Case Notes 2 - Right Sided Lumbro-Sacral Symptoms, Short Right Leg Syndrome
Lower limb symptoms resulting from Short Right Leg Syndrome are predominantly left sided. I observe something in the order of one in ten cases of acute lower limb symptoms that are right sided. The right sided case is more serious as lumbar disk bulges are part of the condition. This case outlined below is complex due to conditions limiting treatment. I have published these notes as I have written extensively on left sided lower limb conditions but not covered right sided cases previously.
The subject exhibits the three cardinal signs of Short Right Leg Syndrome (SRLS)...anterior rotation of the left hip; rigidity at the right hip; and, bulging through the right costals. He has been experiencing right sided lumbro-sacral and hip issues for nearly four decades that has now degenerated to a condition of acute pain, interrupting sleep and causing distress. He has been assessed medically revealing significant right hip joint deterioration and mild disk bulging through the entire lumbar region. The vertebral foramen are unaffected and there is no nerve root compression. My observations of his condition are:
• Left hip in anterior rotation sagittal plane, very high range, ~ 30 degrees. The right hip is level; that is, palpating Subject’s right ASIS and the Iliac Crest in the standing position reveal the line though these points is parallel to the floor.
• The subject is highly flexible, blocking through left SIJ is minimal, only causing tightness in left gluteal musculature. He is little affected otherwise through the back line of the left lower limb.
• Right hip rigid under traction relative to the left.
• Right side, small of the back through the QL’s is in high degree of spasm and painful on palpation...subject’s MRI report states mild disk bulging exists through the entire Lumbar region of the spine, the radiographer neglects to state which direction bulging is occurring...I suggest it is likely to be right sided. The left QL’s are loose and pain free.
• Right gluteal musculature in high degree of spasm and pain.
• Prone position, sign of right leaning scoliosis through thoracic region with bulging costals on the right and flattened costals to the left.
• Supine, legs straight, right malleolus is superior to the left in the order of 1mm to 2mm and the left ASIS is 15mm superior to the right ASIS.
• Supine, knees together and flexed to 90 degrees, the left kneecap is 20mm higher than the right.
By my judgement, without sighting a frontal X-ray of the subject’s hips taken in the standing position, I would place his SRLS in the higher range I typically encounter...likely to be a 15 to 20mm discrepancy in structural leg length. This is partially compensated for by the very high range anterior hip rotation on the left side and would account for the Physiotherapist assessment of a 9mm leg length difference. The Orthopaedic Surgeon stated the leg lengths are even.
The subject describes himself as being hyper-mobile and this accounts for the minimal effect observed to the backline of his left lower limb by very high range anterior hip rotation at the SIJ...merely causing some tightness through the glutes but no undue affect on hamstrings, calf or plantar fascia. I have observed this too in similar cases with highly flexible joints and soft muscle tone. However, this degree of rotation through the SIJ typically causes tightness through the soft tissue of the joint, blocking energetic flow, leading to an immediate subtle thickening and tightening through the entire backline of the lower limb on that side. It is not uncommon for this condition to result in hamstring, calf and/or achilles tightness/tear/rupture, chronic compartment syndrome and/or plantar fasciitis.
I do not expect conventional Western practitioners to be conversant with this phenomenon. The effect down the backline of the lower limb is due to energetic blockage in the lumbro-sacral region rather than biomechanical strain or neurological impingement; the resulting thickening and tightening through the soft tissue does not respond to massage or stretching. This is a phenomena I have discussed previously in relation to distal upper or lower limb soft tissue conditions caused by proximal issues at hip or shoulder and torso.
While the majority of SRLS cases are affected more on the left side through the hips and lower limbs, as described above, a smaller number exhibit right sided symptoms. The mechanism for this on the right is different. Rather than hip rotation at the SIJ being the cause, it is due to low grade lumbar disk bulging to the right and rigidity at the right hip due to the Second Cardinal Sign.
With SRLS there is a tilt across the pelvis, the right hip drops and the left hip elevates. This tilts the sacrum placing the foundation of the spine on an angle where it should be level in the Frontal plane. As a result, spacing between the vertebral surfaces on the right open and on the left close geometrically forming a wedge shape. While it is often only a minor postural anomaly, over a period of years and decades, and under the heavy loads experienced through the lumbar region, even without catastrophic injury, at the very least mild disk bulging to the right can occur. Sign of tenderness and muscle spasm through the QL's on the right is a common symptom with SRLS cases. In my clinical experience, some of these have mild right sided disk bulges to the right confirmed by medical scans.
It could be argued injury and degradation to the subject’s right hip joint described by the Orthopaedic Surgeon would be cause for rigidity being experienced about the joint. This is true, however, every case of SRLS I have sighted does have rigidity at the right hip joint readily noticeable tractioning the leg. Caused by the pendulum effect momentarily interrupting or delaying footfall, it is one of the three cardinal signs of SRLS. It is likely this condition existed in his youth prior to any damage to the joint occurring and was a contributing factor to the condition of the joint today...rigidity and reduced flexibility through the soft tissue can cause injury.
Treatment of the subject’s condition would normally focus on resolving the right sided disk bulging and rigidity at the acetablum by using a prosthetic heel lift under the right foot, elevating the right hip. While the anterior rotation at the left hip is a postural anomaly and frequently the cause for adverse left sided lower limb symptoms, we do not want to change it in this case. The subject is not experiencing these adverse symptoms and the anterior rotation is an anatomical adjustment, functionally shortening the left leg, reducing right leaning tilt through the pelvis in the Frontal plane and protecting the spine to some degree. To normalise the left hip position will increase pelvic tilt and aggravate the subject’s present condition.
Unfortunately, injury to the right hip joint precludes loading greater weight through the joint. I would normally prescribe a 5mm heel lift. This significantly shifts weight loading from left to right. Insertion of a 4mm heel wedge previously prescribed by a Physiotherapist caused acute pain. Replacing it with a 2mm wedge has been do-able for him. Progressing more gradually to a higher heel lift may be possible in time. Short of surgical intervention, use of therapeutic dosages of glucosamine and collagen supplements may assist joint repair sufficiently to make progress with physical therapy.
Massage and Chinese Cupping treatment thorough lower back, hip and leg gives him up to two weeks relief. This will assist healing and recovery but the primary cause of the subject’s condition is SRLS affecting his right lumbro-sacral region. It would be hoped use of a prosthetic heel lift can resolve the lumbar disk bulging by mechanically realigning the vertebrae to eliminate forces pushing disks to the right. Should the hip joint condition degenerate further and hip replacement be carried out, consideration for adjusting leg length be done at that time. Naturally, closer examination of bone structure and carriage would be required. Keeping in mind, adjustment height is not a function of leg length difference but limited by what amount will the body accept. This is typically within 3-5mm. I have encountered rare cases where is it is less than or greater than this range. Any adjustment amount can only be determined on a trial basis considering factors of flexibility, symptoms, SRLS range, etc.
Other related issues...the subject has experienced frozen shoulder in the last year on his left side following injury to the neck and shoulder. Bone density scans have revealed unusually low levels for a man of his age. Low enough to prevent hip replacement surgery at this time. He also has a long history of experiencing anxiety. These issues point to Kidney weakness in TCM medical philosophy. He advises there is a history of kidney disease and death by renal failure in the males of his family. I have recommended consulting a TCM practitioner for examination and treatment.
First published 5 Sept 20 https://www.facebook.com/MassageWorksDandenongRanges