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. I rarely encounter a short left leg. Those sighted are the result of injury in their youth affecting growth. Of the rest, there is the occasional near even leg case and the vast 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, Two Signature Traits and Three Cardinal Signs
• Elevated left hip.
• Elevated right shoulder.
• Anterior rotation of the left hip.
• Rigid and wooden right hip.
• Mild right leaning scoliosis with thoracic right convexity or less common left convexity cases should there be a double switchback lower at the junction of lumbar and thoracic spine. The right convexity cases accompanied by more highly developed spinal erectors in the right mid-thoracic and bulging right costals and vice versa for left convexity cases.
Signs and Symptoms, Left Side Mechanism
Mechanism: Anterior rotation of the hip in Sagittal plane causing SIJ to tighten blocking energy/Qi flow along back line.
• Anterior rotation of the left hip.
• Tight left hip flexors.
• Sensitivity or pain on palpation of the left SIJ may be present but it is not always the case.
• Subtle tightening and thickening through the back line of the left lower limb through glutes, hamstrings, calf, achilles and plantar fascia. Restricted ROM in straight leg raise of left lower limb. May degenerate into more acute pain and injury in specific locations such as plantar fasciitis, chronic compartment syndrome, achilles and hamstring tear/rupture, gluteal tightness/inactivity, piriformis syndrome and sciatic pain.
• 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.
Signs and Symptoms, Right Side Mechanism
Mechanism: Pendulum effect of lighter hesitant foot fall in gait causing imperceptible holding through the hip; and mild right sided lumbar disk bulging due to right leaning pelvic tilt in Frontal plane.
• When tractioning from the ankle, stiffness and rigidity present at right hip. Wooden in comparison to the flexibility demonstrated through the left hip.
• Tight Adductor Magnus at the right groin.
• Tight and tender right QL’s.
• Sensitivity or pain on palpation of the right SIJ may be present but it is not always the case.
• A stuck right SIJ which manipulative therapists attempt to mobilise
• Subtle tightening and thickening through the back line of the right lower limb through glutes, hamstrings, calf, achilles and plantar fascia. Restricted ROM in straight leg raise. May degenerate into more acute pain and injury in specific locations such as plantar fasciitis, chronic compartment syndrome, achilles and hamstring tendinopathies or rupture, gluteal tightness/inactivity, piriformis syndrome and sciatic pain.
• Instances of symptoms presenting in the backline of the lower limbs are most frequently left sided. Something in the order of ten times more common. Where right side symptoms exist, it is more of a concern because it indicates the integrity of the spine may be compromised. Left side cases are less critical as it is the SIJ which is compromised. Both can degenerate to acute levels of pain and dysfunction. Both can be quick to rectify depending on degree dysfunction or damage present in the joints, the subject’s discipline carrying out rehab exercise and use of an adjusting heel lift, if fitted.
Discussion of Short Right Leg Syndrome Assessment in the Context of Remedial Therapy
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. The backline of the left lower limb will be subtly thick and tight from the glutes through to the plantar fascia. The left glutes will be noticeably tighter and in spasm relative to the right side. The left SIJ being chronically rotated to full range of motion is often 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 these lower limb symptoms is thickening and tightening down the right lower limb instead of the left side due to a more acute state of dysfunction in the lumbro-sacral region. While it is hypothetically possible for bilateral backline dysfunction through the lower limbs, I rarely encounter it. Once symptoms become acute causing high degrees of tightness, pain and possible injury, it is almost always clearly a right or left sided issue. Left sided cases being the most common presentation.
Above the pelvis, tilt in the Frontal plane causes the foundation of the spine to lean to the right generating a scoliotic force on the spine. My knowledge and experience of this is rudimentary. It has been studied extensively by physical therapists yet discussion with Chiropractic, Osteopathic and Bowen Therapists indicate the contribution of leg length difference to scoliosis is largely discounted and dismissed. I say this because by and large they do not examine each and every case for the possibility and make the assumption the scoliosis is generated from some factor working its way down from the neck. My observation has been the use of a small adjusting heel lift introduced under the short leg where there is chronic back pain, frequently reduces discomfort enormously. Low back conditions respond quickly in a matter of days. For the effect to progress higher through to the thoracic region takes months. Sometimes up to a year to have an effect on the neck.
Leg length differences estimated between 10mm and 20mm are common. Less than 5mm we will be seeing Cardinal signs but actually detecting the leg length 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. Once I have sighted a leg length difference in the order of 35mm that was experiencing acute symptoms and dysfunction. Unfortunately, he would not 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 https://www.facebook.com/MassageWorksDandenongRanges