Lower Extremity: Osteopathic Approach to Patients with Postural Imbalance: Short Leg Syndrome

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 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: • 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.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