been shattered by it. Treatment of the symptoms aided by exercise and stretching can prove sufficient to avoid acute conditions but an underlying sub-acute state of tightness and restriction remains. The effects of treatment often temporary and limited need to be undertaken regularly to maintain tolerable comfort levels.
Lifestyle, work, diet and gender do play a part. Females with a plant based diet regularly practising yoga and meditation that do not load their bodies with heavy exercise are more likely to have highly flexible joints and relaxed muscle tone. Energy flow in their bodies can flow smoothly despite high range postural aberrations through the pelvis from SRLS. It is a different story for a testosterone loaded meat eating male who performs heavy physical training.
Maintaining a high degree of flexibility through the pelvis and good muscle tone is preventative. Few of us are sufficiently motivated or prepared to put in the time necessary to achieve this.
Use of a small adjusting shim under the heel of the short leg, can rapidly reduce discomfort in acute cases. Lumbar conditions that may be the result of prior injury, as well as, the leg length discrepancy often respond quickly in a matter of days. I have had a number of cases now where ongoing back pain was being attributed the injury where, in fact, it was ongoing aggravation from the pelvic asymmetry that was more to blame. Physical therapy treatment only gave temporary relief until fitting a heel lift to reduce the leg length discrepancy.
I do have reservations about introducing a heel to cases that have had spinal surgery. These are not common in my practice. One such case experiencing effects from the Right Sided Mechanism causing pain in the right glute, and spasm in the right QL's and throughout the backline of that lower limb responded well. Another more advanced case being effected bilaterally following two surgeries I have only given massage and Cupping treatment. I am not prepared to recommend heel lift treatment without consulting his Medical or Chiropractic Doctor.
Rapid results occur through the Lumbar region. For the effect to progress through to the Thoracic region may take weeks/months and months/year to reach the Cervical vertebrae. One client has continued to report incremental improvement to posture, gait, balance and vitality for two years from the commencement of heel lift treatment for a short right leg.
I am now aware pelvic compensation accommodating a short leg impacts not only the physical structure but also has the potential to affect metabolic health. Postural strain tightening soft tissue of the pelvis blocks energetic flow in the lower abdomen and to the lower limbs. Energetically isolating the lower limbs and can result in deteriorating leg function. This will include joint pain and declining ability to mobilise the legs and body. It also inhibits energetic flow in the six organ channels to the lower limbs identified by Traditional Chinese Medical practitioners. These are the acupuncture meridians for the Kidney, Bladder, Liver, Gall Bladder, Stomach and Spleen. The impact on health and vitality can be significant. The metabolic effects of this nature are beyond my scope of practice to diagnose and treat.
However, I regularly hear reports from clients undertaking heel lift treatment indicating improved digestion and increased vitality is a coincidental beneficial side effect when treating lower limb dysfunction and/or chronic back pain. I hypothesise if a leg length discrepancy can have this effect on digestion, it is also likely to have an effect on reproductive organs too. I am sure there are alternative medical practitioners cognisant of the pelvic block I describe vainly trying to treat conditions unaware of the impact of SRLS, nor aware how common it is in the Homo Sapien structure which has the short right leg hardwired into its genetics.