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F. P Wedel, D.O.,HMDCAssistant Adjunct Professor for Midwestern University Associate Adjunct Professor in Osteopathic Principles and PracticeA.T. Still University School of Osteopathic Medicine in Arizona, and Private practice in Family Medicine in Tucson, Arizona

The Long and Short of It

Evaluation, Diagnosis and Treatment of Selected Somatic Dysfunctions

related to the

THE LONG AND SHORT LEG

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Disclosures

• None

Learning Objectives

Review and Use the following anatomic landmarks and maneuvers to diagnose and correct the Short Leg

Anatomic LandmarksASIS AND PSISSacrum (base and ILA) for ID of the deepsulcus and position of the ILAMalleoli for comparison of leg lengths

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Maneuvers

Standing flexion test for iliac dx

Seated flexion test for sacral dx

Learning Objectives

Techniques Covered:

ME and HVLA for :

Innominate dysfunction: anterior and posterior rotation

ANDsacral torsions: anterior and posterior

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1) ASIS 2) PSIS 3) MALLEOLI 4) SACRUM AND SULCUS 5) INFERIOR LATERAL ANGLE

Landmarks we need:

OBJECTIVE FINDINGS SHEET WITH ANATOMIC LANDMARKS

ASIS SUPERIOR R___ L___ASIS INFERIOR R___ L___MALLEOLUS SHORT R___ L___MALLEOLUS LONG R___ L___PSIS SUPERIOR R___ L___PSIS INFERIOR R___ L___SULCUS DEEP R___ L___ILA INF/ POST R___ L___SEATED FLEXION + R___ L___STANDING FLEXION+ R___ L___

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TODAY -we will do the most common presentations of short leg-

POSTERIOR/ ANTERIOR INNOMINATE

ANTERIOR / POSTERIOR SACRAL TORSION

Background and Basis

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Somatic Dysfunction - Defined• “Impaired or altered function of related components

of the somatic (body framework) system:

• Skeletal, arthrodial, and myofascial structures,

• And…

• Related vascular, lymphatic, and neural elements”

All somatic dysfunctions have a restrictive barrier which are considered “pathologic.”

This restriction inhibits movement in one direction which causes asymmetry within the joint:

The goal of osteopathic treament is to eliminate the restrictive barrier thus restoring symmetry….

Treatment Options for Somatic Dysfunctions

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Somatic Dysfunction: CHARACTERISTICS“The acronym TART is used to remember the abnormal changes that accompany somatic dysfunction. (Tenderness by itself is not always an indication of somatic dysfunction):

•Tissue texture changes•Asymmetry•Restricted range of motion•Tenderness

Kimberly Manual, chapter 3

Indirect – movement away from the barrier and more functional than structural :

◦ Cranial-sacral◦ Counterstrain◦ Balanced ligamentous tension (BLT)◦ Facilitated Positional Release

Treatment Methodologies

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Direct – engagement of the restrictive barrier and movement through it and to it by using the body part as a lever

Muscle Energy and MyoFascialR HVLA Chapman’s and Lymphatics

Treatment Methodologies

THE SACRUMMeans “sacred” because of its density it is the last bone to decay and because it protects the reproductive system

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SACRAL ANATOMICAL AXESTransverse axis

Superior: the cranial&primary respiratory mechanism creates motion around this axis

Middle: sacral base anterior and posterior (FB/BB) occur around this axis

Inferior: the innominates rotate around this axis

SACRAL PHYSIOLOGIC AXES

•Oblique: both left and right oblique axes are named for the superior pole• Sagittal: includes both mid-sagittal and an infinite

number of parasagittal axes• Horizontal: functional axis of sacral flexion/extension

occur around this axis (analogous to the middle transverse axis above)

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Why are the Oblique Axes so significant?

They are the Axes of Walking.

The walking cycle as it applies to our discussion1. From a standing (neutral) position, when you take a step forward,

your weight is shifted onto one lower extremity.2. This induces spinal column SB to the weight bearing side, and pins

the upper pole of the sacrum on the side of the SB.3. As the free lower extremity swings forward, it carries the free pole of

the sacrum anterior, creating rotation of the sacrum about theOblique Axis, towards the weight bearing extremity.

Bottom Line: You form Oblique Axes with every step you take!

Ex.: RL on LOA RR on ROA

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The other aspect of the walking cycle is the movement of the torso.

1. From a standing (neutral) position, as you step forward, note how your body compensates. What does your torso do?2. Answer: Rotates towards the moving lower extremity

(ie.: away from the weight bearing lower extremity).

So your sacrum rotates L and lumbar rotate R when you take a step onto R foot thus your spine (most notably Lumbar spine) rotates in the opposite direction of the sacrum in a neutral moving

situation.

L on L, or L on R, ; R on R, or R on L

The 1st Letter is the side of Rotation

It is also :

the posterior or backward edge of the sacral base (NB- there is an anterior /forward edge too)

The Short leg side

The side of the posterior/ inferior ILA

Sacral Naming Conventionsfor Torsions

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Sacral Naming Conventionsfor Torsions

The second letter ( R on R etc) refers to the Oblique Axis side of the sacrum that it is rotated on so- a L on L sacral torsion means the sacrum is rotated Left on its Left axis;A R on R torsion means the sacrum is rotated right on its R axis –A R on L means right rotation on the Left axisWhen the letters are the same You areDealing with an Anterior sacral base issue – when not –a Posterior sacral

base issue

A sacral torsion requires a deep sulcus and a posterior and inferior ILA to be on oppositesides

So for example,

A deep right sulcus must have a posterior andinferior ILA on the Left by the above definition

Sacral Torsion Diagnosis

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Sacral Torsion Rules

Seated flexion test is + on the side of the dysfunctional edge which will be either forward or backward

The seated flexion test is the hallmark objective exam to determine your torsion (OR shear) diagnosis side and thus what edge to treat

Long leg will be deep sulcus and = anterior edgeShort leg on posterior edge

Forward lesions no + spring test (they do move) Just to be confusing +spring test means NO SPRING

Backward lesions do have + spring test (they do not move)

Sacral Torsion Rules

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◦ TESTS REQUIRED to Diagnose

Today’s Dysfunctions

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The patient stands - feet are hip’s width apart- knees extended

The physician’s - fingers on the iliac crest

thumbs rest on the posterior superior iliac spines (PSIS).

Ask the patient, “Bend forward slowly without flexing the knees”

Physician feels and observes the superior movement of the PSIS (The side which moves first and

furthest indicates restriction of the iliosacral joint on that side.)

STANDING FLEXION TEST

THE + FINDING OF EITHER THE STANDING OR SITTING FLEXION TESTS

WILL BE THE DETERMINANT OF WHETHER YOU HAVE AN :

ILIAC OR SACRAL DIAGNOSIS

KEY CONCEPT

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IF YOU HAVE A +STANDING FLEXION RESULT – YOU ARE DEALING WITH

A ILIAC/ INNOMINATE DYSFUNCTION

IF YOU HAVE A +SEATED FLEXION RESULT – YOU ARE DEALING WITH

A SACRAL DYSFUNCTION

KEY CONCEPT

Patient supine Knees up, feet on

table, lift buttocks off table, then down again, and straighten legs

Hip flop to start off exam

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ASIS Levelness

PSIS Levelness

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Medial malleolus position

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Grasp ankles bilaterally, with thumbs Inferior to medial malleolus on each side

Make sure lower extremities are lying straight

Assess relative levelness of medial malleolus (superior/inferior)

Record position of Side of Lateralization

Sacral Sulcus Depth Palpable groove just medial

to PSIS. Space between sacral spines

and lateral sacral crest. Place thumbs in inferior

border of PSIS. Move ½-1” up and medial to

PSIS. Push thumb tips on sacral

base. Pads of thumbs are on ilium

and tips on sacral base.◦ Measure the depth of

each sacral sulcus relative to opposite sulcus?

◦ Record even, deep, or shallow, comparing one side to the other.

◦ Both sides may be shallow or deep as well.

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Inferior Lateral Angle 1. Place flat of hand over sacrum

near its caudal end and identify the coccyx.

2. Thumbs approximately 1” apart. Place thumbs in gluteal area about 1” caudal and on each side of coccyx.

3. Push thumbs cephalad until pads rest on inferior margin of ILA. Take a reading on the lateralized side: Inferior or superior? Possibly even?

4. Move thumbs approximately 1” cephalad from the inferior margin of the ILAs and place the pads of the thumbs over the posterior surface of the ILAs near the apex of the sacrum.

5. Use moderate equal pressure & judge if one side is more anterior or posterior than the other one or are they equal? Record on the lateralized side.

EVERYONE NEEDS TO PARTNER UP

GO TO THE TABLES WITH THE OBJECTIVE FINDINGS SHEET

LOCATE THE LANDMARKS-

PERFORM THE SEATED AND STANDING EXAM-

PALPATE FOR THE ILIAC AND SACRAL FINDINGS-

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Anatomic –congenital or acquired Posterior/Anterior Innominate Sacral Torsion Sacral Shear - relatively rare and Not today

SHORT/LONG LEG CONDITIONS

Effects of Short Leg Pelvis side shifts and rotates

toward long leg Innominate rotates anterior

on side of short leg or posterior on side of long leg

Foot of long leg pronates, internally rotating lower leg

Lumbosacral angle increases by 2 to 3 degrees

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Posterior Innominate

Standing Flexion will be + on the side of:

ASIS will be superior

PSIS will be inferior

Leg will be Short

HVLA POSTERIOR INNOMINATE Grasp above ankle Raise leg 0-5 degrees off table Internally rotate leg Have patient breathe in Tug entire leg during exhalation

NB- YOU ARE PULLING THE SHORT LEG

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ME POSTERIOR INNOMINATE

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Standing Flexion will be + on the side of:

ASIS will be inferior

PSIS will be superior

Leg will be Long

Anterior Innominate

Grasp above ankle Raise leg 20-30 degrees off table Internally rotate leg Have patient breathe in Tug entire leg during exhalation

NB- YOU ARE PULLING THE LONG LEG

HVLA ANTERIOR INNOMINATE

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HVLA for Anterior Innominate

ME Anterior Innominate

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ANTERIOR SACRAL

TORSIONS

Anterior (forward) Sacral TorsionWill be named either R on R or L on L

Will have deep sulcus on side of +seated flexion and ILA on opposite

Remembering that the 1st letter is the posterior edge – you will be treating the opposite edge as the name of the lesion – so the left edge for R on R( and the seated flexion will be + on the L side as well)

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Neutral - Left Oblique Axis FindingsName: L on LOA, RL on LOA,

Landmarks – Static:Sacral Base: L

posteriorSacral Sulcus: L

shallowILA: L

Post/ Inf.STL: L

TightMotion Testing:

Spring: - (neg)L5: SLRR

Left Right

Midline

A +

P+/-

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Neutral - Right Oblique Axis Findings:

Name: R on ROA, RR on ROA,

Landmarks – Static: Sacral Base: R posteriorSacral Sulcus: R shallowILA: R Post/Inf.STL: R tight

Motion Testing:Spring: - (neg)L5: SRRLSacral Base:L + R -ILA: L +/- R +/-

Right Forward TorsionRR on ROA

Left Right

Midline

P+/-

A+

Forward/AnteriorSacral Torsion

Treatment

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HVLA FOR ANTERIOR SACRUM

Forward Sacral Torsion ME(a right on right sacral torsion)

1. Axis side down; chest on the table

1. Monitor at the lumbo-sacral junction

1. Flex the knees and hips until motion is felt at the lumbo-sacral junction

1. Support legs/knees with thigh or pillow

1. Apply pressure downward on lower legs/ankles

1. Ask patient to try to raise feet towards the ceiling while you resist

1. Rest

1. Re-engage barrier by repositioning ankles downward

1. Repeat 6, 7, 8

1. Recheck

Relative contra‐indications‐acute sacroiliac sprain, acute sacrum fracture, severe knee arthritis, deep venous thrombosis, or premature labor

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POSTERIOR SACRAL

TORSIONS

Posterior (backward) Sacral TorsionWill be named either R on L or L on R

Will have shallow sulcus on side of +seated flexion and ILA that is posterior and inferior on same side as well

Remembering that the 1st letter is the posterior edge – you will be treating the same edge as the name of the lesion –the left edge for L on R and

the R for a R on L

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Non-Neutral: Left Oblique Axis Findings(right on left sacral torsion)

Name: R on LOA, RR on LOA,

Landmarks –Static:

Sacral Base: L Anterior

Sacral Sulcus: L Deep

ILA: L Ant/ Sup

STL: L LooseMotion Testing:

Spring: + (positive)

L5 R S

Left Right

Midline

P+/-

A+

Non-Neutral: Right Oblique Axis Findings(left on right sacral torsion)

Name: L on ROA, RL on ROA,

Landmarks:Sacral Base:R AnteriorSacral Sulcus: R DeepILA: R Ant./Sup.STL: R loose

Motion Testing:Spring: +L5: RRSRSacral Base: L +/- R -ILA: L +/- R +

A+

P+/-

Left Right

Midline

Right Backward TorsionRL on ROA

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Posterior Sacral Torsion Treatment

HVLA FOR POSTERIOR SACRUM

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Backward Sacral Torsion Muscle Energy ( left on right torsion)

1. Have the patient lie on the table axis side down

1. Monitor at the lumbosacral junction

1. Rotate the upper torso posteriorly until motion is felt at the lumbosacral junction

1. Hold the position of torso rotation

1. Flex the top leg until motion is felt at the lumbosacral junction; bend the knee and adduct the hip until motion is felt

1. Ask the patient to push their knee up towards the ceiling while you resist

1. Rest

1. Re-engage the barrier by adducting the knee/hip until motion is felt at the lumbosacral junction

1. Repeat 6, 7, 8

1. Recheck

SACRAL DIAGNOSIS

Diagnosis Seated Flexion

Test

Sacral

Base/Sulci

ILA levelness L5

Rot

Spring

Test

LS Flexion Asymmtry

Left on left Right Anterior right Posterior left Right Negative Decreased

Left on Right Left Anterior right Posterior left Right Positive Increased

Right on right Left Anterior left Posterior Right Left Negative Decreased

Right on Left Right Anterior Left Posterior Right Left Positive Increased

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KIMBERLY MANUAL-2006 EDITION POCKET MANUAL OF OMT-2ND EDITION PRINCIPLES OF MANUAL MEDICINE-GREENMAN OMT REVIEW-SAVARESE-3RD EDITION LECTURES FROM OMM FACULTY – A.T.STILL UNIVERSITY-

PHOENIX AZ- WITH PERMISSION JAOA Vol 91 No 3 March 1991 CLINICAL APPLICATION OF COUNERSTRAIN – MYERS 2006

SOURCES AND RESOURCES

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I HAVE NO DISCLOSURES TO MAKE