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

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Lower ExtremityOsteopathic Approach to Patients
with Postural ImbalanceShort Leg Syndrome

• Katrina C. Rakowsky, D.O.

CORE OMM Curriculum 2005 2006 Session 4
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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

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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

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• 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

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More history

• remote trauma 6 MVAs, all gt20 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

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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

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• 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)

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• 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

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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

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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

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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

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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

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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

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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

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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

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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

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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
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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

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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?)

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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

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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

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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

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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