Short Right Leg Syndrome - Considerations for Treatment
I am a Remedial Massage Therapist, graduate Swinburne University of Technology 2007. Clinical background: Athletic and sports client bias but the entire spectrum presents itself across my table. The material covered here was not included in the Remedial Massage curriculum. It should have been. This should be read in conjunction with my article describing signs, symptoms and assessment of SRLS.
The aspect of Short Right Leg Syndrome (SRLS) most prominent in my practice has been symptoms in the lower leg caused by rotation of the left hip binding the SIJ. Athletic activity minimises upper body symptoms of SRLS and aggravates lower limb symptoms.
Most commonly, a subtle thickening and tightening will be evident along the entire back line of the left lower limb from Glutes/Piriformis, Hamstrings, Calf to Plantar Fascia. Low grade conditions can persist for years and with changed activity can progress to acute symptoms of pain and injury.
Acute symptoms are normally experienced in one region only such as the Plantar Fascia or the Hamstrings but I do have a client who successively suffered Piriformis Syndrome and Sciatica, Plantar Fasciitis, full Achilles Rupture and a partial Hamstring tear all on his left side. Interestingly, not one the medico’s (GP, Surgeon, Podiatrist, Chiro and Massage Therapist) he consulted over the years considered his leg length difference or hip rotation relevant. He was not aware of the leg length difference until my assessment of his condition. He is a retired engineer and immediately took it upon himself to use a heel lift when the effect of the structural leg length difference was explained. Being in his 70’s the body had well and truly adapted and was set in its ways; change was slow. Over the course of the first six months he reported gradual improvement to gait and movement. At the 12 month mark there is continued improvement and muscle tone in the left leg has now normalised. Left hip rotation has moved from high range anterior rotation to a low/moderate level. By contrast, a fourteen year old soccer player that could not play beyond half-time in matches due to overwhelming pain and restriction through the hips and lower back, was 100% pain free within two weeks of adopting a heel lift and playing full duration matches.
My approach to treating lower limb symptoms due to SRLS where I estimate the leg length difference is not high range (<10mm) and symptoms are manageable/not too crippling, is normalising hip anomalies by releasing hip flexors and lower back, activating/strengthening abdominals and glutes and giving homework for the client for ongoing rehab. Achieving return to a completely level position has not been necessary to reduce symptoms. I do have concerns for the integrity of an SIJ that has been held chronically (often decades) at full ROM being normalised entirely...stretched soft tissues in the joint may then be too loose and the joint becomes vulnerable to injury. I do have concerns too that normalising hip posture will aggravate upper back condition by increasing hip tilt and scoliotic forces...it's like a heel lift is almost inevitable.
I have previously discussed the futility of attempting to treat the affected areas of the lower limb to achieve release where the hip is chronically held in a rotated position. Incidentally, posterior and anterior rotation has the same affect on the SIJ and backline of the lower limb...posterior rotation rarely rates a mention, I have only sighted three instances. Massage and stretching at best merely provide temporary relief until the hip position is normalised. Then in a matter of days, symptoms of tightness and pain abate without the need for further treatment. Of course, this is only applicable where the condition has not degenerated to a more acute state with the development of heel spurs, tears or rupture.
The left Glutes in these cases are always in considerable spasm...more so than the right…and lumbar pain is usually evident when pressing into the right QL. Apart from the thoracic scoliotic curve bulging costals to the subject’s right side and flattening them on the left, the right spinal erectors being more developed here too, I have not yet worked out a consistent pain pattern for the upper back and neck. Because we are discussing low range length differences that are partially compensated for by the left hip rotation which is an anatomically adjusting flop, the effects of mild scoliosis at the upper thoracic and neck may be more successfully managed through exercise regimes. Other patterns such as a desk bound worker’s overuse of a computer mouse can take prominence.
My treatment consists of conventional massage, Chinese Cupping and Gua Sha as appropriate, plus indirect fascial release techniques through hips, torso, shoulders, skull and spine. Overall, it is an intense experience for the subject effecting dramatic change and may incorprate Craniosacral Therapy once the more overt dysfunction and blockages are relieved.
Fitting a heel lift comes into consideration should initial treatment and rehabilitation fail. The left hip’s anterior rotation will resist attempts to normalise the posture despite all efforts. It would be nice to be able to leave the hip in this position because it is protecting the spine and upper body posture but where it is responsible for lower limb dysfunction, this cannot be allowed to persist and use of a heel lift is required. Some clients who have been struggling for years through a successive range of therapists are quick to adopt the use of a heel lift when they learn the underlying cause of their symptoms is the leg length difference.
Due to the leg length difference, weight loading is not evenly distributed from side to side. The longer leg is supporting a greater weight and it is part of the mechanism driving rotation at the left hip. It is also why efforts to normalise the hip position without a heel lift are not always successful. Occasionally, it is the cause of injury in the longer leg...I have seen tibial stress fracture in a young adult athlete and arch collapse (left foot only) in a juvenile which were influenced by the load imbalance.
Should a reader be thinking of dabbling with a heel lift, understand the body has already made considerable adjustment over the course of many years. It is not necessary to adjust for the full leg length difference. To do so would be over compensating. Start small and only go taller if required over time monitoring progress.
(Note to self...include words on monitoring progression of the effects of heel lift. As left hip position normalises in response to rehab exercises and heel lift, consider possibility for fractional increase in height of heel lift...of course guided by symptomatic response...it is not purely a mechanical process...some have SRLS but require little or no treatment...the less mechanical intervention the better.)
Also be aware balancing leg lengths with a heel lift shifts weight bearing back to a more even distribution. The leg that has been lengthened will now carry a little more weight. A few aches and pains may be felt in that leg. This will pass as musculature and joints become accustomed to the new load.
Success with this treatment approach is sporadic mainly because SRLS is a largely unknown phenomena and the explanation for lower limb symptoms is founded in Chinese medicine and Eastern philosophy...there is no biomechanical or neurological link between the SIJ and symptoms being experienced down the back of the lower limb. It relies on an understanding of Chi flow and the effect its blockage has on fascia and connective tissue. Hence, some clients will not engage with the treatment out of disbelief and scepticism. Another hurdle encountered are clients that must strengthen themselves through exercise that have no prior experience with physical training...I can release tightness, I can encourage muscle activation but I cannot strengthen their muscles...they have to do that and if they do not participate and do homework, outcomes are bleak...but then this can be applicable to all conditions we treat.