Description of Short Right Leg Syndrome

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Two Signature Traits

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​Elevated left hip

Elevated right shoulder

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Anthropological Perspective - Evolutionary Adaptation Theory

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My personal theory...published February 2021...Short Right Leg Syndrome (SRLS) is a dominant genetic trait. It is the result of evolutionary adaptation giving a mother and child a greater chance of survival in prehistoric times. The two signature traits of SRLS enables baby to be securely carried on the elevated left hip, shoulder bag of provisions securely carried on the elevated right shoulder, freeing the dominant right arm for work and defence. This was the most successful model. It is living proof our ancestors were predominantly right handed. Otherwise, we would be seeing short left legs. We do not see short left legs.​

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Three Cardinal Signs

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While a leg length discrepancy may be small and hard to detect without x-ray examination, what it does to the body is magnified. These Cardinal Signs confirm the possibility a leg length discrepancy exists.

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First Cardinal Sign - Anterior Rotation of the Left Hip, Sagittal Plane

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​The First Cardinal Sign of a short right leg is anterior rotation of the left hip in the Sagittal plane. It is an unconscious anatomic adjustment pulling the structurally longer leg upwards. The Ilio-Femoral Joint moves in an arc posteriorly and superiorly as the hip rotates about the Sacro-Iliac Joint, partially reducing pelvic tilt in the Frontal plane, making us feel more comfortable and protecting the spine. This is good but chronically binds the SIJ tightening ligamental structure and compressing cartilage through the Spanish windlass effect with the left hip flexor Iliacus being tighter/shorter than the right. This may or may not cause discomfort or pain at the SIJ. Regardless of discomfort levels, in the short term, inhibiting energetic/Qi flow down the backline of the lower limb causing a subtle thickening and tightening through connective tissue that can morph under loading and other influencing factors into acute pain, dysfunction and injury. In the longer term, leading to instability and damage to the SIJ. The most frequently sighted hip posture is high range unilateral anterior rotation of the left hip in the Sagittal plane with an even right hip. This is so common I call it "normal" despite being bad posture.

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• Left ASIS inferior to the left Iliac Crest assessed in the standing position.

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• High range anterior rotation of 30 to 45 degrees at left hip and level right hip is the most common presentation sighted in clients attending clinic. 

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• Short and tight left hip flexors...Iliacus in particular.

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• Binding the SIJ through Spanish windlass effect tightening ligamental structure and compressing cartilage. This may or may not cause discomfort in the joint.

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• Regardless of discomfort levels, energetic Qi flow down backline of left lower limb from glutes to plantar fascia can be blocked at the bound SIJ  .

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• In the short term, causing a subtle thickening and tightening through the connective tissue frequently mistaken for inflammation but rapidly relieved in a matter of minutes when clearing the blockage. A powerful hip flexor stretch alone can be sufficient to provide temporary relief.

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• Inactive gluteal and hamstring musculature requiring extensive warmup to initiate full activation.

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• This subtle thickening and tightening can degenerate to acute dysfunction, pain and injury such as Plantar Fasciitis, Chronic Compartment Syndrome, Achilles/Calf/Hamstring tendonitis, strains and ruptures, and/or Piriformis Syndrome and Sciatic pain. The most common unforced football injury is the torn left hamstring. Every second or third player on the pro tennis circuit has Rock Tape down the back of the left hamstring. Although, after briefing Ash Barty on the effects of the Left Lower Limb Mechanism from SRLS, she recovered from chronic injury and went on to the major wins of her career and I suspect her Physio is speaking to others on the circuit...there has been a reduction in the amount of left hami's being taped.

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• In the longer term, hip rotation left uncorrected can lead to instability, degradation and injury of the SIJ in older age.

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Second Cardinal Sign - Rigid Right Hip

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Rigidity through the right hip from the QL's in the lower lumbar region through to the Ilio-Femoral Joint and Adductors readily felt by practitioner and client tractioning from the ankle in supine...right side wooden and unmoving, left side soft and giving. This rigidity is due to three factors: altered gait, the impact of the First Cardinal Sign on Gluteal stability of the Pelvis and the effect of Pelvic tilt on the lumbar spine.

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With each step taken the left foot confidently finds the ground whereas due to the Pendulum effect, there is a momentary hesitation before the right foot plants generating holding patterns through hip and adductors. Soft tissue about the right hip becomes rigid, wooden and the right Adductor Magnus will be tight. Most cases are unaware of this rigidity until tractioning each leg from the ankles in supine reveals the glaring contrast.

 

Due to left SIJ binding from the First Cardinal Sign, the left Glute Med becomes inactive due to energetic Qi flow blockage at the SIJ. It is in partial spasm and does not adequately stabilise the pelvis. As a result, the left TFL and the right QL’s are loaded compensating for this. This contributes to the tightness observed in both the right QL’s and left ITB, and knee pain.

 

The other aspect of the story at the right hip is Pelvic tilt in the Frontal plane. A dropped right hip and elevated left hip geometrically distorts lumbar spine into right convexity. Creating a slight wedge shape through the geometry of the lumbar disk spacing, encouraging disks to bulge slightly to the right. Rarely catastrophic but tenderness and tightness in the right QL's is part of the symptomatic pattern of SRLS.

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• The pendulum effect...momentary hesitation before footfall of the short right leg developing unconscious holding patterns through the hip from QL's and Iliac Crest through to the Adductors with each step taken.

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• The inactive left Glute Med fails to adequately stabilise the hips with its cantilevering action when the right foot is lifted off the ground.

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• The left TFL and right QL's are loaded generating tightness and pain in the left ITB and knee and right lower back.

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• Right leaning pelvic tilt distorting the geometry of the lumbar disk spacing into a wedge shape. A dropped right hip and elevated left hip encouraging vertebral disks to bulge slightly to the right.

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• Tightening of the Adductor Magnus, QL and across the length of the Iliac Crest through to the ASIS on the right side.

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• Restricted ROM at the right Ilio-Femoral and Sacro-Iliac Joints.

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• Restricted flexibility through the right hip readily noted when tractioning lower limbs from the ankle in supine...right hip wooden and immobile, left hip soft and giving.

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• Heightened chance of injury due to reduced flexibility.

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• Strong blocking effect on the Bladder meridian's circuitous passage through the right lower lumber and hip region.  I describe this as a choke point on the Bladder meridian frequently leading to pain and mobility issues in the right lower limb. In the long term weakening the right kidney leading to Kidney deficiency symptoms as described by TCM.

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Third Cardinal Sign - Mild Scoliosis

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Mild scoliosis causes asymmetrical development of the rib cage. Always right leaning through the Lumbar spine but may be right or left convexity through the Thoracic. Higher range cases are more convincingly encouraged into right convexity through the Thoracic. Lower range cases are more likely to be either left or right convexity. Left convexity cases are less common overall. The side of convexity can be identified by bulging costals resulting from being crowded by the spine's lateral diversion over a lifetime. This is more readily palpated than seen. Spinal extensors will be more heavily developed and tighter through the middle and lower Thoracic on the side of convexity. Responsible for much upper back, neck and shoulder tightness that is the bread and butter of physical therapists and restricting rotation in the Transverse plane. Musculature in the upper Thoracic on the side of convexity is frequently dysfunctional and problematic.

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• Right leaning pelvic tilt in Frontal plane.

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• The Sacrum being the spine's foundation angled to right.

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• Right leaning scoliosis in the Lumbar region.

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• Right convexity through the Thoracic.

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• Asymmetric costals being crowded to the right, bulge to the right of the spine and are flattened on the left. This mild scoliosis is more readily palpated than seen.

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• Right spinal erectors through middle Thoracic more highly developed and tight.

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• There are occasional exceptions where, despite a right leaning pelvic tilt, a switchback occurs low in the spine causing left convexity through the Thoracic...bulging left costals, flattened on the right, elevated left shoulder. My observation is left convexity cases are typically low range leg length discrepancies; the higher range cases being more convincingly persuaded into right convexity.

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Compensatory Pattern Through the Pelvis and Lumbar Spine

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• Anterior rotation of the left hip in Sagittal plane with a bound left SIJ, tight/short left hip flexors, and spasm in the left gluteals.

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• Rigid/wooden right hip, deep and painful tightening about the full length of the right Iliac Crest and right QL's, and a tight right Adductor Magnus.

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• Right leaning pelvic tilt in Frontal plane generating mild scoliosis, encouraging lumbar disk bulging with tight and tender QL's to the right side. 

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Injury and Dysfunction - Biomechanical Effects

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​With few exceptions, biomechanical issues contributing to pain and injury are generally secondary to issues resulting from energetic effects caused by SRLS. This may explain why minor postural anomalies through the pelvic region are overlooked as the fundamental cause for many conditions. My reading of conventional practitioners assessment of some lower limb conditions are an over thought catalogue of minor anatomical aberrations. These are sublimated when the pelvis is attended to and energetic flow resumes.

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​The primary exception sighted in practice is chronic rotation of the left hip in the Sagittal Plane which has the potential to injure the left SIJ. Pain and discomfort from the tightly bound joint can commence in juvenile years...the Spanish windlass effect compressing cartilage and loading the joint...ligaments becoming unduly tight with a mere 10 or 15 degrees rotation. With advancing age the joint can become unstable and prone to injury. The most commonly sighted hip posture is high range unilateral anterior rotation of the left hip and a level right hip.

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Tightness and sensitivity or pain in the right QL's indicating possible right sided lumbar disk bulging caused by right leaning pelvic tilt is less common but a greater concern because integrity of the spine may be compromised. Rarely catastrophic and usually mild in nature but part of the common lumbro-sacral pattern palpating the QL's. Loading and/or an event can result in varying degrees of dysfunction up to and including catastrophic spinal injury.

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​Naturally, there is direct biomechanical stress through upper back and neck from mild scoliosis. Similarly, due to ignorance of the fact SRLS is so pervasive, theories for spinal conditions exist finding causation in temporal mandibular joint and cervical vertebrae conditions generating dural drag, etc., down the spine. These theories should be reviewed taking into account pelvic distortion and effects from a short leg working up the spine.

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The Nature and Specifics of Energetic Blockage/Inhibition

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Chronic physical distortion and strain on the soft tissue of the pelvis and lumbar spine caused by a leg length discrepancy inhibits energetic flow in three ways. Firstly, Qi flow in the Du and Ren Meridians and vitality of the Root, Sacral and Plexus Chakras is inhibited. Secondly, Qi flow in the bilateral organ channels for the Kidney, Urinary Bladder, Stomach, Spleen, Liver and Gall Bladder passing through the pelvic region to and from the lower limbs is inhibited. Thirdly, flow of protective Wei Qi to the lower limbs through the connective tissue around muscles, bones and under the skin similarly inhibited.

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First and Second Order Energetic Effects

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I separate the outcomes from energetic Qi flow blockage into two categories, being; mobility and internal health. The scope of my practice as a Remedial Therapist is largely restricted to assessing and treating symptomatic effects relating to pain, dysfunction and injury affecting mobility. This was my focus when first observing and eventually treating the effects of structural leg length discrepancy. I describe these First Order Energetic Effects. However, it became evident from client feedback the outcomes from heel lift treatment not only improved mobility issues but there were also coincidental beneficial side effects to internal health with reports of improvement to digestive, reproductive and kidney function. As a Remedial Therapist, I do not diagnose nor directly treat these conditions and describe them as Second Order Energetic Effects.

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First Order Energetic Effects - Restricted Mobility

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First Order Energetic Effects are where energetic flow is inhibited or blocked due to postural anomalies, overwork, injury, attacking pathogens (cold, heat, wind, dampness), emotional factors causing a subtle thickening and tightening of the connective tissue that can lead to pain, dysfunction and injury in the limbs and torso restricting mobility. This is primarily but not exclusively due to inhibited Wei Qi flow. It is analogous to the "nebulous communication" along fascial meridians referred to by Rolfing practitioners. The principle of a proximal block having a distal effect is commonly sighted at hip or shoulder affecting the limb. The subtle thickening and tightening can be mistaken for inflammation where, in fact, clearing the proximal block and promoting smooth energetic Qi flow transforms the affected tissues, tone rapidly becoming normal.

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Left Lower Limb Mechanism

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The Left Lower Limb Mechanism is due to anterior rotation of left hip in the Sagittal plane about the left SIJ, binding the joint and blocking energetic Qi flow down the backline of limb from glutes to plantar fascia generating a thickening and tightening connective tissue. Under loading and other influencing factors this can escalate to acute pain, dysfunction and injury. This is the outcome of the First Cardinal Sign of SRLS which is an unconscious anatomic adjustment to reduce pelvic tilt in the presence of structural leg length discrepancy.

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Right Lower Limb Mechanism

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Three factors contribute to the Right Lower Limb Mechanism being the Pendulum effect on gait, Lumbar dysfunction and reduced hip stability. This is an escalation of the effects from the Second Cardinal Sign of SRLS being rigidity about the right hip.

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The Pendulum effect resulting from the shortened right leg's effect on gait causing momentary hesitation in footfall with each step. The left foot plants with confidence. The right foot not immediately finding the ground there is a brief hesitation and a holding pattern develops about the hip. Adding to this is Frontal plane pelvic tilt widening right side geometric spacing between lumbar vertebrae and reducing left side spacing encouraging lumbar disk bulging to the right. Rarely catastrophic but sufficient to cause tenderness and tightening in the right QL's. Owing to anterior rotation of the left Hip binding the SIJ, the left gluteals become inactive and do not adequately perform their stability function providing a cantilevering action to hold the right hip up when the right foot lifts off the ground. Hence, the left TFL and right QL's are unduly loaded taking up this role.

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The combination of these factors cause the right hip from lumbar region to the Acetablum and Adductors in the groin to tighten. Tractioning from the ankle reveals an unmoving wooden hip. Whereas, the left hip is flexible and giving. The right SIJ while properly aligned can be stuck and painful to palpate. This causes an energetic block not unlike that seen in the Left Lower Limb Mechanism, tightening and thickening the connective tissue down backline of lower right limb.

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While instances of acute symptoms from the Right Lower Limb Mechanism are less frequent than left sided cases, there is more cause for concern than left sided cases owing to the fact spinal integrity is possibly compromised. The distal effect in the lower limb from Left and Right Sided Lower Limb Mechanisms appear similar.

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Lumbar Mechanism

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Scoliosis has been studied extensively and my insights are rudimentary at best. Many fields of therapeutic practice overlook the effect of energetic Qi blockage through the pelvis and lumbro-sacral region on the spine. Misalignment of the pelvis tilts the spine's foundation causing scoliosis and the geometric anomaly already mentioned that encourages right sided disk bulging, generating chronic soft tissue stress inhibiting energy Qi flow. Where energy flow is blocked, thickening and tightening occurs restricting mobility through back and neck.

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Thoracic Mechanism

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Mild scoliosis causes spinal erectors through the thoracic on the side of convexity to tighten and be more highly developed. Right convexity is more common than left convexity. Elevating the shoulder on the side of convexity and tipping the neck and head to the opposite side. The chronic strain imposed trying to bring the head back to vertical lining up our eyes with the horizon causing dysfunction in the upper quadrant of the back and neck on the side of convexity. Rotation in the Transverse plane becoming progressively more restricted with age.

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Injury and Dysfunction - First Order Energetic Effects

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The combination of characteristics defined by gait, loading, prior injury, and flexibility can induce a mild underlying pattern to morph into acute pain, dysfunction and injury. As the subtle thickening and tightening through the connective tissue escalates, the tissues and sinews not only become painful but also lose flexibility and become vulnerable to injury and rupture. Lower limb conditions encountered include: Piriformis Syndrome and Sciatic Pain, chronic Hamstring, Calf and/or Achilles tightness, pain, dysfunction or injury, and Plantar Fasciitis. These conditions result from the Left or Right Sided Lower Limb Mechanisms becoming prominent and restricting energetic Qi flow down the backline of the lower limb. Often readily resolved by addressing the underlying structural leg length discrepancy.

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Back conditions resulting from scoliotic strain have an obvious biomechanical explanation but they too are affected by energetic Qi flow blockage causing thickening and tightening of the connective tissue. This contributes to restricted motion of the spine, particularly rotation in the Transverse plane accompanied by high degrees of tightness and discomfort/pain in the upper back, neck and shoulders which is the bread and butter of the physical therapy industry. There is a tendency for low level right sided mild lumbar disk bulging to cause tightness and tenderness through the right QL's. I have noted a correlation between the right SIJ dysfunction and this right sided lumbar condition. Ultimately, under loading or the impact of an event, catastrophic spinal injury can result under the influence of these underlying issues.

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Either through advancing age, reduced mobility and flexibility or when an overlaying lumbro-sacral injury compounds the energetic block at the pelvis caused by SRLS, lower limb degradation accelerates. Reduced lower limb strength and mobility. Lower limb circulation inhibited leading to fluid retention, meridian pain, joint pain, and increasingly reduced lower limb function over time. This is an outcome I have encountered in practice. There is a sidedness to this effect where the Second Cardinal Sign of rigidity through the right hip predisposes that side to be more affected. Specifically, the Bladder meridian is strangled in the small of the back having the potential to cause meridian pain in the back of the leg and the lateral aspect of the heel, and weaken the right kidney in the long term leading to Kidney deficiency symptoms as described by TCM.

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Second Order Energetic Effects - Internal Health

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Second Order Energetic Effects are where energetic Qi flow is inhibited or blocked due to postural anomalies, overwork, injury, attacking pathogens (cold, heat, wind, dampness) or emotional factors that has an adverse effect on internal health. These effects are due to inhibited energetic Qi flow in the Du and Ren meridians and the six bilateral acupuncture meridians or organ channels for the Kidney, Urinary Bladder, Liver, Gall Bladder, Stomach and Spleen passing through the pelvis to and from the torso and lower limbs. 

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Injury and Dysfunction - Second Order Energetic Effects​

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In TCM theory, inhibiting Qi flow can have a direct effect on internal health. Apart from improved lower limb function and reduced back pain, I have observed a correlation between commencing heel lift treatment for SRLS and improved digestive, reproductive and kidney function. This is accompanied by increased vitality and mental clarity. It would appear to be a coincidental beneficial side effect. This is supported by TCM theory and is known to some TCM practitioners. The internal health outcomes that can be influenced by SRLS are best considered by a TCM practitioner. It is beyond the scope of practice of a Remedial Therapist to consider diagnosing and treating internal health conditions.

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First published 16 May 2021 at https://www.facebook.com/MassageWorksDandenongRanges

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