Leg Length Discrepancy and Short Right Leg Syndrome
in the context of Remedial Therapy
Leg Length Discrepancy and Short Right Leg Syndrome - Overview
Short Right Leg Syndrome is the result of a structural leg length discrepancy affecting the upper body through mild Scoliosis and the lower limbs through Lumbro-Sacral and Hip dysfunction. It is the underlying cause for the majority of clients presenting for treatment in my practice. Assessing relative leg lengths of all clients, virtually all have a structurally short right leg. The bones of one leg are longer than the bones of the other. However, lying on the treatment table, their ankles usually align. This is not so unbelievable considering we stand on flat ground. If there is a leg length discrepancy the ground does not move to accommodate it...look higher up the body. Permanent distortion and tilt occurs at the pelvis. This transfers to the spine causing mild scoliosis. Even or near even leg length is uncommon. Short left legs are rare, sighting only three instances to date, all of whom were injured in their youth presumably stunting growth of that leg. This is Short Right Leg Syndrome (SRLS).
There are Two Signature Traits...an elevated left hip and an elevated right shoulder. There are Three Cardinal Signs...the left hip in anterior rotation while the right hip is level; rigidity at the right hip accompanied by a tight Adductor Longus; and mild right leaning scoliosis. Beyond these common effects there are a raft of conditions and effects throughout the body. Mild symptoms follow a general pattern within which acute symptoms may develop. Maintaining a high degree of flexibility through the Pelvis and good muscle tone is preventative. Overlaying Lumbro-Sacral or Pelvic injury compounds the condition.
We are born this way...midwives commenting to new mothers about high range cases. Owing to the flexibility of infants and juveniles, it is generally of little concern until adolescent growth spurts accentuate the leg length discrepancy. The effects of the condition are more prominent as we age and lose flexibility.
My theory...a short right leg is a dominant genetic trait in Homo Sapiens. It is the result of evolutionary adaptation giving a mother and child a greater chance of survival in prehistoric times by freeing the dominant right arm for defence and work while securely carrying baby on the left hip. We all carry baby on left hip and bag over right shoulder. Do we not? Consider the Two Signature Traits of elevated left hip and elevated right shoulder. It is the most successful model for bipedal creatures with a dominant right arm.
The downside is there is no other benefit apart from the increased survival prospect. In modern society, while it is handy to be able to perch baby on left hip when doing work and chores...it is no longer a survival issue. We have shopping trolleys, prams and pushers, capsules and pods, maternity leave and day care. We do not have to protect ourselves from carnivorous predators. Every other attribute of Short Right Leg Syndrome is not beneficial. As we age beyond the lifespan of our prehistoric ancestors we begin to bemoan its effects and wonder why we have a short right leg.
The nature of the condition and assessment methods I describe are rudimentary. Interpreting effect on the body utilising Eastern concepts of energetic/Qi flow is advanced and gives insight to conditions that are not fully understood by conventional therapists. Considering the condition in its totality is complex. The biomechanical effect of pelvic tilt causing mild scoliosis of the spine is easy to imagine. However, it is the constant strain through the soft tissue of the pelvis and lumbro-sacral area from distortion caused by the Three Cardinal Signs that blocks energetic/Qi flow and impacts us the most. The effects are wide ranging through the musculo-skeletal system and also affect internal metabolic health. Unfortunately, conventional therapists are not trained to sense, cultivate and control Qi. They do not recognise or consider its effects in any way. Furthermore, consideration of leg length discrepancy is not a part of medical examination in this country, even in the event of lumbro-sacral injury where it is a major contributory factor.
This subject warrants close attention and study...with few exceptions, we all have a short right leg. Many are unknowingly suffering acute conditions impacting mobility of the lower limbs and spine due to this postural asymmetry. Treatment is surprisingly simple. Initial results can be rapid and dramatic. More subtle benefits to movement, balance and vitality continue to manifest over the longer term.
Summary of Short Right Leg Syndrome
Two Signature Traits
Elevated left hip
Elevated right shoulder
Anthropological Perspective - Evolutionary Adaptation Theory
Short Right Leg Syndrome (SRLS) is a dominant genetic trait in Homo Sapiens. It is the result of evolutionary adaptation giving a mother and child a greater chance of survival in prehistoric times. The two signature traits of SRLS enables baby to be securely carried on the jutting elevated left hip, shoulder bag of provisions securely carried on the elevated right shoulder, freeing the dominant right arm for work and defence. This was the most successful model. It can be deduced our ancestors were predominantly right handed. Otherwise, we would be seeing short left legs. We do not see short left legs.
Three Cardinal Signs
While a leg length discrepancy may be small and hard to detect without x-ray examination, what it does to the body is magnified. These Cardinal Signs confirm the possibility a leg length discrepancy exists.
First Cardinal Sign - Anterior Rotation of the Left Hip, Sagittal Plane
The First Cardinal Sign of a short right leg is anterior rotation of the left hip in the Sagittal plane. It is an unconscious anatomic adjustment pulling the structurally longer leg upwards. The Ilio-Femoral Joint moves in an arc posteriorly and superiorly as the hip rotates about the Sacro-Iliac Joint, partially reducing pelvic tilt in the Frontal plane, making us feel more comfortable and protecting the spine. This is good but chronically binds the SIJ tightening ligamental structure and compressing cartilage through the Spanish windlass effect with the left hip flexor Iliacus being tighter/shorter than the right. This may or may not cause discomfort or pain at the SIJ. Regardless of discomfort levels, inhibiting energetic/Qi flow down the backline of the lower limb causing a subtle thickening and tightening through connective tissue that can morph into acute pain, dysfunction and injury. In the longer term, leading to instability and damage to the SIJ. The most frequently sighted hip posture is high range unilateral anterior rotation of the left hip in the Sagittal plane with an even right hip. This is so common I call it "normal" despite being bad posture.
Second Cardinal Sign - Rigid Right Hip
Rigidity through the right hip from the QL's in the lower lumbar region through to the Ilio-Femoral Joint and Adductors readily felt by practitioner and client tractioning from the ankle in supine...right side wooden and unmoving, left side soft and giving. This rigidity is due to altered gait, the impact of the First Cardinal Sign on Gluteal stability of the Pelvis and the effect of Pelvic tilt on the Lumbar Spine.
With each step taken the left foot confidently finds the ground whereas due to the Pendulum effect, there is a momentary hesitation before the right foot plants generating holding patterns through hip and adductors. Soft tissue about the right hip becomes subtly rigid and the right Adductor Magnus will be in some degree of spasm.
Due to SIJ binding from the First Cardinal Sign, the left Glute Med becomes inactive, is in partial spasm and does not adequately stabilise the pelvis. As a result, the left TFL and the right QL’s are loaded compensating for this. This contributes to the tightness frequently observed in the right QL’s and is cause for left ITB and knee issues.
The other aspect of the story at the right hip is Pelvic tilt in the Frontal plane. A dropped right hip and elevated left hip geometrically distorts lumbar disk spacing creating a slight wedge shape (right convexity) encouraging disks to bulge slightly to the right. Rarely catastrophic but tenderness and tightness in the right QL's is part of the symptomatic pattern of SRLS.
Third Cardinal Sign - Mild Right Leaning Scoliosis
Mild right leaning scoliosis causes asymmetrical development of the rib cage. Always right leaning through the Lumbar spine but may be right or left convexity through the Thoracic. Higher range cases are more convincingly encouraged into right convexity through the Thoracic. Lower range cases are more likely to be either left or right convexity. Left convexity cases are less common overall. The side of convexity can be identified by bulging costals resulting from being crowded by the spine's lateral diversion over a lifetime. This is more readily palpated than seen. Responsible for much upper back, neck and shoulder tightness that is the bread and butter of physical therapists and restricting rotation in the Transverse plane. Musculature in the upper Thoracic on the side of convexity is frequently dysfunctional and problematic.
Compensatory Pattern Through the Pelvis and Lumbar Spine
• Anterior rotation left hip in Sagittal plane with a bound left SIJ, spasm in the left gluteals and tight/short left hip flexors.
• Rigid/wooden right hip and a tight right Adductor Magnus.
• Right leaning pelvic tilt in Frontal plane generating mild scoliosis, encouraging lumbar disk bulging and tight QL's to the right side.
Injury and Dysfunction - Biomechanical Effects
The primary biomechanical effect sighted in practice is chronic rotation of the left hip in the Sagittal Plane which has the potential to injure the left SIJ. Pain and discomfort from the tightly bound joint can commence in juvenile years...the Spanish windlass effect compressing cartilage and loading the joint...ligaments becoming unduly tight with a mere 15 degrees of rotation. With advancing age the joint can become unstable and prone to injury. This is part of the Left Lower Limb Mechanism.
Secondary to SIJ issues and related to hip rotation is the effect this has on gluteal musculature and consequent loading imbalance through the lower limb causing knee pain, etc. This can be resolved in the short term with appropriate rehab exercise and more permanently by rectifying hip posture.
Another biomechanical issue in the SRLS pattern is tightness and sensitivity or pain in the right QL's indicating possible right sided lumbar disk bulging caused by right leaning pelvic tilt. Rarely catastrophic and usually mild in nature but part of the common Lumbro-Sacral pattern palpating the QL's. Acute right sided Lumbar/QL cases are less common than acute left sided SIJ cases but a greater concern because integrity of the spine may be compromised. Loading and/or an event can result in varying degrees of dysfunction up to and including acute spinal injury. This is part of the Right Lower Limb Mechanism.
Naturally, there is direct biomechanical stress through upper back and neck from mild scoliosis. Similarly, due to ignorance of the fact SRLS is so pervasive, theories for spinal conditions exist finding causation in Temporal Mandibular Joint and Cervical vertebrae conditions generating dural drag, etc., down the spine. These theories should be reviewed taking into account pelvic distortion and effects from a short leg working up the spine.
The Nature and Specifics of Energetic Blockage/Inhibition
Chronic physical stress on the soft tissue of the pelvis and lumbar spine caused by a leg length discrepancy inhibits energetic/Qi flow. The effects from this are significantly greater and broader ranging than biomechanical effects only. There are three aspects:
• Qi flow in the Du and Ren Meridians and vitality of the Root, Sacral and Plexus Chakras is inhibited.
• Qi flow in the organ channels for the Kidney, Urinary Bladder, Stomach, Spleen, Liver and Gall Bladder passing through the pelvic region to and from the lower limbs is inhibited.
• Flow of protective Wei Qi to the lower limbs through the connective tissue around muscles, bones and under the skin similarly inhibited.
First Order Energetic Effects - Restricted Mobility
Where energetic flow is inhibited or blocked due to postural anomalies causing a subtle thickening and tightening of the connective tissue restricting mobility, I describe this as a First Order Energetic Effect. This is primarily but not exclusively due to inhibited Wei Qi flow. It is analogous to the "nebulous communication" along fascial meridians referred to by Rolfing practitioners. The principle of a proximal block having a distal effect is commonly sighted at hip or shoulder affecting the attached limb. The subtle thickening and tightening can be mistaken for inflammation and can escalate to pain, dysfunction and injury. Clearing the proximal block and promoting smooth energetic/Qi flow transforms affected tissues, tone rapidly becoming normal...frequently within one to three treatment sessions on the table.
Left Lower Limb Mechanism
Anterior rotation of the left hip in the Sagittal plane binding the left SIJ causing an energetic/Qi block and consequent thickening and tightening down backline of limb from gluteal musculature to plantar fascia. Cases exhibiting symptoms from the left sided mechanism are more common than right sided cases.
Right Lower Limb Mechanism
Two factors contribute to the right sided mechanism being Lumbar dysfunction and the Pendulum effect on gait.
The Pendulum effect resulting from the shortened right leg's effect on gait causing momentary hesitation and a lightened footfall with each step. The left foot plants directly with confidence. The right foot not immediately finding the ground there is a momentary hesitation and a holding pattern develops about the hip. Adding to this is Frontal plane pelvic tilt widening right side spacing between lumbar vertebrae and reducing left side spacing encouraging lumbar disk bulging to the right. Rarely catastrophic but sufficient to cause tenderness and tightening in the right QL's.
The combination of these two factors cause the right hip from lumbar region to the Acetablum and Adductors in the groin to tighten. Tractioning from the ankle reveals an unmoving wooden hip. Whereas, the left hip is flexible and giving. The right SIJ can be painful to palpate and stuck. This causes an energetic block not unlike that seen in the Left Side Mechanism, tightening and thickening the connective tissue down backline of lower right limb when reaching a sufficiently acute degree.
While instances of acute symptoms from the Right Sided Mechanism are less frequent than left sided cases described above, there is more cause for concern than left sided cases owing to the fact spinal integrity is possibly compromised. The distal effect in the lower limb from Left and Right Sided Mechanisms appear similar.
Scoliosis has been studied extensively and my insights are rudimentary at best. Conventional therapeutic practice overlooks the effect of energetic blockage through the Pelvis and Lumbro-Sacral region on the spine. Misalignment of the pelvis tilts the spine's foundation causing scoliosis and the geometric anomaly already mentioned that encourages right sided disk bulging, generates chronic soft tissue stress inhibiting energy flow. Where energy flow is blocked, thickening and tightening occurs restricting mobility through back and neck most apparent in the Transverse plane.
The right leaning scoliosis with right sided convexity will cause spinal erectors through the thoracic on that side to be tighter and more highly developed than the left and vice versa for the less common left convexity cases. Associated dysfunction and pain behind that shoulder blade is common. Rotation in the Transverse plane becoming progressively more restricted with age.
Injury and Dysfunction - First Order Energetic Effects
The combination of characteristics defined by gait, activity type/levels/load, prior injury, flexibility, core integrity can induce a mild underlying pattern to morph into acute pain, dysfunction and injury. Lower limb conditions encountered include: Piriformis Syndrome and Sciatic Pain, chronic Hamstring, Calf and/or Achilles tightness, pain, dysfunction or injury, and Plantar Fasciitis. These conditions result from the Left or Right Sided Mechanisms affecting energetic/Qi flow down the backline of the lower limb and can be rapidly and effectively resolved by addressing the underlying leg length discrepancy.
Back conditions resulting from scoliotic strain have an obvious biomechanical explanation but they too are affected by energetic blockage causing thickening and tightening of the connective tissue. This contributes to restricted motion of the spine, particularly rotation in the Transverse plane accompanied by high degrees of tightness and discomfort/pain in the upper back, neck and shoulders which is the bread and butter of the physical therapy industry. There is a tendency for right sided mild lumbar disk bulging to cause tightness and tenderness through the right QL's. I have noted a correlation between the right SIJ dysfunction and this right sided lumbar condition. Ultimately, under loading or the impact of an event, unexpected catastrophic spinal injury can result under the influence of these chronic underlying issues.
Second Order Energetic Effects - Metabolic Health
Where energetic flow is inhibited or blocked due to postural anomalies, Second Order Energetic Effects generated can have an adverse effect on metabolic health such as digestion and reproduction. These are internal medical conditions beyond my scope of practice. I suggest in relation to SRLS, these effects are due to inhibited Qi flow in the Du and Ren meridians and the organ channels of the lower limbs and reduced Chakra vitality in the lower abdomen.
Injury and Dysfunction - Second Order Energetic Effects
Either through advancing age, reduced mobility and flexibility or when an overlaying Lumbro-Sacral injury compounds the energetic block at the pelvis caused by SRLS, lower limb degradation accelerates. Lower limb energetic circulation is inhibited leading to fluid retention, meridian pain, joint pain, and increasingly reduced lower limb function over time. Skin infection and wound healing on the feet can be increasingly problematic. This is an outcome I have encountered. There is a sidedness to this effect where the Second Cardinal Sign of rigidity through the right hip predisposes that side to be more affected. Specifically, the Bladder meridian is strangled in the small of the back and the latero-superior aspect of the Iliac Crest on the right side causing meridian pain in the hamstring, at the Biceps Femoris insertion behind the knee, calf and the lateral aspect of the heel, weakening the right kidney in the long term.
In TCM theory, Qi flow has a direct effect on metabolic function and vitality. It may be coincidental, but apart from improved lower limb function and reduced back pain, a beneficial side effect of heel lift treatment for SRLS is markedly improved digestion and vitality. The metabolic health outcomes that can be influenced by SRLS are better considered by a TCM practitioner. It is beyond my scope of practice to diagnose and treat internal health conditions.
Remedial Massage Therapist
Member of Massage & Myotherapy Australia
Massage Works Dandenong Ranges
18 First Ave, Cockatoo VIC 3781 Australia
+61 416 268 255
Keywords and Concepts: Leg Length Discrepancy; Structurally Short Right Leg; Evolutionary Adaptation that gave Mother and Child Greater Chance of Survival in Prehistoric Times; Two Signature Traits - Elevated Left Hip and Elevated Right Shoulder; Three Cardinal Signs - Anterior Rotation Left Hip, Rigid Right Hip, and Mild Scoliosis; Biomechanical Effects; Right Leaning Pelvic Tilt Frontal Plane; Uncomfortable Standing; Anterior Rotation Left Hip; Unconscious Anatomic Adjustment to Functionally Shorten Longer Left Leg; Left SIJ Tightly Bound; Spanish Windlass Effect; Left SIJ Dysfunction, Pain, Injury, Instability; Right Leaning Pelvic Tilt; Mild Scoliosis; Lumbar Spine Geometrically Misaligned; Wedge Shape Disk Spacing; Right Sided Lumbar Disk Bulge; Low Back Pain; Structurally Short Right Leg; Pendulum Effect on Gait; Hesitant Right Footfall; Rigidity About Right Hip and Tight Adductor Magnus; Postural Misalignment Causing Soft Tissue Tightness Blocks Energy/Qi Flow; First Order Energetic Effects affect Mobility; Proximal Block Having a Distal Effect; Subtle Thickening and Tightening; Plantar Fasciitis; Compartment Syndrome; Piriformis Syndrome; Achilles Calf and Hamstring Tightness, Pain, Dysfunction and Injury; Right Hip, SIJ and Lumbar Region Rigidity; Rehabilitation Strengthening and Stretching; Heel Lift Treatment; Heel Lift Adjustment Not a Function of Leg Length Difference; No Formula For Determining Adjustment Amount; Adjustment Amount is a Question of How Much Adjustment Will the Body Accept; This is a Trial and Error Approach and is Typically Between 3mm and 5mm; Second Order Energetic Effects affect Metabolic Health; Impacting Digestion and Fertility; Second Order Effects Beyond my Scope of Practice