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

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Presentation on theme: "Lower Extremity: Osteopathic Approach to Patients with Postural Imbalance: Short Leg Syndrome Katrina C. Rakowsky, D.O. CORE OMM Curriculum 2005 – 2006."— Presentation transcript:

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 l 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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4 OPPQRST…(a) l worst at the end of the work day l improved with rest initially, now getting progressively worse l constant ache, feeling of pressure in whole left leg l occasional stabbing pain in the low back l frequent spasms L paraspinal, L calf, l radiation of pain down back of left leg to just below knee (sometimes) l 5-7/10 severity, does not let her sleep

5 l ‘mother of all herniated discs” L3-4 l laminectomy and discectomy, at 35 –needed cane/wheelchair for 6 months prior –trace residual weakness left leg l surgery very helpful at first, same symptoms returning now l no new numbness, weakness, bowel or bladder change l no fever, chills, weight loss, night sweats

6 More history l remote trauma: 6 MVA’s, all >20 y ago, l worst: injury to sacrum when landed on the stick shift l taking Motrin last few days for pain, minimal relief l no allergies l family history noncontributory l no alcohol or illicit substances. Smokes 1/2 to 1 ppd, interested in quitting l chiropractic treatment helped in the past

7 Physical exam l Steady but antalgic gait l heel and toe walks l left hip high l shoulders level l left ear and left eye low l decreased AP curves with head held forward of body

8 l Right foot larger l Arches normal l Left knee slightly higher l Left PSIS and iliac crests noticeably higher l Left positive standing flexion test l Left positive stork test l group lumbar curve convex to the right (functional)

9 l bilateral spasm throughout lumbars l surgical scar from L5 to L2, midline l compensatory lower thoracic curve convex to the right, upper convex to the left l scapulae level l restriction at OA with left condyle low

10 Seated... l right seated flexion test l straight leg raising (bench) negative l reflexes 2/4 biceps, triceps, brachioradialis, achilles bilaterally l Left patellar reflex only 1/4 l strength 5/5 LE throughout l sensory intact LE bilaterally l Left calf circumference slightly smaller than Right

11 Supine/Prone l Leg lengths: –left long, right long, or equal? l left knee cephalad l left acetabular motion restricted l left ASIS, pubic tubercle and PSIS cephalad l left SI joint very tender to palpation l right on right torsion, l left piriformis spasm l L5 rotated to the right, sidebent left

12 Do you order postural studies before or after a treatment (OMT) trial? l Order films / obtain full work up if any red flags for serious or progressive disease l 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 l release locked left SI l muscle energy for left upslipped ilium and pubic tubercle l balanced ligamentous tension for left acetabulum l muscle energy and myofascial release for compensatory lumbar and thoracic curves l suboccipital and OA myofascial releases

14 Recheck: l Standing Flexion test: –positive right? Left? Equal? l Leg length: –long on right? Left? Equal? l Back and leg pain significantly diminished l Continues to have somewhat awkward gait

15 What would you do next? l prescribe a 3mm (initially) heel lift for short leg syndrome: l prescribe a half inch heel lift for short leg syndrome l send the patient home with stretching exercises and a follow-up appointment in 2 weeks l measure legs from greater trochanters to lateral malleoli l order postural films

16 So you want standing postural studies... l Sacral tilt 1/4 inch to the right l right leg shorter by 3/8inch (9mm) l compensatory lumbar scoliosis with apex to the right l weight bearing line anterior to the 1st sacral segment

17 Now what would you like to try? l 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 l initial estimate only l function is more important than symmetry l final amount of lift should be equal or less than Sacral base unleveling duration + compensation

19 Exceptions/Hints l Traumatic or surgical short leg should be fully corrected as soon as possible –try to achieve symmetry as well as function l hip replacement can lead to a long leg on the operated side l children tolerate more correction than adults but need frequent rechecking l patients with a small hemipelvis may also need an ischial pad while seated

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22 Does the treatment help? l Recheck flexion tests and evaluate lumbar curves –after the patient walks around l evaluate pelvic motion while standing l follow up: –repeat structural exams, treat as needed –patient tolerance (look for new symptoms) –(repeat postural films?)

23 By the way, doc… l always ‘clumsy’ l diagnosed with short leg in childhood l treated with a lift in the right shoe l threw lift away age 15

24 How many short legs are there? l Up to 90% of the population l 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? l Short leg of 4mm is significant l sacral tilt of 2mm can translate to 4mm out over the femoral head l lumbar tilt or asymmetry of 1mm can be as much as 3-4 mm when carried out to the femoral heads l smaller asymmetries may be significant if patient unable to compensate

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


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