Lumbar Dysfunction in Short Leg Syndrome

1
Lumbar Dysfunction in Short Leg Syndrome
Developed for OUCOM CORE
by the CORE Osteopathic Principles and Practices
Committee Session 1 - Series A
2
Case Study

• A 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.

3
Case Study - continued

• On 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

4
Treatment and Follow-up

• You 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.

5
Diagnostics

• What do you think the diagnosis is?
• Short Leg Syndrome
• What tests can you use to confirm this?
• Postural X-ray series
• This 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.

6
Anatomical Short Leg

• Congenital
• Birth defect e.g. Pes planus, cerebral palsy
• Trauma
• Fracture, burns and etc.
• Infection
• Polio, osteomyelitis and etc.
• Apparent short leg (functional)

7
Biomechanics

• When 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.

8
Foundations of Osteopathic Medicine, 2nd Ed., p.
621
9
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.

10
Foundations of Osteopathic Medicine, 2nd Ed., p.
620
11
Netter
12
Consequences

• Ligaments (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.

13

• Iliolumbar Ligaments
• Note the attachments onto the ilium

Primal Pictures, Interactive Series
14
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.

15
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.

16
Treatment

• If unleveling is significant, a heel lift is
  often needed.
• Maximum of ¼ inch in the shoe.
• Chronic Short leg, the goal may be only ½-¾ of
  total unleveling.
• Normally the lift is put under the short side.
  Especially if the lumbar curve side-bends away
  from the short leg.

17
Guidelines for initial heel lift height

• 1/3 - 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.

18
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.

19
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.

20
Kimberly Manual, Millennium Edition
21
Kimberly Manual, Millennium Edition
22
Kimberly Manual, Millennium Edition
23
Kimberly Manual, Millennium Edition
24
Kimberly Manual, Millennium Edition
25
Kimberly Manual, Millennium Edition
26
Kimberly Manual, Millennium Edition
27
References

• American Osteopathic Association, Foundations for
  Osteopathic Medicine, 2nd ed. 2003.
• Kimberly, Paul E. Outline of Osteopathic
  Manipulative Procedures, Millennium Edition.
  2000.
• CORE OMM Curriculum
• 1st Year