Assessment Notes Describing Classic SRLS
There are many variations on the presentation of the effects from SRLS. This is the most common.
Structurally Short Right Leg
Right leaning Pelvic Tilt
Prominent Left Lower Limb Mechanism
Mild Scoliosis with Right Convexity through Lumbar and Thoracic Spine
A. Signature Trait of elevated right shoulder resulting from mild scoliosis with right convexity through Thoracic. We carry our bag over the right shoulder. The off the shoulder look is to the left. There are occasional exceptions to this where low level leg length discrepancy cases are less strongly encouraged to continue through the Thoracic with right convexity and will flop to the left.
B. Signature Trait of elevated left hip observed both standing and supine at ASIS and Greater Trocanter. The right leaning Pelvic tilt is generally between 5mm and 10mm higher at the ASIS of the left hip when standing. Whereas, in Supine it will be greater and typically appears to be between 10mm and 25mm. This is not an accurate reflection of actual leg length discrepancy due to each hip being aligned differently in the Sagittal plane. It is an indication only. A more accurate estimate is gained by observing the discrepancy at the Greater Trocanter.
C. Second Cardinal Sign of SRLS, rigidity at right hip observed tractioning ankle in supine. The right hip being wooden and stiff whereas the left hip is soft and giving. Caused largely by gait issues associated with the short leg not confidently finding the ground with each step taken. The momentary hesitation setting up unconscious holding patterns through the hip. There are other factors at play here too and should they become more acute, the Right Lower Limb Mechanism becomes prominent and presentation becomes more right sided.
D. Comparing relative positions of lower limbs at the Malleolus in supine…most commonly this is level. We stand on flat ground. If there is a leg length discrepancy look to the Pelvis for permanent distortion accommodating the difference.
E. First Cardinal Sign of SRLS, high range anterior rotation of the left hip about the SIJ in the Sagittal plane, the ASIS will be 50mm to 60mm inferior to the Iliac Crest. This is so common I call it “normal” despite being poor posture. An unconscious anatomic adjustment pulling up the longer leg, reducing but not eliminating Pelvic tilt, to make us feel more comfortable and protect the spine to some degree. I classify this anomaly from Low to Very High Range in four stages.
F. Right hip will be level, the line through the ASIS and Iliac Crest is horizontal to the floor in the standing position.
G. Third Cardinal Sign of SRLS, mild scoliosis with right convexity. Shifting the upper body to the right of centre causing the Pelvis to counterbalance moving to the left. The elevated left hip jutting to the left becomes the perfect perch for baby.
H. Scoliosis with right convexity is accompanied by greater development and tightness of the spinal erectors on the right side. Generates discomfort and tightness issues in the upper right quadrant of the Thoracic behind the Scapula.
I. Tightness and tenderness through the right QL’s is a function, in part, of right convexity through the Lumbar spine encouraging slight disk bulging. There is more to the story here. It is part of the Right Lower Limb Mechanism which is complex but in this example is not prominent. The most common presentation being a prominent Left Lower Limb Mechanism.
J. The left SIJ held in chronic anterior rotation in the Sagittal plane tightens and strains the ligamental structure, compresses joint through the Spanish windlass effect. May or may not be painful or tender to palpate. In the short term blocks energetic Qi flow down back line. Primary contribution to the Left Lower Limb Mechanism. In the longer term causes instability and injury to the SIJ.
K. Left Lower Limb Mechanism is the outcome of thickening and tightening down backline of left lower limb from Gluteals and Piriformis through to the Plantar Fascia resulting from energetic Qi flow blockage at left SIJ tightly bound by First Cardinal Sign. Under loading can morph into pain, dysfunction and injury at any point along this line. The condition may waft and wain as activity levels and other contributing factors vary day to day or month to month. Readily palpable comparing left to right limb. In low level cases almost undetectable by the client/patient and feels like low level inflammation to the assessing practitioner. Responsible for the most common unforced injury in AFL football of the torn left hamstring. Every second or third player on the pro-tennis circuit has Rock Tape down the back of their left hami for the same reason. Symptoms such as Piriformis Syndrome and Sciatic pain result, Hamstring Calf and Achilles issues, Compartment Syndrome and Plantar Fasciitis individually. I have had much success treating these cases by normalising hip position to eliminate binding of the SIJ. Chronic Plantar Fasciitis can be resolved within days/weeks of doing so.
Nett Effect at the Pelvis
The postural response at the pelvis and lumbro-sacral region to the leg length discrepancy from a short right leg places the structure under constant strain generating the mild Scoliosis with Right Convexity and a prominent Left Lower Limb Mechanism. Specifically this looks like:
• Tight left Hip Flexors;
• Bound left SIJ with compressed cartilage and tight ligamental structure;
• Spasm in the left Glutes and Piriformis;
• Tight right Adductor Magnus;
• Rigidity about the Iliac Crest and TFL of the right hip;
• Limited rotation at the right Acetabular-Femoral joint;
• Right QL's tight and tender;
• Rigid right SIJ, and;
• All sorts of strain about Sacrum and Lumbar vertebrae being loaded by scoliotic strain from pelvic tilt and Lumbar vertebral disks being encouraged to bulge to the right.
This presentation is similar to the Osteopathic view purported by Tom Bowen. However, rather than attributing the effects from a leg length discrepancy working through the Pelvis and up the Spine, he did not assess structural leg length. Sighting the effects of an elevated left hip, right leaning pelvic tilt, mild scoliosis with right convexity that causes slight head tilt affecting Cervical vertebrae and loading the right TMJ with chronic low level strain, he chose to view this dysfunction at neck and jaw as the primary cause for “Dural Drag” working down the spine, straining torso, lifting the left hip. Overlooking the structural leg length discrepancy elevating the hip in the first place, this Osteopathic interpretation is inaccurate and not the full story. I am inclined to view the Dural Drag explanation as a fiction concocted in the absence of the full facts.
With a practice that was largely sports based in my early years, the Left Lower LImb Mechanism was the first aspect of this condition to come to my attention. While aware of the hip rotation’s effect on the SIJ blocking energetic Qi flow and generating backline symptoms, I did not know why this postural anomaly occurred. It was a mystery to me. The adhoc hip rotation seemed to be random and would defy treatment. It was not until I learned of the common structural leg length discrepancy did full understanding come to me. That is, the underlying impact of the short right leg generating an unconscious anatomic adjustment pulling the longer left leg up. Hip rotation will often resist responding to rehab and treatment until an adjusting heel lift is placed under the short leg.
Many minds quickly go to questioning exactly what the structural leg length discrepancy is in millimetres. 5mm is low range. The medium or average is in the order of 10mm. I consider high range to be anything from 15mm and above. 20mm is not uncommon. 25mm or greater is rare. The largest I have seen I would estimate to have been 35mm. At 62yrs of age that one had never been told he had a short leg despite much consultation with Medical Doctors and Specialists.
In some respects, it is not too important exactly how large or small the leg length discrepancy is. Every case is different and the degree of impact on the individual can vary greatly. A lower range discrepancy can be affecting one person more than a high range is another. Two vastly different discrepancies may have the same adjusting heel lift size.
In clinical practice, knowing the actual leg length discrepancy to the accuracy of a millimetre is not required. The Cardinal Signs indicate a discrepancy exists. A comparative examination of structural leg length confirms there is a discrepancy and it can be classified as low, medium, high or very high range. That is sufficient information to commence treatment where acute symptoms are present. Treatment is a trial and error approach basically determining what amount of heel lift adjustment the body will accept.
There is no expectation of realigning a body that has been crooked for decades into a fully symmetrical state. The bony structure and joints have been permanently altered. There is no formula for calculating adjustment size based on leg length discrepancy. It is a matter of determining by trial and error what amount of adjustment the body will accept. This is typically between 3mm and 5mm which is no more than one quarter to one third of the actual discrepancy.
Because full symmetry is not achieved, a partial leg length discrepancy still exists and heel lift treatment alone may not be adequate to fully treat the condition. Dramatic enduring change can result for pelvis, spine and lower limb mobility. Internal health function can improve. However, gait will still be affected and supplementary exercise and massage treatment may be necessary. Particularly for the Second Cardinal Sign at the right hip. Lumbar tightness and spasm through the Hip and Iliac Crest blocks energetic Qi flow in the Bladder meridian. Energetically starving the Kidney meridian and Kidney deficiency symptoms develop. The right side is affected more in this way than the left but both sides are susceptible to this blocking effect on the Bladder meridian. This is not fully understood by TCM doctors much less the conventional medical and therapeutic community.
I make this statement about TCM doctors based on the experience of being assessed and treated by six TCM doctors for a variety of internal health issues and injuries over a period of 45 years. You could say my regular consulting physician is a TCM doctor. The common theme has been the presence of Kidney deficiency. I now know the First Cardinal Sign made itself known to me at age fifteen and symptoms demonstrating I was afflicted by Kidney deficiency began in the late teens. TCM practitioners have been treating the Kidney deficiency successfully with acupuncture and herbal treatment. However, should I pause treatment, the symptoms would quickly reappear. It was not until addressing and eliminating chronic muscular spasm and tightness through the right hip from the Second Cardinal Sign and clearing the blocked Bladder meridian, were Kidney deficiency symptoms dramatically alleviated. For the first time the TCM doctor doing Pulse Diagnosis stated "Pulse is normal" and "Pulse is good." They have never said that in 45 years.
Following lumbro-sacral injury suffered at age 60 from leg length discrepancy and a high athletic training load, my lower limb mobility progressively deteriorated and internal health suffered. Pelvic tilt and distortion now compounded by lumbro-sacral injury, energetic blocking effects at the pelvis escalated. This became what I now call an advanced case of Short Right Leg Syndrome. I am Case 4 in the Notes section. Advanced cases are rarely seen in my practice. Should I visit a retirement home, I suspect many would be found.
Much ineffective treatment was received from medico's and therapists over a five year period. While suffering low back and lower limb symptoms, none examined structural leg length. Their treatment yielding no more than limited temporary outcomes. It was not until faced with the prospect of forced retirement from active life that I began self treatment. Insertion of a small adjusting wedge under the short leg brought about dramatic enduring change.
I describe specific patterns of effect from the postural strain placed on the pelvis and lumbro-sacral region from structural leg length discrepancy. While the biomechanical effects on gait and through the spine are easy to see, making a connection to lower limb symptoms is not. This is because they are due predominantly to blocked energetic Qi flow. This is unknown to conventional practitioners and not considered in their examination.
The impact of blocked energetic Qi flow through the pelvis is not restricted to mobility issues alone. Many clients being treated for structural leg lengthy discrepancy report coincidental beneficial side effects to their internal health. I eventually came to realise there is a condition I describe as the Pelvic Block. In TCM medical theory, six organ channels or acupuncture meridians pass through the pelvis to the lower limbs. Chronic soft tissue strain through the pelvis inhibits energetic Qi flow through these channels, directly impacting internal health. Digestive and reproductive organs and kidneys are affected. This aspect of the condition might be considered a greater concern than mobility issues. Health, well being, vitality and lifespan potentially being impacted in the longer term. The effects from Short Right Leg Syndrome increase as we gain weight, lose flexibility and become more sedentary with age. Research into the extent of the Pelvic Block's effects should be conducted.