Leg Length Discrepancy and Short Right Leg Syndrome
in the context of Remedial Therapy
Description of Short Right Leg Syndrome
Two Signature Traits
Elevated left hip
Elevated right shoulder
Anthropological Perspective - Evolutionary Adaptation Theory
My personal theory published February 2021...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 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, in the short term, 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.
• Left ASIS inferior to the Iliac Crest assessed in the standing position.
• High range anterior rotation of 15 to 20 degrees at left hip and level right hip is the most common presentation sighted in clients attending clinic.
• Tight left hip flexors...Iliacus in particular.
• Binding SIJ through Spanish windlass effect tightening ligamental structure and compressing cartilage. This may or may not cause discomfort in the joint.
• Regardless of discomfort levels, energetic/Qi flow down backline of left lower limb from glutes to plantar fascia can be blocked at the SIJ.
• In the short term, causing a subtle thickening and tightening through the connective tissue frequently mistaken for inflammation but rapidly relieved in a matter of minutes when clearing the blockage. A powerful hip flexor stretch alone can be sufficient to provide temporary relief.
• Inactive gluteal and hamstring musculature requiring extensive warmup to initiate full activation.
• This subtle thickening and tightening can degenerate to acute dysfunction, pain and injury such as Plantar Fasciitis, Chronic Compartment Syndrome, Achilles/Calf/Hamstring tendonitis, strains and ruptures, and/or Piriformis Syndrome and Sciatic pain. The most common unforced football injury is the torn left hamstring. Every second or third player on the pro tennis circuit has rock tape down the back of the left hamstring.
• In the longer term, hip rotation left uncorrected can lead to instability, degradation and injury of the SIJ in older age.
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 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.
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.
• The pendulum effect...momentary hesitation before footfall of the short right leg developing unconscious holding patterns through the hip with each step taken.
• Right leaning pelvic tilt distorting the geometry of the lumbar disk spacing into a wedge shape. A dropped right hip and elevated left hip forcing disks to bulge slightly to the right.
• Tight Adductor Magnus and QL's.
• Restricted ROM at Ilio-Femoral and Sacro-Iliac Joints.
• Restricted flexibility through the right hip readily noted tractioning legs from ankles...right hip wooden and immobile, left hip soft and giving.
• Heightened chance of injury due to reduced flexibility and rigidity.
• Strong blocking effect on the Bladder Meridian's circuitous passage through the lower lumber and hip region.
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.
• Right leaning pelvic tilt in Frontal plane.
• The Sacrum being the spine's foundation angled to right.
• Right leaning scoliosis in the Lumbar region.
• Convexity to the right through the Thoracic.
• Asymmetric costals being crowded to the right, bulge to the right of the spine and are flattened on the left. This mild scoliosis is more readily palpated than seen by noting this characteristic.
• Right spinal erectors through middle Thoracic more highly developed and tight.
• There are occasional exceptions where, despite a right leaning pelvic tilt, a switchback occurs low in the spine causing left convexity through the Thoracic...bulging left costals, flattened on the right, elevated left shoulder. My observation is left convexity cases are typically low range leg length discrepancies; the higher range cases being more convincingly persuaded into right convexity.
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
With few exceptions, biomechanical issues contributing to pain and injury are generally secondary to issues resulting from energetic effects caused by SRLS. This may explain why minor postural anomalies through the pelvic region are overlooked as the fundamental cause for many conditions. My reading of conventional practitioners assessment of some lower limb conditions are an over thought catalogue of minor anatomical aberrations. These are sublimated when the pelvis is attended to and energetic flow resumes.
The primary exception 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 10 or 15 degrees rotation. With advancing age the joint can become unstable and prone to injury. The most commonly sighted hip posture is high range unilateral anterior rotation of the left hip and a level right hip.
Tightness and sensitivity or pain in the right QL's indicating possible right sided lumbar disk bulging caused by right leaning pelvic tilt is less common but a greater concern because integrity of the spine may be compromised. Rarely catastrophic and usually mild in nature but part of the common lumbro-sacral pattern palpating the QL's. Loading and/or an event can result in varying degrees of dysfunction up to and including acute spinal injury.
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 flow in three ways. Firstly, Qi flow in the Du and Ren Meridians and vitality of the Root, Sacral and Plexus Chakras is inhibited. Secondly, 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. Thirdly, 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, overwork, injury, attacking pathogens (cold, heat, wind, dampness) or emotional factors causing a subtle thickening and tightening of the connective tissue that can lead to pain, dysfunction and injury in the limbs and torso restricting mobility. 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 limb. The subtle thickening and tightening can be mistaken for inflammation where, in fact, clearing the proximal block and promoting smooth energetic/Qi flow transforms the affected tissues, tone rapidly becoming normal.
Left Lower Limb Mechanism
Anterior rotation of 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 glutes to plantar fascia. Cases exhibiting symptoms from the left sided mechanism are more common than right sided mechanism 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 hesitates 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 space encourages 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 energetic block, tightening and thickening down backline of lower right limb when reaching a sufficiently acute degree.
While instances of symptoms from this 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. Many fields of therapeutic practice overlook 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, generating chronic soft tissue stress inhibiting energy flow. Where energy flow is blocked, thickening and tightening occurs restricting mobility through back and neck.
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 sided convexity cases. Associated dysfunction and pain behind that shoulder blade is common.
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. Secondary issues can arise from inactive stabilising musculature in the glutes loading and straining the legs and knees
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. Often accompanied by high degrees of tightness and discomfort/pain in the upper back, neck and shoulders which is the bread and butter of the massage therapy industry. There is a tendency for right sided mild lumbar disk bulging causing 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, overwork, injury, attacking pathogens (cold, heat, wind, dampness) or emotional factors that can have an adverse effect on metabolic health such as digestion or fertility. 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. Reduced lower limb strength and mobility. Lower limb circulation inhibited leading to fluid retention, meridian pain, joint pain, and increasingly reduced lower limb function over time. This is an outcome I have encountered in practice. 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 having the potential to cause meridian pain in the back of the leg and the lateral aspect of the heel, and weaken the right kidney in the long term.
In TCM theory, inhibiting Qi flow can have a direct effect on metabolic function and vitality. It may be coincidental, but apart from improved lower limb function and reduced back pain, I have observed a correlation between commencing heel lift treatment for SRLS and improved digestion and vitality. It would appear to be a beneficial side effect. 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 consider diagnosing and treating internal health conditions.
First published 16 May 2021 at https://www.facebook.com/MassageWorksDandenongRanges