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.
Three 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. Sub-acute symptoms reflect the common pattern. Acute symptoms manifest more specifically within the overall common pattern...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 can give a different reading depending on the subject’s girth. 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 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 exceptions are hyper-mobile individuals with soft muscle tone.
Right Leaning Scoliosis
In most cases, the degree of right leaning scoliosis present is so mild subjects are not aware of it. Nor have they been told by prior practitioners 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. At this point in the discussion, it is another piece of evidence supporting the fact a LLD exists.
Where one hip is inferior to the other due to a LLD, there will be a tilt across the Frontal plane through the pelvis. This also tilts the sacrum which is the foundation for the spine. As a result, the spine leans towards the side of the shorter leg with a convexity to that side through the Thoracic region. In mild cases, the curve through the spine is difficult to sight. However, the affect on the rib cage is readily palpated. There will be bulging through the ribs being pressed to one side while the opposite side flattens as they are pulled. With SRLS, the rib cage will bulge on the right side and be relatively flat on the left. The right spinal erectors will be more developed.
Note that where where a subject has legs of even length and the left hip is in forward rotation, the right hip is level, you would expect to see a left leaning scoliosis. The anterior rotation of the left hip being an anatomical adjustment that functionally shortens the left leg, making the left hip inferior to the right. I have never sighted this. Every case I have examined has been accompanied by a short right leg. The anatomical adjusting rotation of the left hip reduces the LLD but never eliminates it entirely. Mild right leaning scoliosis results.
Rigidity at the Right Femoro-Acetabular Joint
Rigidity at the right hip in SRLS is likely due to the fact that with every step taken during the course of life, the right foot stepping through does not find the ground. I call this the pendulum effect. Even after all the tilting and rotating compensation at the hips, 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. The SRLS subject's left hip flexors are short/tight owing to that hip being held in chronic anterior rotation. The right hip is usually level and the right hip flexors are not short/tight but the hip is rigid when tractioning inferiorly and compressing superiorly. The adductors at the right hip will be tight and will require more stretching than the left side.
This article is still a work in progress
First published 29 September 2020