Lower Extremity: Osteopathic Approach to Patients with Postural Imbalance: Short Leg Syndrome Katrina C. Rakowsky, D.O. CORE OMM Curriculum 2005 – 2006 Session 4

49 year old female CC: LBP with no new trauma otherwise healthy except asthma left hip pain, difficulty walking -similar to prior symptoms PT, Rx and repeat neurosurgical evaluation suggested epidural injections have not helped back surgeon refuses to operate again

OPPQRST…(a) worst at the end of the work day improved with rest initially, now getting progressively worse constant ache, feeling of pressure in whole left leg occasional stabbing pain in the low back frequent spasms L paraspinal, L calf, radiation of pain down back of left leg to just below knee (sometimes) 5-7/10 severity, does not let her sleep

‘mother of all herniated discs” L3-4 laminectomy and discectomy, at 35 needed cane/wheelchair for 6 months prior trace residual weakness left leg surgery very helpful at first, same symptoms returning now no new numbness, weakness, bowel or bladder change no fever, chills, weight loss, night sweats

More history remote trauma: 6 MVA’s, all >20 y ago, worst: injury to sacrum when landed on the stick shift taking Motrin last few days for pain, minimal relief no allergies family history noncontributory no alcohol or illicit substances. Smokes 1/2 to 1 ppd, interested in quitting chiropractic treatment helped in the past

Physical exam Steady but antalgic gait heel and toe walks left hip high shoulders level left ear and left eye low decreased AP curves with head held forward of body

Right foot larger Arches normal Left knee slightly higher Left PSIS and iliac crests noticeably higher Left positive standing flexion test Left positive stork test group lumbar curve convex to the right (functional)

bilateral spasm throughout lumbars surgical scar from L5 to L2, midline compensatory lower thoracic curve convex to the right, upper convex to the left scapulae level restriction at OA with left condyle low

Seated... right seated flexion test straight leg raising (bench) negative reflexes 2/4 biceps, triceps, brachioradialis, achilles bilaterally Left patellar reflex only 1/4 strength 5/5 LE throughout sensory intact LE bilaterally Left calf circumference slightly smaller than Right

Supine/Prone Leg lengths: left knee cephalad left long, right long, or equal? left knee cephalad left acetabular motion restricted left ASIS, pubic tubercle and PSIS cephalad left SI joint very tender to palpation right on right torsion, left piriformis spasm L5 rotated to the right, sidebent left

Do you order postural studies before or after a treatment (OMT) trial? Order films / obtain full work up if any red flags for serious or progressive disease if no red flags, treat first psoas and quadratus spasm, other compensatory changes may make postural study invalid if not treated first

Basic Treatment Techniques release locked left SI muscle energy for left upslipped ilium and pubic tubercle balanced ligamentous tension for left acetabulum muscle energy and myofascial release for compensatory lumbar and thoracic curves suboccipital and OA myofascial releases

Recheck: Standing Flexion test: Leg length: positive right? Left? Equal? Leg length: long on right? Left? Equal? Back and leg pain significantly diminished Continues to have somewhat awkward gait

What would you do next? prescribe a 3mm (initially) heel lift for short leg syndrome: prescribe a half inch heel lift for short leg syndrome send the patient home with stretching exercises and a follow-up appointment in 2 weeks measure legs from greater trochanters to lateral malleoli order postural films

So you want standing postural studies... Sacral tilt 1/4 inch to the right right leg shorter by 3/8inch (9mm) compensatory lumbar scoliosis with apex to the right weight bearing line anterior to the 1st sacral segment

Now what would you like to try? Lift right side or left side? heel lift, 9mm heel lift, 6mm heel lift, 3mm Ischial lift, 6mm ischial lift, 3mm

Calculating amount of lift initial estimate only function is more important than symmetry final amount of lift should be equal or less than Sacral base unleveling duration + compensation

Exceptions/Hints Traumatic or surgical short leg should be fully corrected as soon as possible try to achieve symmetry as well as function hip replacement can lead to a long leg on the operated side children tolerate more correction than adults but need frequent rechecking patients with a small hemipelvis may also need an ischial pad while seated

Does the treatment help? Recheck flexion tests and evaluate lumbar curves after the patient walks around evaluate pelvic motion while standing follow up: repeat structural exams, treat as needed patient tolerance (look for new symptoms) (repeat postural films?)

By the way, doc… always ‘clumsy’ diagnosed with short leg in childhood treated with a lift in the right shoe threw lift away age 15

How many short legs are there? Up to 90% of the population Are they really short? The most important finding is the unlevel sacral base rotation of the innominates often gives the illusion of a short leg postural adaptations occur throughout the musculoskeletal system, not just in the pelvis

How short is too short? Short leg of 4mm is significant sacral tilt of 2mm can translate to 4mm out over the femoral head lumbar tilt or asymmetry of 1mm can be as much as 3-4 mm when carried out to the femoral heads smaller asymmetries may be significant if patient unable to compensate

References Greenman, PE. Lift therapy: Use and abuse. Postural Balance and Imbalance, AAO publications 1983 pp.123-34 Heilig, D. Principles of lift therapy. JAOA 1978 Feb; 77(6): 466-72 Ward, Foundations for Osteopathic Medicine Williams and Wilkins, 1997, pp. 983-90