Lower Extremity: Osteopathic Approach to Patients with Postural Imbalance: Short Leg Syndrome...
-
Upload
david-durant -
Category
Documents
-
view
217 -
download
5
Transcript of Lower Extremity: Osteopathic Approach to Patients with Postural Imbalance: Short Leg Syndrome...
Lower Extremity:Lower Extremity:Osteopathic Approach to Patients Osteopathic Approach to Patients
with Postural Imbalance:with Postural Imbalance:Short Leg SyndromeShort Leg Syndrome
Katrina C. Rakowsky, D.O.
CORE OMM Curriculum
2005 – 2006
Session 4
49 year old female49 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
OPPQRST…(a)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
‘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
More historyMore history remote trauma: 6 MVA’s, all >20 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
Physical examPhysical 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
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)
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
Seated...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
Supine/ProneSupine/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
Do you order postural studies Do you order postural studies before or after a treatment before or after a treatment
(OMT) trial?(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
Basic Treatment Techniques 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
Recheck: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
What would you do next?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
So you want standing postural So you want standing postural studies...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
Now what would you like to Now what would you like to try?try?
Lift right side or left side?– heel lift, 9mm– heel lift, 6mm– heel lift, 3mm– Ischial lift, 6mm– ischial lift, 3mm
Calculating amount of liftCalculating amount of lift
initial estimate only function is more important than
symmetry final amount of lift should be equal or
less thanSacral base unleveling
duration + compensation
Exceptions/HintsExceptions/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
Does the treatment help?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?)
By the way, doc…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
How many short legs are How many short legs are there?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
How short is too short?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
ReferencesReferences
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