Sighted four times recently, patients suffering low back pain while standing due to anatomical leg length differences between 6mm and 12mm tilting the hips and sacrum, stressing lumbar joints. Also observed in each instance, the hip contra-lateral to the short leg in chronic anterior rotation with pain on palpation of the SIJ. I do not understand the mechanism causing the rotational flop at the hip but speculate it is an unconscious bodily response to correct the postural imbalance caused by different leg lengths. As the hip rotates about the pivot point at the SIJ, the head of the femur moves in an arc posteriorly and superiorly, effectively shortening the longer leg by up to 5mm. Unfortunately, hip rotation can introduce other anomalies due to stress chronic rotation has on the soft tissues of the SIJ.

Where leg length differences are minor, say in the order of 2 or 3mm, this natural coping mechanism may succeed with no undue side effects. However, if the leg length difference equals or exceeds the potential corrective action that can be achieved by hip rotation, the low back pain persists and the resulting SIJ dysfunction causes pain and affects the back line of that lower limb...thickening and tightening of the fascia from the glutes to the bottom of the feet. I have frequently observed symptoms from inactive gluteals, proximal hamstring tendinosis, through to achilles strain or plantar fasciaitis that can result from this phenomenon.

Where these lower limb backline symptoms are sufficiently acute to warrant correction of the anterior hip rotation, sacral tilt will increase and lower back pain while standing will be aggravated. This backward step in the treatment process cannot be avoided if the issues associated with anterior hip rotation must be corrected. However, by inserting thin spacers under the heel in the shoe of the short leg, hip/sacral tilt can be neutralised and lowback pain eliminated.

While this is not rocket science, coverage in my remedial diploma studies was scarce to minimal. More recently the topic was touched on at the Australian Craniofascial Therapy School. Each of the four patients observed have been under the supervision and treatment of higher qualified physical therapists repeatedly over periods of several years but it escaped their attention.

I have limited experience using this method of treatment. Hip rotation issues I have addressed extensively in earlier articles. Regarding treatment of leg length differences, within reason, if it ain't broke...don't fix it. Where there are symptoms and it has been positively confirmed there is an anatomical leg length difference, start with a heel lift no larger than half the leg length difference or less. Be conservative. Build height incrementally as it takes time for the body to adjust. It may not be necessary to correct for the full anatomical shortfall in leg length. Monitor progress.

Low Back Pain - Anatomically Short Leg and Contra-Lateral Anterior Hip Rotation - Remedial Massage and Myotherapy Assessment and Treatment

Short right Leg Syndrome and Contralateral Hip Rotation - Remedial Assessment and Considerations for Treatment

Body builder getting regular sports rubdowns asks the question, "What issues or conditions do I have?" On reflection I had noted left hami'/calves were marginally tighter than the right. He concurs but states he only notices it during massage sessions. Otherwise, at all other times there is no discernible difference...except...the left calf measurement is significantly larger than the right. He is right side dominant.

Examining further I note the left hip is anteriorly rotated, no pain on palpation of the left or right SIJ's, and the right hip is level. Apparent leg length indicates right leg is fractionally shorter (1-2mm) than the left leg...if both legs were actually the same length, the expectation would be left leg apparently shorter than the right by 5mm due to anterior hip rotation of this degree. Hence, I suspect the subject's right leg is actually shorter than the left. This is verified by testing isolating hip anomalies from tibia/femur length comparison. Estimated leg length difference is 5-7mm...the right being the short leg.

As the leg length difference is only moderate, postural anterior flop/rotation of the contra-lateral hip to the short leg successfully balances the leg length difference, eliminating potential hip tilt that would otherwise cause low back pain.

However, low grade tightness along the backline of the left leg is occuring due to anterior hip rotation binding the SIJ and blocking energy flow. Resulting fascial thickening has been objectively noted when measuring his anatomical dimensions. At this time, the subject claims no adverse symptoms have been experienced during training sessions.

Advice: Be cognisant of the condition and should training loads elevate, there is potential for left leg backline tightnness to be aggravated. Should that transpire, inserting a 2-3mm heel lift in the right shoe to correct hip posture will reduce backline restriction/tightness and reduce risk of injury. Regardless of training loads, using a posture correcting heel lift to equalise left versus right leg measurements caused by fascial thickening could be considered.

Mini rant and discussion of Sacro-Iliac Joint assessment for therapists...

 

My response to a Massage Australia Q&A query "Do we use Reflexology or Remedial Massage to treat an inflamed Sacro-Iliac Joint?" after a flurry of ineffective responses that recommended referring to physio/chiro/osteo (my all time pet hate response, no disrespect intended but this is a Massage forum for Christ-sake)...consoling words of advice that we do not FIX (from the guru of all guru's who should know better...yeah, I know what you meant but totally unhelpful, totally)...advice proffered to use this that or the other technique. Sheesh!?!? No mention of assessment of the subject's lumbo-sacral complex was made. Of course there are SIJ conditions Remedial Massage is well able to rectify.

Offering the first real point of advice in the entire thread of 20 something platitudes, I state...Check the patient's hip position...SIJ dysfunction commonly due to chronic anterior rotation of the hip caused by one or all of the following: tight hip flexors, weak abs, tight QL, weak/inactive glutes. Remedial Massage Therapists are well able to rectify this problem with facilitated stretching and release of tight musculature and giving instruction for exercise to strengthen weakness. For patients who spend much of their day sitting at a desk or driving a vehicle, merely stretching the hip flexors is sometimes sufficient to rectify the problem.

Followup remarks by the enquirer indicated a treatment consisting of a bit of rubbing took place but there was no mention of assessment.

Excuse me, I respond, exactly what does "...focused on glutes, erectors, QL's and hip flexors" mean? I hear no words describing any form of assessment. Just rubbing everything will not necessarily correct the condition described earlier...if in fact, it is that condition at all. Are there fundamental physical abberations to the subject's posture (specifically at the hips, sacrum and lower back) that might be corrected by the principles of remedial massage and relieve strain on the SIJ? If any such aberration is identified, determining what caused it may require looking beyond the lumbo-sacral complex but usually it is not so difficult...we sit too much and we are out of shape...stretch, release, strengthen as I indicated previously.

Subject standing, therapist seated at their side, locate the ASIS with the fingers of one hand and the PSIS with the other. Compare their relative positions to one another. Females should be level or tipped slightly anteriorly in the Sagital plane; that is, the ASIS not more than 5mm lower than the PSIS. Males should be level. Check both sides and take note of the result.

In my experience, there can be four possible results: both hips are level; one hip is level and one is rotated anteriorly (unilateral rotation) anything up to 25mm; both hips are rotated anteriorly (bilateral rotation); both hips are rotated posteriorly. The most common is unilateral anterior rotation. The least common is posterior rotation...I have only seen two such cases.

Subject standing and therapist seated behind them, using the thumb, press with light to moderate force on the SIJ. A healthy joint with no chronic strain on it will be pain free. If it has been held in a unilateral anterior rotation long term it is likely to be painful. In the case of bilateral rotation, the integrity of the SIJ's are not usually compromised but the L5/S1 joint and lumbar spine will be affected.

Typically, the pain level at the SIJ is low. So low the patient is not aware of it day to day beyond a mild ache and they dismiss it. When palpating the SIJ it is necessary to closely question the patient whether they feel any discomfort or differences between the left and right sides.

In terms of the affect this hip anomally may have more distally, the pain level at the SIJ is not relevant but it does verify chronic hip rotation is taking place and causing dysfunction at the SIJ...the joint does not like being forced continuously to full ROM. Regarding relevance of SIJ pain, I do encounter instances of unilateral anterior hip rotation, with or without any pain on palpation of the SIJ, that are experiencing symptoms distally in the lower limb as a direct result of the hip anomally but that is a story for another time.

In your subject's case you state "inflammation" of the SIJ...hot, red, puffy, swollen??? What is the pain level? Can you verify its' source by palpation? Where the SIJ pain level is high, it is frequently perceived by the subject as lower back pain but it can merely be hip rotation causing discomfort at the SIJ. Where the pain level is crippling and they are unable to move, unable to rise out of a chair, there is the possibility of more serious degeneration or damage in the joint. Never-the-less, still work to correct hip posture because I have been able to provide significant relief to these more serious cases by doing so.

So far I have only discussed examining movement of the hip in the Sagital plane. Understand that when the hip does so, and does so to a significant degree unilaterally, it introduces a tilt to the pelvis and sacrum in the Frontal plane throwing a temporary scoliotic force on the spine. It also creates an apparent or functional leg length difference as the hip joint rotates in an arc posteriorly and superiorly with anterior hip rotation; that leg will appear to be and is effectively shorter for functional purposes posturally. Should it transpire there are actual or anatomical leg length differences, and in my experience this is unusual, this may lead to the need to insert heel lifts to correct issues at the hip. Initially though, focus on rectifying hip rotation anomalies in the Sagital plane as I described in my earlier comment and relieve any lateral stresses through the ITB, TFL, QL, Lats that may be throwing out Frontal plane balance. When treatment and the subject's efforts to strengthen weakness and stretch tightness have taken affect, reassess. Then take it from there. Positive outcomes can be very quick to achieve.

Use of Reflexology to assist treatment of an SIJ problem of this nature can enhance treatment should the therapist choose to do so, but assessment of the patient's condition is essential and use of a strategic Remedial plan of release, stretching and strengthening will generally yield a better and more rapid recovery. This is how I was taught to practice Remedial Massage Therapy. I have not gone into the detail of treatment techniques I might employ but highlight assessment concepts that should be considered. If you have any further questions, do not hesitate to ask.

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