Approximately 75% of us present with one leg longer than the other. It’s staggering, literally, that so many people walk about with an imbalance. Yet to have one leg longer than the other doesn’t seem to create pain for everyone but for those that it does it brings pain in a myriad of dysfunction from TMJ, headaches, low back pain, IBS, bladder problems, sexual dysfunction, sacroiliac joint pain, pubis dysfunction, groin strain, gluteal dysfunction as well as the formation of trigger points.

by Ruth Duncan

I’ve got one leg longer than the other

Approximately 75% of us present with one leg longer than the other. It’s staggering, literally, that so many people walk about with an imbalance. Yet to have one leg longer than the other doesn’t seem to create pain for everyone but for those that it does it brings pain in a myriad of dysfunction from TMJ, headaches, low back pain, IBS, bladder problems, sexual dysfunction, sacroiliac joint pain, pubis dysfunction, groin strain, gluteal dysfunction as well as the formation of trigger points.

Let me just be clear here when I say ‘leg length discrepancy’. This is when we measure the difference between the foot and the greater trochanter on both legs. This is a true test and really can only be performed by use of an x-ray. When the test is performed correctly the two legs will be the same length unless there has been a fracture or disease affecting the leg that will distort its length. Factually, very few people have a true leg length discrepancy.

So what is the difference when someone is lying on your treatment table and you can clearly see that one leg looks longer than the other? Many patients will complain of having to take up the hem on one leg of their trousers or that their waistband or belt seems to creep around their waist in one direction only. This is because the pelvis has twisted or torqued around itself affecting the position of the acetabulum where the leg articulates with the pelvis making it look like the legs are two different lengths. This is what we call a presenting leg length discrepancy but not a true leg length discrepancy.

The pelvis is like a bowl. It carries, supports and protects many vital visceral organs as well as being a base of support for the upper body. When this bowl becomes imbalanced it moves in order to find the best point of gravity and support for the body above. The upper body then compensates to accommodate in order to maintain as much balance and propreoception as possible. This is when we see upper and lower cross syndromes and trigger points appear and it is very common for a pelvic imbalance and leg length discrepancy to cause pain in a somewhat unrelated area.

Whilst we know that individual muscles are important for regional stabilization and mobility it is also important to understand how they function together to create a global muscle system and muscular slings of support particularly in the pelvic area. In understanding how they function we also learn what happens when they become dysfunctional. This can help us when we do a postural and palpatory examination to determine the true dysfunction from the compensatory dysfunction, both of which can be creating pain. However, we must take into consideration the unique 3D fascial strain that will be pulling muscles and bones out of balance creating dysfunction. We must look further than muscle and skeletal anatomy in order to resolve the abnormal pulls and trusses affecting the balance of the whole human frame.

Imbalance

So what are the main reasons for pelvic imbalance?

Usually, it’s a prolonged activity using the same muscle groups and limbs or a prolonged period of inactivity both coupled with habitually poor posture. 

Key things to look for are:-

- posture at work

- posture at home

- posture that they sleep in

We must also take into consideration, stress, infection, nutrition and dehydration, inflammation and physical and emotional injury. If you hear something like they are seated all day at work, they watch the TV for two hours per night and they sleep curled up in a ball, then you are hearing all the same muscles being constantly activated whilst others are constantly inactive. This is a recipe for disaster.

The body is a tensegrity model, in other words no one part moves in isolation. The body grows a poor posture over time. To help stabilize this poor posture, and to maintain function, the fascial network, including the muscles, bind down like scar tissue in the form of thick ropes of collagen. These ropes create a unique line of pull throughout the network pulling bones out of alignment and putting strain on vital internal structures. As this binding down gets stronger and more widespread the patient begins to lose flexibility, function and shock absorption as well as becoming dehydrated. This will all result in the slightest injury, fall or infection affecting them in a far greater way.

Poor posture creates habitual compensatory holding patterns and vice versa. When you are in pain, or have had an injury, you will compensate to cope. This compensation will eventually harbour its own aches and pains. It is an experienced therapist that look’s, senses and feels past the symptom to find what has caused it in the first place. You should not simply treat the label of the dysfunction but look and find the cause.

Cause and effect

So let’s look at why people can have a leg length discrepancy. The pelvis has two inominate bones made up of the ilium, ischium and pubis. The 2 sides of the pelvis articulate with the sacrum at the sacroiliac joint at the back, the last lumbar vertebrae, and the pubis symphysis at the front. The sacrum is the keystone of the pelvis. It is made of five sacral segments plus the coccyx. The pubis at the front of the pelvis is a non-synovial amphiarthrodial joint with its role being that of shock absorption, compression and separation, particularly during labour. The pelvis articulates with the greater trochanter of the femurs at the acetabulum.

All human beings tend to have a dominant or tighter side. When an area fascially and muscularly becomes tight the correct articulation at these joints becomes diminished or locked down forcing the body to compensate in other ways to get that particular posture or movement until that is exhausted and so on and so forth. Imbalances in our foundation, the pelvis and lower extremities, will create an imbalance in the thorax, shoulder girdle, and cervical and craniomandibular regions.

So if we look at the most common poor posture, particularly in the pelvis we see a dominant right side yet they may be complaining of pain on their left. They may tend to stand more on their left leg due to it being functionally shorter than the right and complain of pain in their left buttock and back and side of the left leg. As the person is dominant on one side the fascial network tightens asymmetrically in order to function and to meet demand. Even though the presenting pain may be left sided, low back and or grain strain, usually what we see is the right leg longer than the left on supine testing and the right ASIS lower than the left ASIS.

What this means is that the muscular attachments on the right side of the pelvis are pulling the pelvic bowl into an anterior tilt and to compensate the left ilium is moving into a posterior tilt.

Illium

When the ilium tilts anteriorly, it will functionally drop the leg longer on that side. This means that with every step the person takes they are pounding down on that leg creating an abnormal strain through the hip transmitting imbalanced shock throughout the system perpetuating whole body strain. This pounding functionally creates an upslip or hip hike of the same side pelvis jamming the sacro iliac joints, L4, L5, S1 joints and puts an excessive strain on the pubis symphysis. The adductors no longer have a firm foundation and the lower extremity stabilization is lost creating its own pain and dysfunction. As one ilium tilts one direction and the other tilts the opposite this creates a rotatoscoliosis and pelvic floor torsion again bringing its own seemingly unrelated symptoms.

When the ilium tilts anterior, the attachments to the ASIS become short, perpetuating the pull and weakening the muscle. This in turn causes knee strain including patella tracking and collateral ligament strain. Furthermore, as this leg is functionally longer it will tend to externally rotate at the hip, creating piriformis issues, and the foot and ankle will tend to pronate causing a fallen arch. Orthotics may resolve the pain and dysfunction in the short term but if the overall imbalance is not addressed the relief will only be short lived.

iliopsoas

As the iliopsoas attaches and crosses the hip as well as attaching to each lumbar vertebra it will also become dysfunctional. It will shorten and pull the low back forward into a Lordosis affecting quadratus lumborum and the other back extensors resulting in further shortening to accommodate the pelvic tilt. In turn their dysfunction will also perpetuate the leg length discrepancy, Lordosis, lumbar sacral pain creating possible nerve compression and disk problems. Sound familiar?

Pelvic tilt

It is very rare to have an imbalance in just one plane. Most people have pelvic tilt forward or back as well as an upslip, downslip, rotation to the right or left side and possibly also a lateral shift to one side or the other.

Mostly we find that the lateral shift and rotations are compensations for the unilateral anterior pelvic tilt. Therefore if we address this anterior tilt first then it is far easier to treat the lateral shift and rotation next, if in fact they still occur after the anterior tilt is resolved.

For those patients that you see who have low back issues including sacroiliac joint pain, if you treat the major muscle going in and through the pelvis, you can resolve the pelvic imbalance that will be harbouring their pain. This will be the cause of their symptom. The same goes for those will constant groin strain and sacrum, coccyx and gluteal pain including trigger point formation. The pain is there because the pelvis is out of balance making the fascial network dysfunctional and the muscles weak. Simply treating the trigger points is not the answer. We must treat the reason the trigger points manifested in order to resolve the cause.

As the body is a whole it is vital to treat it as a whole regardless of what the diagnosis is. If there was an ankle or foot injury, fracture of the leg, or knee surgery, this is what may have caused the pelvic imbalance. However it may also have been the pelvic imbalance that created the need for the knee surgery or made the ankle or foot vulnerable. We must look at the cause and effect relationship.

References

John F. Barnes. Myofascial Release: The Search for Excellence--A Comprehensive Evaluatory and Treatment Approach (A Comprehensive Evaluatory and Treatment Approach). Rehabilitation Services, Inc. ISBN-13: 978-1929894000 

Diane G. Lee. The Pelvic Girdle: An Approach to the Examination and Treatment of the Lumbopelvic-Hip Region: An Approach to the Examination and Treatment of the Lumbo-pelvic-hip Region. Churchill Livingstone; 3 edition. ISBN-13: 978-0443073731

Leon Chaitow, Judith DeLany. Clinical Applications of Neuromuscular Techniques: The Lower Body, Volume 2: Lower Body v. 2. Churchill Livingstone. ISBN-13: 978-0443062841