Leg Length Discrepancy and Short Right Leg Syndrome
in the context of Remedial Therapy
Rehab Exercises to Correct Anterior Rotation Left Hip
Basic rehab to normalise left hip position where chronic anterior rotation in the Sagittal plane exists due to a Short Right Leg entails stretching the hip flexors, strengthening the abdominals and activating the gluteal musculature. It should be understood that while normalising hip rotation will release SIJ tightness that can block energetic flow causing thickening, tightening and dysfunction down the backline of the lower limb, it also increases pelvic tilt in the Frontal plane and may aggravate upper body issues associated with scoliosis of the spine. It is almost like we always have to resort to the use of an adjusting heel lift under the short right leg where acute symptoms are being experienced.
Normalising hip position is possible with dedicated rehab exercise. However, the hip will have a tendency to default back to the anteriorly rotated position at the drop of a hat under the influence of the leg length discrepancy. If hip position remains problematic with pain in the SIJ, tightness down backline of left lower limb and/or effects manifest through the spine due to the mild scoliosis, progressing to use of an adjusting heel lift should be considered. Apart from these rehab exercises, maintaining flexibility generally through the pelvis and waist is beneficial to manage SRLS.
Note: This rehab is also applicable for a right hip in an anteriorly held position too although in practice this is relatively uncommon. The thrust of this article focuses on the left hip, associated effects and outcomes.
Lengthen Hip Flexors
It is often the case a good hip flexor stretch session alone will partially normalise hip rotation and release SIJ binding sufficiently to relieve the energetic block down the backline of the limb. Those who work primarily in a seated position...office workers, students and drivers...will have tighter hip flexors than those who work on their feet. The hip held for extended periods of time in the flexed position at 90 degrees to the torso is holding musculature in the shortest position. Hip flexor stretching in the lunge position pictured below lengthens Iliacus in the front of the hip, Psoas deep in the abdomen on the lumbar spine and the Quads through the front of the thigh. A hip held chronically in an anteriorly rotated position in the Sagittal plane will have a tight short Iliacus. Hence, the primary muscle targeted, where our intention is focused and where you will feel this stretch is Iliacus that holds the hip down at the front. Psoas will frequently make its presence known too...particularly, while in the lunge position, if you rotate your body to the opposite side and reach for the sky. That is, stretching the left hip flexors, left leg trailing behind, body erect, rotate torso to the right and reach for the sky with the left arm. It is beneficial to be stretching the Psoas muscle too but its effect is directed more on the lumbro-sacral area than hip position.
Where the left hip is in high range anterior rotation and the right hip is level, we find the left side needs more stretching than the right. Do a little for both but more for the left. To create change it is necessary to overcome the stretch reflex which means holding the stretch for a minimum of 30 seconds. Only then the nervous system realises it is OK to let go and allow the muscle to lengthen.
Stretching Cautions
Deep prolonged stretching switches off musculature and it will need some time to switch back on. The muscle will be vulnerable to injury during this time if loaded to maximum effort. Do not do this type of stretching, as opposed to shorter duration ballistic warm up stretches, prior to high intensity training sessions or competition. It is better performed at the end of day.
Practise these stretches in a relaxed easy manner on a soft surface or with padding to protect the knee on the floor. There is no need to push hard. Give it time to release. Initially when very tight you may feel multiple releases in the course of the session until end range of motion is achieved. You can stop then. It is easy to overstretch causing damage to muscle and tendon...loosening joints too much. Overstretching can cause long term pain and restriction only healed by long term rest (months). So, take it easy and allow the body time to change over a few weeks rather than in one day.
Strengthen Abdominal Muscles
Planking strengthens and activates the abdominal musculature which pull hips up at front. These muscles are the Rectus Abdominus, the Internal and External Obliques and Transverse Abdominus. Suggest building up to doing a total of two minutes minimum. This does not need to be continuous. Four 30 second stints with a short break in between works too. Barefoot rather than with shoes as depicted here...stretches the plantar fascia in the feet. Adding side planks rounds it out too. Where a horizontal plank on the floor is too strenuous to attempt, doing so at 45 degrees against a kitchen bench or staircase is more achievable. Start out doing several short duration sessions...say 10, 20 or 30 seconds. Tucking in the tail bone braces the lower back to take load and activates Transverse Abdominus. Gradually increase duration over time and then begin reducing the angle.
Abdominal Strengthening Cautions
Where acute spinal injury exists it is likely this exercise is too strenuous and may cause further damage. Only attempt this where able to do so without pain in the spine. If you have reason to believe spinal injury is aggravated by this loading, wait until the injury has healed sufficiently to take the load. Similarly, this exercise is not suitable if abdominal herniation exists. If you are coming from way behind the eight ball of injury and/or poor development, the lightest form of exercise to strengthen abdominals is to lie supine on the floor with knees bent and soles of feet flat on floor, tuck in tailbone and round out the lumbar to brace lower spine and tuck in chin to brace the neck and merely begin to try lifting head. It is not necessary to actually lift the head off the floor. Just begin loading the musculature through the front line. Progress to lifting head then shoulders off the floor. Progressing to a full situp or crunch is not recommended for individuals with a history of back injury without supervised instruction. Of course there are more dynamic exercises than these to strengthen abdominal musculature. Swimming freestyle and backstroke are amazingly good for this. Pilates is an uber method. Consulting a qualified Physical Trainer, Clinical Pilates instructor or Physiotherapist is a good idea for the inexperienced. I do not discriminate against Yoga or martial exercises like Tai Chi and Chi Gong...they are actually my preferred avenue of practise. It is just that where fundamental weaknesses of this nature exist in the presence of postural fault and/or injury, a more focussed and directed effort is necessary to overcome and rehabilitate the problem. Once past initial rehabilitation, then a more wholistic practice can commence.
Activate Gluteal Musculature
The Back Bridge activates the gluteal musculature in its shortest range of motion. They will be switched off by the SIJ binding caused by anterior rotation of the hip and not contributing as much as they should stability wise walking and moving generally. This throws unwanted loading on the legs and can cause knee pain. Activating the glutes engages them and they begin contributing to hip posture by pulling the hip down at the back. Position supine on floor with knees bent and soles of feet flat on floor. A few gentle reps lifting hips off the floor as warmup and then a prolonged hold pushing hips toward ceiling. Push through heels to target glutes and cut out hami's and calves. Hold for a duration you find comfortable and extend this with further practice. Athletes, track and field sprinters and weight lifters will place a weighted bar across the hips doing hip extensions. This is not necessary for the purpose of this exercise.
Gluteal Activation Cautions
As with Planking, be cognisant of spinal injury that may be aggravated by the exercise. If new to this level of training and the lumbar spine is vulnerable due to poor conditioning and possible injury, alternating between rounding out the lower spine by tucking in the tailbone/sacrum and extending back again mobilises the lumbar spine without lifting hips off the floor. This looks and feels like a rocking motion forward and back through the hips and lower back. Warming up the lower back musculature and mobilising joints but also giving an awareness of limitation and possible injury in this area. Perform new moves slowly at first feeling your way through them to assess condition and ability. Condition can improve with repeated mobilising sessions without attempting to lift the hips off the ground. This same activity can be performed on hands and knees, lifting back and stretching entire back up and down like a cat stretching. Lying on the back focuses the action on the lumbar spine. Ultimately, it may then be possible to push the hips off the floor to begin loading, strengthening and activating the glutes more rigorously. Be gentle on yourself. Sometimes we have to take baby steps for awhile. Do not overlook the benefit of qualified instruction if you are new to physical training.
