What is Short Leg Syndrome?

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What is Short Leg Syndrome?

 

By Andrew Germanovich DO and Robert Stowe MS
Restore Orthopedics and Spine Center, Orange County

Short leg syndrome (SLS) is better known in the medical community as Leg Length Discrepancy. In the simplest terms, one who suffers from SLS will have one leg that is shorter than the other. The length difference does not have to be large to make a difference in your body. We are not symmetric. Leg length discrepancy up to 1.5 cm (0.6 of an inch) is usually tolerated well into middle age, but by around age 40 the mechanisms the body employs to compensate for this discrepancy begin to fail.

What causes SLS?

SLS can be caused by congenitally different bone lengths and sizes or by acquired deficits between legs that are otherwise structurally intact. Two different classifications exist for SLS: Anatomic and Functional. When one leg is structurally shorter than the other due to bone length differences or other causes, this is called Anatomic SLS. On the other hand, if the legs appear to have different lengths but structurally are intact, this is Functional SLS. This can be caused by muscular, ligamentous, or other soft tissue injuries, overuse, or another dysfunction.

An injury or other outside influence to any area from the foot to the back will create an imbalance of forces, leading to over compensation of the legs, hips, and spine. Gravity plays a harsh role on our biomechanics, leading to ankle, knee, or pelvic misalignment, sacral unleveling, scoliosis of the lumbar, thoracic, or even cervical spine. This chain of events will give way to unequal burden on joints and overuse of certain muscles, possibly leading to early osteoarthritis and muscular compensation in the spine, hip joint, knees, or ankles. This is when we see the symptoms of SLS.

Below is a limited list of causes of SLS:

  • Anatomic
    • Congenital Scoliosis
    • Hip Replacement Surgery
    • Normal or abnormal leg length variation
    • Late effects of childhood growth plate injuries/fractures
  • Functional
    • Psoas spasticity or IT band tightness
    • Ankle, Knee, Hip injury, Poor Running Biomechanics
    • Dropped Foot Arch
    • Osteoarthritis of the back, hips, knees, or ankles

What are the symptoms of SLS?

Today, back pain plagues the American society. According to the American Academy of Pain Medicine, approximately 26 million Americans between the ages 20-64 suffer from low back pain. While back pain can have many causes, SLS represents a largely overlooked source for those suffering from back pain. Even if the SLS is not the root cause of the low back pain, it can result in a SLS and further a patient’s suffering. Our musculoskeletal system can temporarily adapt to adverse situations such as short leg syndrome.  For this reason many patients with SLS are pain free.  It is not until our musculoskeletal system is unable to adapt or there is tissue property failure (degeneration) that patients experience pain.

Symptoms include:

  • Neck or Back Pain, Hip, Knee, or Ankle Pain on one or both sides
  • Asymmetric tightness in the Psoas, Glutes, Piriformis, Hamstrings
  • Sciatica (Neuropathic pain radiating the back of the leg)

How is SLS diagnosed and what is the treatment for SLS?

If you are suffering from SLS, you should schedule a visit with a RESTORE physician, particularly one well trained in musculoskeletal disorders.  Patients with a painless limp without a known cause should also consider being evaluated.  An orthopedic surgeon or pain management physician with experience diagnosing and treating these problems can make the diagnoses. In particular, an osteopathic trained physician of any specialty, or D.O., has the training and skills to effectively diagnose SLS. A detailed physical examination can point the physician towards the diagnosis.  One of the more common findings seen during the examination is a particular walking pattern that is often mistaken as a simple limp.  Patients with SLS will have a short leg limp which can be identified by an experienced clinician.  Patients with SLS secondary to scoliosis will have other subtle findings including asymmetrical shoulder heights, a posterior rib cage prominence and asymmetrical waist lines.  Often times these patients were never aware of the SLS nor aware of their spine curvature.  Patients with spine curvatures will have tilting of the pelvis which will lead to one hip joint being higher up than the other.  Patients with advanced arthritis will have narrowing of the joint space leading to a slightly shorter leg.  A full length standing X-ray called a “scannogram” may be indicated to properly and accurately measure the leg length discrepancy.   Full length spine X-rays are necessary to measure spinal curvatures.

Once the patient is diagnosed and a root cause is identified, treatment should be aimed at treating the root cause and prescribing a heel lift for the short leg. A heel lift is often a simple cork insert that is placed under the insole of the shoe of the short leg. It is supplied in a variety of shapes and sizes.  In cases where a large correction is necessary a shoe modification can be permanently fabricated into the sole of a shoe by a cobbler.

A heel lift will not fix all short leg problems.  For example, a child with congenital scoliosis should establish treatment with our Restore orthopedic scoliosis spine surgeon Dr. Bederman to discuss treatment options. On the other hand, someone with a functional deficit such as Psoas spasticity should be prescribed a stretching routine, physical therapy, and manipulative therapy directed at the Psoas. If the patient is an avid runner with poor mechanics, the physician should identify the deficit and educate the patient on how to correct it, while also sending the patient for physical therapy.  There are also extreme short leg cases where surgical leg lengthening is required to correct the difference.  This type of surgery is rarely done in adulthood.

Below are two spine X-rays photographs of a patient with SLS.

sls

Figure A- X ray before the heel lift

sls1

Figure B-X ray of the same patient 4 days after wearing a heel lift under the shorter leg. Note an improved spine alignment just after few days.

Short Leg Syndrome is a very treatable condition if diagnosed in an early stage. Proper diagnosis and treatment is key to resolution, allowing the patient to return to normal activity with new strategies on how to prevent any return of SLS.  Correcting SLS may also prevent other pathological adaptive musculoskeletal changes that can affect the spine and lower extremity joints. We hope you found this information helpful.  Please let us know if we can be of service.

References:

http://www.orthobullets.com/pediatrics/4045/leg-length-discrepancy-lld

http://orthoinfo.aaos.org/topic.cfm?topic=a00259

http://jaoa.org/article.aspx?articleid=2094690&resultClick=1#73014238

https://www.ncbi.nlm.nih.gov/pubmed/clipboard

https://www.ncbi.nlm.nih.gov/pubmed/18836788

https://www.ncbi.nlm.nih.gov/pubmed/1469342

 

About Dr. Germanovich

TEAM_Germanovich

With the philosophy that a thorough physical exam is crucial for successful treatment, Dr. Germanovich takes a hands-on approach to the diagnosis and treatment of pain conditions.  He uses a multi-modal treatment approach for every patient starting with therapeutic exercises, manual manipulation, heel lifts, aqua therapy and medications. If basic treatments fail, Dr. Germanovich utilizes precise spine, joint, tissue and nerve injections using ultrasound, fluoroscopy and CT guidance. For complex clinical pain syndromes he may implant spinal cord stimulation and intrathecal drug delivery systems.  Dr. Germanovich’s particular areas of interest are postural biomechanics and musculoskeletal pain due spinal and pelvic misalignment in conditions such short leg syndrome or psoas syndrome.  He is an expert on chest wall pain due to slipped rib syndrome. In addition to his traditional medical education, Dr. Germanovich utilizes osteopathic manual techniques for an accurate diagnosis and effective treatment.  Dr. Germanovich is an active member of many professional Pain Medicine and Anesthesiology societies.

 

For an appointment with Dr. Germanovich or our other Restore physicians please call 714 598-1745

 

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