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

2. 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

4. 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

5. ‘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

6. 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

7. 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

8. 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)

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

22. 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?)

23. 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

24. 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

25. 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

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