Short Right Leg Syndrome - Considerations for Treatment
I am a Remedial Massage Therapist, graduate Swinburne University of Technology 2007. Clinical background: Athletic and sports client bias but the entire spectrum presents itself across my table. The material covered here was not included in the Remedial Massage curriculum. It should have been. This should be read in conjunction with my other material describing signs, symptoms and assessment of SRLS.
SRLS is common. Formal studies carried out reveal 70% of the population have a short right leg. I have some doubt about the accuracy of that study because I believe it was carried out using basic tape measure methods rather than X-Ray examination. It is likely the percentage with SRLS is greater than reported as inaccuracy of the tape measure technique (+/-5mm) will not allow the examiner to detect low level cases. I sight a much greater proportion in clinic but that is why they are there...SRLS is frequently the underlying cause for the condition that has brought them to the treatment table. However, the reality is many people manage with little or no adverse symptoms they are aware of. Particularly while they are young, flexible and active. It is not until reaching an older age where we have lost the flexibility of youth and are more sedentary or have a compounding injury that the condition becomes problematic. Every case is different. I have had clients between the ages of 12 and 75 adversely affected by the condition.
The aspect of Short Right Leg Syndrome (SRLS) most prominent in the early years of my practice where I had a large sports bias in my client base has been symptoms in the back line of the left lower limb caused by rotation of the left hip binding the SIJ. Athletic activity minimises upper body symptoms of SRLS and aggravates lower limb symptoms. Similar symptoms, different mechanism, is sighted down the backline of the right lower limb. Lumbro-sacral dysfunction, discomfort and pain due to pelvic tilt, mild scoliosis, sometimes accompanied by a history of lumbar disk bulge and chronic upperback and neck tightness requiring endless treatment can be due to SRLS too.
Symptoms occurring down the backline of the lower limbs commonly present as a subtle thickening and tightening from Glutes/Piriformis, Hamstrings, and Calf to Plantar Fascia. Low grade conditions can persist for years and with changed activity progress to acute symptoms of pain and injury. Acute symptoms are normally experienced in one area only such as the Plantar Fascia or the Hamstrings but I do have a client who successively over a period of 20 years suffered Piriformis Syndrome and Sciatica, Plantar Fasciitis, full Achilles Rupture and a grade 3 Hamstring tear all to his left side. Interestingly, not one the medico’s (GP, Surgeon, Physiotherapist, Chiropractor and Remedial Massage Therapist) consulted over the years considered his leg length difference or hip rotation relevant. He was not aware of the leg length difference until my assessment of his condition. He is a retired engineer and immediately took it upon himself to use an adjusting heel lift when the effect of the structural leg length difference was explained. Being in his 70’s the body had well and truly adapted and was set in its ways...change was slow. Over the course of the first six months he reported gradual improvement to gait and muscle tone in the left leg had normalised as the left hip’s anterior rotation unwound moving from high range anterior rotation to a low/moderate level. Over the following two years he continued to report improvement to gait, balance, and energy levels. At 60 he had stopped climbing ladders because of balance issues. At 75 he now is up the ladder and walking about on his sloped tiled roof using a leaf blower to clean the gutters. It took two years for his gait and balance to improve sufficiently for him to perform this feat. By contrast, a fourteen year old soccer player that could not play beyond half-time in matches due to overwhelming pain and restriction through the hips and lower back, was 100% pain free within two weeks of adopting a heel lift and playing full duration matches.
I have previously discussed the futility of attempting to treat the affected areas of the lower limb to achieve release where the hip is chronically held in a rotated position. Incidentally, posterior and anterior rotation has the same effect on the SIJ and backline of the lower limb...posterior rotation rarely rates a mention, I have only sighted three instances in fifteen years. Massage and stretching at best merely provide temporary relief until the hip position is normalised. Then in a matter of days, symptoms of tightness and pain abate without the need for further treatment. Of course, this is only applicable where the condition has not degenerated to a more acute state with the development of heel spurs, tears or rupture.
The left Glutes in these left lower limb cases are always in considerable spasm and lumbar tightness and pain is usually evident when pressing into the right QL. Apart from the thoracic scoliotic curve bulging costals to the subject’s right side and flattening them on the left, you will note the right spinal erectors are more developed than the left. Because we are discussing low range structural leg length differences that are partially compensated for by left hip rotation, an anatomical adjustment functionally shortening the longer leg, the effects of mild scoliosis at the upper thoracic and neck may be more successfully managed through exercise regimes. Other patterns such as a desk bound worker’s overuse of a computer mouse, shoulder/torso rigidity leading to RSI and Carpal Tunnel in the arms or sporting injuries can take prominence.
Less common are right sided lower limb issues occurring as a result of SRLS. They will appear identical in nature to left sided cases except the cause rather than being a bound and tight SIJ is lumbro-sacral dysfunction. Right leaning pelvic tilt in the Frontal plane closes lumbar vertebral spacing on the left and opens it on the right encouraging mild disk bulging to the right. Rarely catastrophic, tightness and tenderness on palpation in the right QL’s combined with spasming left Gluteal musculature from the anteriorly rotated left hip is a common pattern. Where the lumbro-sacral dysfunction from right sided disk bulging becomes sufficiently acute it causes an energetic block affecting the backline of the right lower limb.
My approach to treating lower limb symptoms due to SRLS where I estimate the leg length difference is not high range (<10mm) and symptoms are manageable/not too crippling, is normalising hip anomalies by releasing hip flexors and lower back tightness, activating/strengthening abdominals and glutes and giving homework for the client for ongoing rehab. Achieving return to a completely level hip position has not been necessary to reduce symptoms. I do have concerns for the integrity of an SIJ that has been held chronically (decades) at full ROM being normalised too quickly...stretched ligaments across the joint may then be too loose causing instability and make the SIJ vulnerable to injury. I do have concerns too that normalising hip posture will aggravate any upper back condition by increasing pelvic tilt and scoliotic forces...it's almost like a heel lift is inevitable. However, I need to stress, all cases are different and individual ability to manage and live with these minor leg length differences varies enormously and are affected by age, flexibility, strength and activity levels.
Fitting a heel lift comes into consideration should initial treatment and rehabilitation fail or where acute symptoms directly attributable to SRLS are present. The left hip’s anterior rotation will resist attempts to normalise the posture despite rehab and treatment efforts. It would be nice to be able to leave the hip in this position because it is protecting the spine and upper body posture but where it is responsible for lower limb and/or SIJ dysfunction, this cannot be allowed to persist and use of a heel lift is required. Some clients who have been struggling for years through a successive range of therapists are quick to adopt the use of a heel lift when they learn the underlying cause of their symptoms is the leg length difference.
Weight loading is not evenly distributed from side to side. The longer leg is supporting a greater weight and it is part of the mechanism driving rotation at the left hip. Occasionally, it is the cause of injury in the longer leg...I have seen tibial stress fracture in a young adult athlete and arch collapse (left foot only) in a juvenile which were influenced by the load imbalance.
Should a reader be thinking of dabbling with a heel lift, understand the body has already made considerable adjustment over the course of many years. It is not necessary to adjust for the full leg length difference. To do so would be over compensating. Start small and only go taller if required over time monitoring progress.
There is no formula for calculating the height of the adjusting heel lift. Every case is different and regardless of the magnitude of leg length difference, the body is only willing to accept adjustments in a limited range. The body has made huge compensation over many decades. This will not all be undone. Forcing the skeletal frame to perfect alignment is not going to happen. Attempting to do so will cause injury and pain. Heel lift height is not a function of leg length difference. It is more a case of what amount of adjustment will the body accept to fractionally back off tightness through the soft tissue, allowing energy/Qi to flow again reducing thickening, tightness and pain. There is a degree of trial and error determining the correct height for each case. I find between 3mm and 5mm...which may only be a quarter of the leg length...difference backs things off sufficiently to release soft tissue stress through the pelvis. This will eventually work its way up the spine relieving stress through the Thoracic spine and increasing mobility. In my case this took ten months to reach my cervicle vertebrae using the heel lift at all times.
A large person with a high range difference, I will go with 5mm. A small person with low range difference, start with 2mm or 3mm. I am guided too in the fitting process trialling first a smaller size in the client’s right shoe. If they definitely feel it kicking up their hip, we will stay with that. In some cases, they cannot feel the smaller heel lift and we will trial the higher 5mm size. If they begin to experience pain or symptoms worsen, reduce the height. I provide clients with a heel lift constructed from layers of 1.5mm and 2.0mm fibre reinforced rubber sheet. Several layers are glued together with contact adhesive. If it is too high, it is easy to simply peel off one of the layers. In my limited experience, I have not encountered anyone for which 3mm was too large but it is possible. I have only had one case where it has been necessary to increase the thickness beyond 5mm.
Be aware balancing leg lengths with a heel lift shifts weight bearing back to a more even distribution. The leg that has been lengthened will now carry a little more weight. A few aches and pains may be felt in that leg. This will pass as musculature and joints become accustomed to the new load and revised gait.
I recommend the heel lift be used at all times when standing and walking. Obviously it is not necessary when sitting and may not aggravate the condition if dispensed with when running but I do not have enough experience with this treatment yet to make a qualified statement about running. I would definitely recommend use of the heel lift during gymnasium training. The worst pattern would be to use it during the working day and on return home, stand barefoot in the kitchen for several hours undoing the benefit achieved. Several cases have reported removing the heel lift while walking and within a few minutes triggered their condition quickly reigniting pain and dysfunction. None of these cases had been using this treatment for more than a short period of time (months) and it may prove to be less sensitive in the longer term. I do have one client who since recovering from his right sided lumbro-sacral dysfunction accompanied by high pain levels and having an overwhelming affect down the backline of the right leg, commenced a dedicated training regime and now no longer uses the heel lift. His condition is still pain free.
Personally, I recommend continuing use of the heel lift if a leg length difference has resulted in pain, dysfunction and/or injury. Apart from the readily apparent symptoms of pain and dysfunction affecting mobility for which the client has sought out therapeutic treatment, there is another aspect to SRLS that affects our metabolism. It is outside the scope of my practice but improved digestive and metabolic health and increased vitality has been reported by clients treated with a heel lift. I experienced this too at the three month mark in my own treatment and attribute it to release of soft tissue stress enabling energetic flow in the TCM meridian channels through the pelvis to the lower limbs. Pelvic tilt in the Frontal plane places large scoliotic forces on the lumbar region, the right QL’s aggravated by resulting mild disk bulging are in spasm, the left hip is in high range anterior rotation in the Sagittal plane tightening the the left SIJ and left hip flexors, the right ilio-femoral joint is rigid and the right adductors are tight...basically there is a high degree of rigidity through the entire pelvis from SRLS. This inhibits energetic flow in the Kidney/Bladder, Stomach/Spleen, Liver/Gall Bladder yin yang pairs of acupuncture meridians and the primary Governing and Conceptions vessels, and may explain improved digestion and increased vitality reported after commencing use of the heel lift. I call this a second order energetic effect. It is outside the scope of my practice. I do not diagnose or treat its symptoms. It is a beneficial side effect occurring when treating first order energetic conditions that result from SRLS such as, plantar fasciitis, chronic compartment syndrome, achilles, hamstring and gluteal thickening and tightness, SIJ issues from hip rotation and back pain and tightness from mild scoliosis.
Success with the use of heel lift treatment approach is sporadic mainly because SRLS is a largely unknown phenomena and the explanation for lower limb symptoms is founded in Chinese medicine and Eastern philosophy...there is no biomechanical or neurological link between the SIJ and symptoms being experienced down the back of the lower limb. It relies on an understanding of Chi flow and the effect its blockage has on fascia and connective tissue. Hence, some clients will not engage with the treatment out of disbelief and scepticism. Another hurdle encountered are clients that must strengthen themselves through exercise that have no prior experience with physical training...I can release tightness, I can encourage muscle activation but I cannot strengthen their muscles...they have to do that and if they do not participate and do homework, outcomes are bleak...but then this can be applicable to all conditions we treat.
Without the use of an adjusting heel lift, the body will otherwise default to the most comfortable position with a rotated hip as a long held reflex action without the use of an adjusting heel lift. Hypothetically, diligent rehab exercises can rectify hip rotation anomalies causing lower limb dysfunction and symptoms. I imagine it requires the fitness and determination of a highly trained athlete to achieve. However, achieving a normalised level hip position will be at the expense of increasing pelvic tilt in the Frontal plane aggravating the spine above the pelvis. Sometimes it is like the use of an adjusting heel lift under the short leg cannot be avoided where acute symptoms exist.
First published 5 August 2019 https://www.facebook.com/MassageWorksDandenongRanges