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 Short Right Leg Syndrome (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 in the Sagittal plane with binding and tightening 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 dominant genetic trait of a structurally short right leg. I simply assumed it had to do with loading and activity patterns beyond my understanding. The first success came resolving a chronic Plantar Fasciitis condition by normalising left 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 I do not see. 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 presentation of SRLS is an elevated left hip with right leaning pelvic tilt in the Frontal plane. The left hip is in high range anterior rotation in the Sagittal plane. The right hip is level. The left SIJ being chronically rotated several times beyond normal range of motion is often tender to palpate. In the short term, this generates a subtle thickening and tightening along the backline of the lower limb from the glutes through to the plantar fascia. Under loading and other influences, this subtle thickening and tightening can escalate to acute pain, dysfunction and injury anywhere along that backline. In the longer term, the SIJ becomes unstable and vulnerable to injury. The right QL's are tight and tender to palpate. Right leaning pelvic tilt encourages mild scoliosis with right convexity through the Thoracic evidenced by bulging right costals. The left costals are flattened in comparison. The scoliotic curve commencing in the lower back in a rightward direction curves back around on itself and moves through the nexus of shoulders and neck in a leftward direction creating a left leaning tilt through the shoulders; elevating the right shoulder over the left and loading the right vertebral extensors 24/7 from sub-occipitals down to the lower thoracic. This musculature becomes more highly developed and tighter. It is frequently three to four times larger than the left side. The exception being athletes and workers training their back symmetrically. In the absence of mobility and strength training, this condition leads to dysfunction in the upper right quadrant of the back and neck, contributing to right shoulder issues to some degree.
Exception cases having mild scoliosis with left convexity through the Thoracic in lieu of right convexity are sighted. My observation is these are frequently lower range leg length discrepancy. The spine is not so convincingly encouraged to the right as with higher range cases. So while the lumbar spine is still directed rightward by the right leaning pelvic tilt, it flops 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, and we see musculature on the left side being more highly developed and tighter with dysfunction in the left upper quadrant of back and neck contributing to left shoulder issues. This is compounded by "The Heart Story" where emotional effects block Heart Qi impacting left pectorals, scalenes and upper trapezius.
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 as described by the Right Lower Limb 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.
Discussion with Chiropractic, Osteopathic and Bowen Therapists indicate the contribution of leg length discrepancy to mild scoliosis is largely dismissed or not considered at all. By and large, they assume pelvic tilt is generated by dural drag working down from neck or TMJ dysfunction pulling up the hip rather than the presence of a structural leg length discrepancy pushing up the hip. It is a procedural error to make this assumption without first eliminating the possibility structural leg length discrepancy is the underlying causation for the scoliotic curve generating dysfunction through upperback and neck as described above.
Structural leg length discrepancies estimated to be between 15mm and 20mm are common. Even or near even leg length is rare. We basically do not see short left legs. In the eleven years I have been examining structural leg length in clinical practice I have sight four cases, of which, three had major injury during their youth that may have stunted growth of the left leg. A 15mm discrepancy 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 and rarely sighted. I have once sighted a leg length discrepancy in the order of 35mm, aged 62, that was experiencing acute symptoms and dysfunction. He had been examined by medical doctors and specialists since he was a child. He had never been told he had a high range structural leg length discrepancy. This is not included in medical examination. 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 does not compensate fully for the leg length discrepancy, 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.
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 generating unconscious holding patterns through the musculature of the right 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 in the Sagittal plane, with tightness and pain on palpation along the Iliac Crest, tightness and tenderness in the right QL's, and Adductor Longus will be tight. The right hip is noticeably rigid like a block of wood when tractioning inferiorly from the ankle. The left hip is soft and giving.
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 off the ground. Due to energetic blockage at the chronically twisted and bound left SIJ from anterior hip rotation, the left gluteal musculature is inactive and Piriformis in spasm. Loading to stabilise the hips when walking is shunted to the left TFL (causing tightness and pain in the distal portion of the left ITB) and right QL's.
While the postural position of the right hip in the Sagittal plane is normal, the not infrequent 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. I only speculate. 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 this was my personal experience. I encourage mobility through the SIJ by Indirect Fascial Release techniques using the leg as a lever working through the hip and pelvis, facilitated stretching of the hip and gluteal musculature, lower back, gluteal and hamstring Chinese Cupping treatments, giving rehab exercises to mobilise the lumbro-sacral region 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 insert an adjusting heel lift under under the short leg.
It is my theory a structurally short right leg is an evolutionary adaptation increasing a mother and child's chances of survival in prehistoric times. It is now a dominant genetic trait. 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. As a nomadic hunter gatherer in the forest, the most successful model was a short right leg, generating a right leaning pelvic tilt, encouraging right convexity through the thoracic spine, shifting the centre of gravity in the torso slightly to the right and the hips make a counterbalancing shift to the left. The elevated and now jutting left hip is the perfect perch for baby freeing the strong right arm for work and defence. Mothers and fathers today by and large carry baby on the left hip because of this mechanism. It is so secure we hardly have to hang with our left arm. Only being able to do so on the right side by contorting stance and hanging on so tight you will break baby. This is living evidence that from the beginning of time, homo sapiens and early hominid forms were predominantly right handed.
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. The left bra strap falls off. The off the shoulder Marilyn Munro floppy jumper look is too the left. Mild scoliosis encouraged by the right leaning pelvic tilt is universal. The most common presentation is right convexity through the thoracic spine which elevates the right shoulder tipping the head slight leftward. Hence, why we have issues with which shoulder to use carrying a bag. Left convexity case are less common but not rare elevating the left shoulder. The off the shoulder look being to the right for them. Apart from bag carrying effects, this loads the vertebral extensors on one side more than the other eventually causing tightness and strain from the sub-occipital musculature of the neck down to the lower thoracic. This contributes to dysfunction and pain in that upper quadrant of the back and to shoulder issues. As with all symptoms associated with Short Right Leg Syndrome, this becomes more prominent and escalates as we age begond the life expectancy of our prehistoric ancestors.
The varying degree of dysfunction from Short Right Leg Syndrome 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 and forced into retirement from active life. 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 practised 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 and do not stand all day long 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. Yoga gurus and dancers manage it well. Most others do not. Few of us are sufficiently motivated or prepared to put in the time necessary to achieve this. Also too, as symptoms escalate with age, we often find the restrictions of age, degenerating joint condition, declining health (which can be attributed to the effects of the Pelvic Block on internal health) are barriers to our ability to perform adequate physical activity to manage the condition.
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.