Lumbar Dysfunction in Short Leg SyndromeDeveloped for OUCOM CORE

by the CORE Osteopathic Principles and Practices Committee

Session #1 - Series A

Case StudyA 23 year old college student presents to the office complaining of low back pain.

The pain is achy in nature, is located nearly midline and does not radiate.

She first noticed it about 6 months ago when she started an exercise program consisting of running and lifting weights. It seems to hurt more when she runs longer distances.

She has never had any injuries to her back.

Case Study - continuedOn exam she has the following findings:

Cervical spine neutral

Thoracic spine neutral, T5-T11SRRL

Lumbar spine neutral, L1-L5SLRR

Sacrum L on L, R ant rotated innominate

R medial malleolus superior to L

Treatment and Follow-upYou treat her and have a return of symmetry and good range of motion in all areas. However, you note a persistent positive standing flexion test on the right, though the seated flexion test is negative.

The patient returns in one month, she had relief of pain for about one week after her first treatment, but has experienced the same pain every since.

On exam you find all the same dysfunctions that you had on your first exam. You treat her again and the dysfunctions once again resolve.

At her next follow-up, all the same dysfunctions are present.

DiagnosticsWhat do you think the diagnosis is?

Short Leg SyndromeWhat tests can you use to confirm this?

Postural X-ray seriesThis should be done shortly after the pelvis has been balanced with OMT, otherwise the x-rays may only reflect the innominate rotation.

This patient is found to have an 8 mm sacral base unleveling with the right side being lower than the left.

Anatomical Short LegCongenital Birth defect e.g. Pes planus, cerebral palsy

Trauma Fracture, burns and etc.

InfectionPolio, osteomyelitis and etc.

Apparent short leg (functional)

BiomechanicsWhen the sacral base is unlevel, the body compensates to try to keep the eyes level.

Early in the process the thoracic and lumbar spine form a long C-shaped curve that is concave away from the short leg.

With more time the compensatory mechanisms redistribute and an S-shaped curve forms with the lumbar concavity away from the short leg and the thoracic concavity towards the short leg.

Foundations of Osteopathic Medicine, 2nd Ed., p. 621

Musculature

Postural muscles - (made to support the body against gravity for long periods) - Respond to stress by becoming tight.

Phasic muscles - (antagonist to the postural muscles) - Respond to stress by becoming weak.

Foundations of Osteopathic Medicine, 2nd Ed., p. 620

Netter

ConsequencesLigaments (such as the iliolumbar ligament) will calcify if under prolonged stress.

Bone will remodel when under stress.Within the compensatory curve wedging of the vertebrae will occur.

Joint degeneration will occur with arthritis of the hip on the long leg side.

Iliolumbar Ligaments: Note the attachments onto the iliumPrimal Pictures, Interactive Series

Diagnosis

After treatment a persistent standing flexion positive with seated flexion negative also points to a short leg.

Postural X-rays will show an unleveling of the sacral base. Anything above 5 mm may be significant. Above 10 mm of unleveling the likelihood of multiple compensatory curves forming is greatly increased.

Lumbosacral Implications

33-35% of patients with short legs have a lumbar concavity away from the short leg side.

All other possible combinations of lumbar and thoracic concavities occur with much lesser frequency.

TreatmentIf unleveling is significant, a heel lift is often needed.

Maximum of inch in the shoe.

Chronic Short leg, the goal may be only - of total unleveling.

Normally the lift is put under the short side. Especially if the lumbar curve side-bends away from the short leg.

Guidelines for initial heel lift height1/3 - 1/2 total Sacral Base Difference

More patient factors to consider :

Frail Patients - Start at 1/16 inch and increase by 1/16 every two weeks. (Frail = elderly, osteoporotic, arthritic, acute pain)

Flexible spine with mild to moderate strain - Start 1/8 inch and increase by 1/8 every two weeks.

Sudden length difference (fracture, prosthesis) in a patient with previously equal sacral bases - entire height at once.

Treatment - continued

With OMM to address compensatory curves, lift therapy to create less than 1mm of sacral base unleveling will result in 80% reduction in pain.

OMM is necessary, or old patterns of compensation probably will not resolve even with lift therapy.

OMM for the Lumbar Spine in Short Leg Syndrome

Most segmental dysfunction will be neutral.

No type of treatment contraindicated in short leg syndrome.

Use a patient-by-patient approach to decide what treatments to use.

Kimberly Manual, Millennium Edition

Kimberly Manual,Millennium Edition

Kimberly Manual, Millennium Edition

Kimberly Manual, Millennium Edition

Kimberly Manual, Millennium Edition

Kimberly Manual, Millennium Edition

Kimberly Manual, Millennium Edition

ReferencesAmerican Osteopathic Association, Foundations for Osteopathic Medicine, 2nd ed. 2003.

Kimberly, Paul E. Outline of Osteopathic Manipulative Procedures, Millennium Edition. 2000.

CORE OMM Curriculum1st Year