We’re going to talk about the clinical applications
of osteopathic manipulative medicine.
Today’s topic is short leg syndrome. When you think
of short leg syndrome, people think of a short leg.
But that’s actually a misnomer. Short leg syndrome
is an abnormality in the hip flexors,
the hip extensors, that make it look like one leg is a
different length than the other.
In actuality, yes. One leg will be longer or shorter
but not because there’s a leg length inequality
but because the hip extensors and flexors have made
one leg come shorter or look longer than the other.
This is something that we use just in general functioning.
You look at a person. You look at how they walk.
You look at how they stand. You look at whether or not
there’s symmetry. Some things stand out.
They just, you can’t help but notice it, and a big one
is whether or not the legs look equal.
When we talk about short leg syndrome, we talk about
what’s going on with the person’s gait
what they look like. So we still call it a short leg syndrome
even though it is not a leg length inequality.
It is a disorder of the hip flexors, hip extensors affecting
the functioning of the pelvis and the sacrum.
There are causes that are unrelated to leg lengths
causing the short leg syndrome.
We’re calling it a syndrome because there are
multiple symptoms and multiple findings.
Some people may get lower sacral pain. Some people
may say that when they run or walk
they feel that all of the work is coming from one leg
or the other. Those are common symptoms
that don’t always lend themselves to needing to come
to a doctor but do make it harder to function.
So the sacral base will be unlevel causing one leg to be
higher or shorter on the bottom than the other.
The innominates or the pelvis may be rotated.
You may have a curve on the side away
from the sacral base where you have the anomaly.
If there is a true leg length discrepancy
and there may be for nutritional reasons,
trauma, mechanical reasons
then that’s a leg length inequality, not a short
leg syndrome. For short leg syndrome,
a lot of times one somatic dysfunction will cause
other somatic dysfunctions to develop.
We want to treat all somatic dysfunction diagnoses
as well as getting X-rays and an evaluation
before you say there is a leg length inequality.
Again, a short leg syndrome can be easily corrected.
When you do an X-ray, you want to measure the coronal
values of the iliac crest, of the scapular base
of the shoulders, and of the skull to make
sure that you have a good sense
of where the body is in alignment.
Just be aware that when you get an X-ray,
you’re always going to see some discrepancy.
Some of that is errors in measurement.
Some of that is the picture and 2 mm in difference is not
something we treat or even note as a diagnosis.
It may just be part of measuring and
what we can do comfortably.
So when somebody comes to you saying
that I feel like I’m walking with one leg,
or I’m not running right, or I need help to run
more efficiently, or to walk more efficiently,
or when I walk upstairs, I feel like I’ve got to hike
up my hip, those are just vague complaints
that you’re going to dig deeper on. You’re going to ask
the person about acute symptoms.
Does this happen all of a sudden?
Are you walking when you feel it happen?
Or is this a chronic problem? Has this been going
on for years? Have you always noticed it?
Has it gotten worse lately or more chronic
to where it doesn’t go away?
How long has this been happening? Is this
one week, one month, one year?
Has it correlated with the change in activity? Is there
pain or discomfort or dis-ease in functioning?
Where does that pain or discomfort go? When does
it occur? Are there any medications
or changes in your functioning that we need
to know about? Then we look at the person.
You look at how they’re standing. Are they standing
to one side? Are they trying to compensate?
Are they twisting? When they move, do they move fluidly?
Do they get up side to side or
do they look comfortable when they do it or
do they look lanky and uncomfortable?
Can you notice just by looking whether or not
there’s a leg length discrepancy?
Often you can. Have you noticed a limitation
or restriction in how they move?
Do they tend to turn to the right or can
they turn to the right and the left?
When you look at the muscle strength, do you notice
major changes when you add some resistance?
Are there any abnormalities of the neurologic exam,
any sensory abnormalities
or functional abnormalities? We’ll go through
a bunch of tests you can do
to see which muscle group, which bony group, and what
level of functioning you need to focus on.
Again, I would refer you back to the 10-step
osteopathic examination video which
will go through a full osteopathic examination.
Let’s start with a case.
You have a patient come in with a chief complaint
of chronic, intermittent low back pain
and moderate right hip pain. The patient is
a 46-year old man who presents with
a history of chronic, intermittent low back pain, worse
with exacerbations from sports or lifting
and it’s been going on for about 28 years,
started when he was moving furniture
into his dorm room in college. It gets better
with rest. NSAIDS help.
Occasionally, an ice pack or heating helps.
Generally, everything gets it better.
But the patient’s also got moderate right hip pain
for the past two to three years.
That’s there more than it’s not there.
This intermittent pain radiates
to the right lower extremity as well.
Now, you’ve got some radiation.
This person has a past medical history
So you have to worry about whether or not
there are medications.
Surgical history is significant only for a skin
lesion removal which was benign
and it was on the left shoulder. Family history is significant
for a father with hypertension,
mother with osteoarthritis. The patient is
a non-smoker, no alcohol, no drugs,
married for 20 years. He has two daughters. He likes
to play the jazz saxophone with the local band.
Medication: He is on Niaspan for the hypercholesterolemia,
1000 mg every night
which raises issues of side effects. Allergies:
The patient has no known drug allergies.
Review of systems: The pertinent positives show
that he has moderate low back pain
and right hip pain. Pertinent negatives,
there is no neurological findings.
Urinary review of systems: There is no urinary
urgency, frequency, dysuria
or history of recent infection. In general, this is
a well-developed, well-nourished
man in no acute distress, alert and oriented x 3.
He is ambulating well without a cane,
no help, slightly leaning to the right with his gait,
and the posture is slightly twisted.
HEENT: Normocephalic, atraumatic,
extraocular motility is intact.
So, you have no
Clear TMs and the throat is clear. Neck is supple,
Heart: Regular rate and rhythm with mo murmurs.
Lungs: Clear to auscultation.
No rales, rhonchi or wheezing, good expansion
Abdomen: Bowel sounds are present. The back:
Negative Lloyd’s, no signs of pain.
Skin: Clear, no lesions. Extremity exams
show full range of motion.
Lower extremities have a full range
But the right side has some decreased
internal rotation of the hip joint.
We’ll get to those tests
in a little while.
Neurologic exam is intact.
Deep tendon reflexes are 2/4
in the bilateral upper and lower extremities.
Muscle strength is 5/5.
On the musculoskeletal exam, straight
leg raising is negative.
But there is a positive Thomas
test on the right side
and a positive FABERE test
on the right as well.
So some findings that the musculoskeletal
system has some abnormalities
that we will get to in
detail in a little bit.
The hip drop test is limited because
of the pain and discomfort.
Osteopathic structural exam: The left lumbar
paraspinal musculature is hypertonic
So you’re going to feel some tightness,
thickness, and just different.
The right lumbar paraspinal musculature
shows some hypertrophy.
The L1 is rotated right, side-bent right which is
telling you there is type 2 mechanics.
There is a right on right forward sacral torsion
and a right anterior innominate
with left piriformis muscle
showing some hypertonicity.
The piriformis is a flexor
of the hip as well.
There is a left piriformis tender point with
moderate right psoas spasm.
The right malleolus is slightly higher
than the left malleolus.
The right tibial and femoral leg length
discrepancy was noted
at about a half an inch difference with
the right extremity being shorter.
So the ASIS to medial mallelous is
visualized to be asymmetrical.
The knees are also noted to be asymmetrical.
A radiological procedure was done.
We did get a postural study and it showed
sacral base unleveling
and the SBU of 3/4” as the sacral base
unleveling was noted.
There was a lumbar right
convexity as well
with side-bending and rotation
only and no wedging.
MRI showed an L2-L3 mild disc bulge.
That’s the end of the examination.
Now, we have to think about
where we are with therapy
and with treatment
gets to a lift.
When we talk about lifts and
we have a noted abnormality
on MRI and radiology, some kind of chronic therapy
like a lift will be needed.
We use David
of the lift equals the sacral
over the duration and
So we look at the sacral
of about three quarters
of an inch.
We put that over the duration
and number of years
which is 28 years, which will
give you a 2,
and the compensation
where he had
That will give you the
formula to figure out
how much of a
lift is required.
The patient was given stretches of
the rectus abdominis,
piriformis, to help loosen the muscles
as well as the psoas,
education on lifting technique to
avoid lumbar strain
and also to give the back
time to heal.
The MRI did show
a disc bulge.
We do know that disc bulge,
is going to be chronic and
will take anywhere
from three months to two
years to get better.
So we’ve got to find a way of
keeping this patient comfortable,
keeping them functioning,
and get them to be
as efficient in their musculoskeletal
functioning as possible.
We are going to start this
patient on medication
because once you have
you’re going to
The body is no longer
It looks like the patient
from normal neutral mechanics to
which is going to make
even more chronic and harder
to deal with.
Medication like an anti-inflammatory
and this patient was
meloxicam 7.5 mg daily in
order to help.
Osteopathic manipulative therapy
will free up motion,
bring the patient back to the
In this case, facilitative position or
was used for the diskogenic
Going back to the examination.
One of the things
you’re going to use
how effective the initial
is looking at the
So yes, you know the sacral
base is unlevel,
but you have to check
You have to check
the inferior angle of
You have to check the
and the level of the occiput
and the evenness.
This all goes to the symmetry
of the body,
the ease of functioning and
how the body
reacts to motion
Does the patient go into an asymmetry
when they’re static,
but once they get kinetic and start moving,
the symmetry returns?
That’s one of the first signs because
when you start moving,
the body goes back into
So look at all these levels,
the base of the skull,
the shoulders, the inferior angle
of the scapula,
the pelvis, and the
When you observe a patient, here’s
a picture of a person’s back,
look at the iliac crest,
are they level?
We always check the posterior
superior iliac spine
and make sure that both
sides are equal.
We check the anterior superior
to see if it’s compensatory and
to make sure
that there’s a mechanical logic
to what’s going on.
You check the curvatures
of the spine,
both side to side and
looking for kyphosis or lordosis,
as well as side-bending.
You look at the orientation of
the knees and feet
to see how the person
and what action does
This diagram just shows
you’re going to check
the knees, and the medial
I know I use the medial
malleoli a lot
because you're at the end of
the exam table,
you can see differences and the
patient notices it as well.
So it’s a good confirmation
to the patient
that something is
and it reinforces to the person
that their pain
has a real mechanical
After you do a treatment and
ease up motion,
they’ll be able to feel and
see the difference.