Short Right Leg Syndrome – Cardinal Signs and Assessment Protocol in the Context of Remedial Massage Treatment
Physical therapists are taught to assess structural leg length in basic training. How often do they actually do so in practice? My clinical experience has revealed many individuals are struggling with pain and injury from pelvic tilt across the Frontal Plane caused by minor structural leg length differences. They have often been on the planet many decades...yet they were never told they have a leg length difference. In my clinical experience, in the order of three out of four clients present with a short leg. It is always the right leg...sightings of a short left leg are rare. This is an outline of my assessment protocol for Short Right Leg Syndrome highlighting the use of cardinal signs. It is as yet incomplete and a work in progress.
Cardinal Signs of Short Right Leg Syndrome
Symptomatically there are common patterns to Short Right Leg Syndrome (SRLS). Some subjects show the signs but have no acute symptoms and manage fine with maintenance activities of exercise, stretching and massage. Other subjects can be crippled and their life a misery. The symptoms are wide ranging affecting subjects from head to toe. Sub-acute symptoms reflect the common pattern. Acute symptoms manifest more specifically within the overall pattern...in a sense, the subject breaking at the weakest link owing to congenital weakness, postural and gait habits, loading or prior injury. Naturally, it cannot be assumed the cause is SRLS without confirming the anatomical asymmetry actually exists.
In some instances, subjects exhibit symptoms resulting from a Leg Length Difference (LLD) so small it is difficult to detect by simple examination without the use of X-Ray equipment. However, the effect a LLD has on the body is amplified generating several cardinal signs that are easy to detect by palpation. In practice, I use these cardinal signs to confirm the possibility a short leg is contributing to presenting symptoms before attempting a leg length assessment. The cardinal signs of SRLS are:
a. Anterior rotation of the hip on the side of the longer leg. That is, in a standing position the ASIS will be lower than the Iliac Crest as the hip rotates in the Sagittal Plane about the centre of rotation at the SIJ. The side of the short leg will typically be level;
b. Sign of right leaning scoliosis with a bulging rib cage and more developed spinal erectors through the middle Thoracic on the side of the short leg. The opposite side will be flattened. This is more readily palpated than seen with the subject prone; and
c. Rigidity at the Femoro-Acetabular Joint of the short leg and the adductors on that side will also be tight. Tractioning legs from the feet reveals free movement through the joint on the side of the long leg and a rigidity at the hip of the short leg.
Hip Posture Assessment – Standing and Prone
Anterior rotation of the hip of the longer leg is an anatomical adjustment that functionally shortens the longer leg, reducing the LLD and tilt across the Frontal Plane of the hips, affording the spine some protection. I rate the degree of rotation from Level successively through to Very High Range measuring the difference in height between the top corner of the ASIS and the Iliac Crest as follows:
a. Level to Mild Range, 10mm or less (0 to 6 degrees);
b. Medium Range, 20 – 40mm (8 to 15 degrees);
c. High Range, 50-60mm (18 to 22 degrees); and
d. Very High Range, greater than 60mm...the largest sighted being approximately 100mm (25 to 30 degrees).
Level to Mild Range is the ideal hip alignment in the upright standing position. It might be considered normal or good posture but it is not the norm. In clinical situations, three out of four clients have a LLD which present with some degree of chronic anterior rotation of hip on the side of the longer leg. The greatest number have unilateral, left sided anterior hip rotation in the High Range.
I typically carry out an assessment of hip posture following initial discussion of the client’s condition prior to commencing treatment. Practitioner seated to the side of the client standing looking straight ahead. Noting Lordosis, Kyphosis, FHC, and degree of chest tightness. Hip orientation in the Sagittal Plane is examined by palpating the Iliac Crest and top corner of the ASIS to determine hip position on both left and right sides.
My preference is to do the standing assessment, however, it is also possible to do so with subject lying prone. In the standing assessment we are looking at the hip position in relation to a horizontal line parallel to the floor. In the prone position it is in relation to a vertical line perpendicular to the floor. My concern is with gravity force vectors rotated 90 degrees the test may give a different reading. While I have not made a close study comparing the test in different positions, it does seem to give a similar indication of hip alignment. I resort to testing in the prone position when reacquainting myself with a particular client’s condition or checking for progress during the course of a treatment. It is a quick, non-invasive although sometimes ticklish test to carry out.
Testing hip posture in the prone position, place the thumb on the Iliac Crest and forefinger on the top corner of the ASIS. Visually sighting the height difference front to back is not really possible. It becomes a judgment made by feel and estimating the distance off vertical. Comparison to the opposite side which you may have previously tested and know to be level aids judgement. If you are not confident with your ability to make this assessment in the prone position, refrain from doing so and rely on the standing assessment.
Sacro-Iliac Joint Assessment
Owing to the direct affect hip rotation has on the SIJ, I palpate it too at this time. Client standing, back to the practitioner, palpate SIJ’s with thumbs to determine sensitivity or pain present in each side. Take care to question client closely on this comparing side to side. Light to moderate pressure on the SIJ should illicit no pain or sensitivity in a normal joint. Clients will be inclined to disregard low level discomfort and report no problem.
Where a hip has been chronically held in a rotated position there is frequently some discomfort and dysfunction at the SIJ. Not all cases of chronic hip rotation generate pain in the SIJ, nevertheless, the tightness present in the soft tissues of the joint due to ligamental twist and compression through the cartilage (the Spanish Windlass effect) can cause energetic blockage that will affect the lower limb distally. In some cases, Medium Range hip rotation (8 to 15 degrees) is sufficient. High Range hip rotation will almost always have this affect yet there are some exceptions...my observation has been these are individuals with hyper-mobile joints and soft muscle tone.
Right Leaning Scoliosis
There are tried and true methods for assessing scoliosis but I am not going there with my clients. In most cases, the degree of right leaning scoliosis present is so mild they are not aware of it and they have usually never been told by any practitioner they have it. I do not wish to alarm them yet even though mild, it can be the cause for their history of upper back and neck issues of discomfort, pain and/or headaches. It can be cause for low back pain and disk bulging through the lumbar region. It is another piece of evidence supporting the fact a LLD exists.
This article is still a work in progress...
First published 29 September 2020