Short Right Leg Syndrome - Signs and Symptoms
Chatting with my Craniosacral instructor, Malcolm Hiort, a few years ago, he mentions that 68% of his clients have a short right leg. I go… “What?!?!” ”No...not possible!!!”
We were taught to assess leg length in the Diploma of Remedial Massage at Swinburne Uni. I had not noticed a significant number of leg length discrepancies in clinical practice. Had I really been looking? Well...the truth of it was, I had not. Once I started doing regular assessments I observed many cases and after several months had to agree with my instructor. About once every year or two I encounter a short left leg which is the result of injury in their youth affecting growth. Of the rest, there is the occasional even leg case and the majority of clients on my table have a short right leg. This is Short Right Leg Syndrome (SRLS). Most clients with SRLS are unaware of it and have a range of mild to acute symptoms affecting the backline of either lower limb, SIJ, back and/or neck.
Signs and Symptoms
• Anterior rotation of the left hip in the Sagittal plane and a level right hip.
• Tight left hip flexors.
• Sensitivity or pain on palpation of the left SIJ may be present but it is not always the case.
• Elevated left ASIS in standing and supine...ankles will be level in supine unless there is overwhelming distortion through lumbro-sacral region resulting from a QL spasm, in which case, supine ankle and ASIS positions must be examined more closely and compensation made.
• Tenderness and tightness through the QL's in the right lumbar region. More acute cases will have possible disk bulging to the right.
• Tightening and thickening through the back line of the left or right lower limb through glutes, hamstrings, calf, achilles and plantar fascia >>> pain and injury such as plantar fasciitis, chronic compartment syndrome, achilles and hamstring tear/rupture, gluteal tightness/inactivity, piriformis syndrome and sciatic pain. While the mechanisms for left and right sided symptoms differ and I have not yet sighted a SRLS case experiencing both together, a bi-lateral case is hypothetically possible. Left sided presentations are far more common. Right sided cases less frequent and more concerning because indicates possible injury to spine.
• The same tightening and thickening through the backline of the left lower limb restricts forward movement of the left hip inhibiting rotation about the lower spine in that direction. That is, subject side-lying on right side, rotation through spine (press shoulder back on table, push hip forward) is restricted compared to same action side-lying on left. Descriptions of scoliosis put this in terms of the lumbar spine being rotated in an anti-clockwise direction.
• Stiffness/rigidity at right hip easily felt tractioning from the ankle.
• Tight adductors in the right lower limb.
• Mild right leaning scoliosis with thoracic vertebrae pushed to the subject's right (viewed posteriorly), bulging the ribcage to the right of the spine, flattening it on the left >>> more highly developed spinal erectors on the right mid thoracic >>> elevated left hip and right shoulder. In rare instances a double switch back occurs at the lower thoracic resulting in a left leaning scoliosis with bulging costals on the left.
In summary, the most common pattern sighted is pelvic tilt in the frontal plane with the left hip elevated and sloping down to the right. The left hip is in high range anterior rotation. The right hip is level. A small degree of anti-clockwise rotation of the lumbar spine in the horizontal plane...I do not consider this in assessment, it is minor and not directly relevant to major symptoms encountered. The backline of the left lower limb will be subtly thicken and tight from the glutes through to the plantar fascia. The left SIJ being chronically rotated to full range of motion is commonly tender to palpate. The right QL's are tight and may be tender to palpate. Right leaning scoliosis is evident through the thoracic with bulging costals and more developed costals to the right. The right shoulder will be elevated over the left.
A variation on this is thickening and tightening down the right lower limb instead of the left side due to a more acute state of disk bulging and dysfunction in the lumbro-sacral region. While it is hypothetically possible for bilateral backline dysfunction through the lower limbs, I have never encountered it. Once symptoms become acute causing high degrees of tightness, pain and possible injury, it is always clearly a right or left sided issue. Left sided cases being the most common presentation.
Leg Length Tests Demonstrating SRLS
• Standing, viewed from the front, subject's left ASIS superior to the right.
• Standing, viewed from the rear, the subject's right gluteal fold inferior to the left.
• Supine, raise knees flexed to 90 degrees, forming a triangle with hip, knee and ankle, feet flat on table top. Should one hip be superior in the supine position, adjust the foot position of that leg superiorly by an equivalent amount and compare the height of the triangle at the knee. Even without making this adjustment to ensure each triangle has the same length base, it will still demonstrate a leg length difference. This test confirms the straight leg comparison result and is also a concrete way of bringing it to the subject’s attention there is a leg length difference...by simply raising their head slightly they have an ideal view of the knee height discrepancy.
• Frontal X-Ray of the subject’s hips, standing upright gives indisputable evidence measurable with great accuracy.
(Note to self...incorporate words on back bridging and lateral release eliminating major aberrations at lower back and hips that may be affecting results in supine)
Leg length differences estimated between 10mm and 20mm are common. Less than 5mm we will be seeing signs but actually detecting difference may be a challenge and I am uncertain. 15mm is big and normally expect back pain and high degree of rotation at the hip of the longer leg and all that goes with it. 25mm is huge but I have one client with this (determined by a Chiropractor with x-ray) and he is just fine clomping around like a pirate on a peg leg totally unaffected by it...a boxer so enormously fit and strong his torso maintains its integrity...when older, out of shape drinking beer on the couch and watching reruns it may be a different story. Twice I have sighted leg length differences in the order of 35mm. Both were experiencing acute symptoms and dysfunction. Neither wished to acknowledge the condition or engage in treatment.
When one leg is longer than the other, standing both legs evenly planted feels uncomfortable...the higher hip throwing an unhealthy tilt into the spine. Unconsciously we make a postural flop, anteriorly rotating the hip on the side of the longer leg. This is an anatomical adjustment pulling the left leg upwards and we feel better. The hip rotating about the SIJ is a cam adjustment for the hip joint at the acetabulum which rotates about the SIJ posteriorly and superiorly on an arc with a radius of approximately 120mm...this has the potential to pull the limb upwards in the order of 5mm at full rotation, adjusting the apparent leg length, levelling the hips to some degree. This is good because it is protecting the spine. It is bad because the left sacroiliac joint rotated anteriorly is causing chronic tightness in the soft tissue of the joint by a mechanism analogous to a Spanish Windlass. It is rarely sufficient to compensate fully for the leg length difference and sign of scoliosis results.
Due to the leg length difference, weight loading is not evenly distributed between both legs. The longer leg is supporting greater weight and it is part of the mechanism for the hip rotation observed at the left hip. It is also why efforts to normalise the hip are not always successful. 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 and of course, the SIJ in chronic pain or repeatedly suffering acute injury.
Rigidity at the right hip in SRLS is likely due to the fact that with every step taken during the course of their life, the right foot stepping through does not find the ground...even after 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. I call this the pendulum effect. 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 Adductor Longus at the right hip will be tight.
While the postural position of the right hip is normal, occasional cases present with pain and dysfunction in the right SIJ. This may be due to abnormal hip rhythm issues resulting from rigidity at the right hip plus lumbar pain and tightness present in the right QL's. As a result the right SIJ is forced to mobilise through a higher range compensating for the lack of mobility at hip and lumbar region. This may be a part of the story for right sided lower limb cases described above, however, lumbar disk bulging would definitely be the primary influencing factor.
The effects of SRLS first came to my attention treating tightness, injury and pain in the back line of the lower limbs. Correlating forward rotation of the hip with tightness in the soft tissue of the SIJ, in turn blocking energy flow down the back of the lower limb, causing thickening and tightening through the fascia and connective tissue. The first success came clearing a chronic Plantar Fasciitis condition by normalising the hip posture through stretching chronically tight hip flexors. Why the left hip was pushed into anterior rotation remained a mystery until I learned of SRLS. This is not to say a subject having legs of equal length cannot have a rotated hip and suffer the same fascial tightening down the backline but the majority of cases I have sighted do have SRLS.
Think about this, how many of you find it more comfortable to carry a bag over the right shoulder? It just seems to continually slip off the left shoulder. SRLS causing an elevated left hip and elevated right shoulder encourages mothers to carry their child on the left hip and bag over right shoulder, leaving the dominant right hand free for tasks. I am now fairly convinced SRLS is an evolutionary adaptation increasing a mother and child's chances of survival in prehistoric times. It is now a dominant genetic trait in Homo Sapiens.
The varying degree of dysfunction or otherwise is wide ranging individually and no one description fits all cases. Some subjects are virtually unaffected, exhibiting no adverse symptoms while at the other end of the spectrum, lives and careers have been shattered by it. Treatment of the symptoms with Remedial Massage aided by exercise and stretching can prove sufficient. Frequently a prosthetic heel lift under the short leg is life changing for a suffering individual who had never been told by prior therapists they have a short leg.
First published 29 July 2019