PELVIC BALANCE

Dealing with Shifts, Tilts, Rotations and Their Effects

Part 2: The Short Leg Syndrome
with Doug Keller

Short Right Leg Syndrome

R
Main Sources of Information concerning the
Short Leg Syndrome: the chapter The Short
Right Leg Syndrome by Erik Dalton in his book
Advanced Myoskeletal Techniques, second edition
2010,
and also his articles Treating Short Leg Syndrome
and Leg Length Discrepancy (Parts 1 and 2)
published on his web site at
www.ErikDalton.com/media/published-articles.
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Functional Leg Length Difference

There is not an actual difference in leg length
Instead one leg feels or acts as if it were shorter

Functional Leg Length Difference

There is not an actual difference in leg length
Instead one leg feels or acts as if it were shorter
The reasons for this are a combination of:

Patterns of Rotation Compensatory Patterns of Rotation

possibly established by fetal positioning in the womb

Functional Leg Length Difference

There is not an actual difference in leg length
Instead one leg feels or acts as if it were shorter
The reasons for this are a combination of:

Patterns of Rotation Compensatory Patterns of Rotation

possibly established by fetal positioning in the womb

Patterns of Side-Shifting of the Pelvis and weighting of the

legs

Functional Leg Length Difference

There is not an actual difference in leg length
Instead one leg feels or acts as if it were shorter
The reasons for this are a combination of:

Patterns of Rotation Compensatory Patterns of Rotation

possibly established by fetal positioning in the womb

Patterns of Side-Shifting of the Pelvis and weighting of the

legs

Patterns of Side-Tilts and Rotations in the pelvis which

cause side-bends and rotations in the spine, ultimately
contributing to a functional scoliosis

Functional Leg Length Difference

There is not an actual difference in leg length
Instead one leg feels or acts as if it were shorter
The reasons for this are a combination of:

Patterns of Rotation Compensatory Patterns of Rotation

possibly established by fetal positioning in the womb

Patterns of Side-Shifting of the Pelvis and weighting of the

legs

Patterns of Side-Tilts and Rotations in the pelvis which

cause side-bends and rotations in the spine, ultimately
contributing to a functional scoliosis

Compensations that the body makes to accommodate these patterns

can lead to Decompensations or changes in and around the joints
especially at key points in the spine with dysfunctions in
joints: damage to cartilage
muscles: tensing of postural (tonic) muscles; and imbalances of
tension and weakness in larger movement (phasic) muscles
nervous system: abnormal patterns of tension for holding
postural balance are written into the nervous system as normal.

Major Points of Decompensation in the Spine

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Pelvic Rotations Contributing to a Functional Leg Length Difference:

The primary cause in creating and perpetuating functional leg length differences is the rotation
of the ilium on the sacrum often called iliosacral rotation or tilt.

Two Kinds of Rotation can take place in

the pelvic girdle:
The hipbone rotates around the sacrum
(Iliosacral tilt)

Pelvic Rotations Contributing to a Functional Leg Length Difference:

The primary cause in creating and perpetuating functional leg length differences is the rotation
of the ilium on the sacrum often called iliosacral rotation or tilt.

Two Kinds of Rotation can take place in

the pelvic girdle:
The hipbone rotates around the sacrum
(Iliosacral tilt)

the hipbones and sacrum can also rotate

as a block around the lumbar spine.

The Effect on the Muscles

of Left Vestibular (Balance) Right Motor (Movement) Dominance

The bodys reaction to using the right leg for movement:

the bodys postural muscles on the right side, especially the hip flexors and
their synergistic stabilizers (adductors, TFL) react by tightening and shortening,
tilting the right hip bone forward.
Iliopsoas:
psoas major

TFL
(tensor
fascia lata)

iliacus

adductor

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The Effect on the Muscles

of Left Vestibular (Balance) Right Motor (Movement) Dominance

The bodys reaction to using the right leg for movement:

the bodys postural muscles on the right side, especially the hip flexors and
their synergistic stabilizers (adductors, TFL) react by tightening and shortening,
tilting the right hip bone forward.
Iliopsoas:
psoas major

TFL
(tensor
fascia lata)

iliacus

gluteus
medius

adductor

this can exert a pull on the hamstring attachment (especially in

forward bends)
weaken the piriformis (destabilizing the sacrum)
cause gluteus medius to be locked short, weakening its role as
abductor/stabilizer for the hip, while inwardly rotating the thigh

piriformis

hamstring
attachment
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The Effect on the Muscles

of Left Vestibular (Balance) Right Motor (Movement) Dominance

The bodys reaction to using the left leg for balance:

tightens the quadratus lumborum and iliocostalis on the left side tighten: which
rotates the left hip bone back and up (posterior/superior rotation)
flattens the lumbar curve on the left

quadratus lumborum

iliocostalis
Longissimus
Thoracis

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Summary on Functional Leg Length Difference:

Change the bodys habits from Shifting Left
Use weight-bearing one-legged balances to reduce our tendencies toward side-shifting

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An indication that distortions in the pelvis come from our tendencies to side-shift:

Differences in the height or

level of the hip points
disappear
or shift significantly
when we check them while
reclining
If the difference between
hip points disappears, then
the apparent leg length
difference is more likely to
be functional

If the imbalance remains the same, then the distortion is in the pelvis itself
one of the causes of which may be a structural leg length difference

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Basic Principles of Pelvic Stability

Uddiyana Bandha for Postural Support

Key Actions:
1. Hip points narrow or draw toward
each other via the Transverse
Abdominals
2. Draw the lower abdomen in & up:
Rectus Abdominis
These actions might be described as
tightening the drawstring and zipping
up

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Hip Points In Tightening the Drawstring

The first action takes place along lateral lines,
and so it involves primarily the Transverse
Abdominals at a level below the navel.

Zipping Up
The second action of toning and lift at the pit
of the abdomen involves the combined
actions of Rectus Abdominis and the Internal
and External Obliques, while keeping the
spine stable (particularly at T12, while
stabilizing the tilt of the pelvis).
The work of Rectus Abdominis prevents the
obliques from tilting the chest and pelvis and
impinging on the spine.
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A Practice: Engaging the Core

Zipping Up
A first practice for learning to zip up from bottom
to top is to practice the Cat Tilt, rounding the
spine up vertebra by vertebra.
Initiate from the tailbone, but let the movement
come from the lower belly.
It is helpful to practice with a partner, to see if any
segments of the spine are stuck.
Release the stuck areas by engaging the
abdominals in that specific area to release and
round the spine.
Press the hands into the earth to help you engage the abdominal muscles.

Focus not just on the flexion or forward bending of the spine, but on the
feeling of wrapping around through the abdominals along the latitudes of the
spine to lift up toward the spine.
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Second Aspect of Pelvic/Sacral Stability

The Lumbar Multifidus Muscles as Stabilizers

The multifidi, which originate at the

transverse processes of the vertebrae
and insert below that at the spinous
processes, are involved in rotation of the
spine but because they run vertically
to the vertebrae, they do not directly
cause rotation of the vertebrae, but
rather stabilize by resisting rotation. They
are similarly involved in side-bending.

The multifidi, because they are at the back of

the spine, have a bowstring effect in the
lumbar, supporting the lumbar curve. Without
them, when the obliques cause the torso to
twist, they would also cause the torso to bend
forward. The multifidi keep the spine upright
during twisting.

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The Core = Transverse Abdominals + Multifidi Working Together

They co-contract: when the transverse abdominals activate to stabilize the trunk
particularly in the area below the navel the lumbar multifidus muscles activate as well.
Their combined action helps the vertebrae facets stack firmly against each other, so that
the individual spinal segments can work together as one strong cohesive unit.

If the transverse works unevenly, or if there is a failure in one or two segments of

the multifidus, the vertebrae at that segment are vulnerable to having the disc slide
which is one of the most common dysfunctions in low back pain.

In particular at L5, the multifidus must produce enough

tension to ensure that L5 does not slide forward on the
sacral plateau (spondylolisthesis), which can happen
especially because this surface naturally, and sometimes
significantly, slopes downward. To counter this, the
multifidus is thicker especially at this segment of the
spine. Unfortunately, it often suffers from disuse, atrophy,
and is often infiltrated with fat.

And beyond the matter of the discs sliding, research has shown (Carolyn Richardson and
others) that failure of a particular segment of the multifidus is the most common
denominator in cases of chronic back pain in precisely the location where the failure
takes place.
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As stabilizers, the transverse abdominals and multifidus work together best within
the neutral zone or in the range of a relatively neutral spine
The Multifidus:

The multifidus muscles work to support the inward curve of the lumbar spine. They continue this
work as you go into a forward bend, stabilizing the spine.

Their work is made harder when the spine compresses or overly rounds in a forward bend from the
action of the abdominals pulling the rib cage downward.
Hence a forward bend begins with a neutral spine and the lifting action of the bandhas maintaining the connection with

the abdominals and can round progressively. As the forward bend goes further toward the end range of motion, its up to
the ligaments of the spine to protect it.

The Transverse Abdominals:

The transverse abdominals likewise are less and less effective as a stabilizer as you go beyond the
neutral zone of muscular stabilization and deeper into a backbend; it is up to the ligaments to protect
the spine in deep backbending, as the core becomes less and less effective.

The Ligaments:

By the same token, if the stabilizer muscles take too long to fire while in the neutral zone, then the
ligaments are at risk for injury since they are not sufficiently taut to protect themselves or the
joint.
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How Do You Get Them To Work Together?

These are not movement muscles: their job is to stabilize. And so the exercises for
these muscles should challenge them to stabilize the trunk, without putting more load
upon them than they can bear.
In other words, for these muscles, you dont need to go outside of the neutral zone (i.e. toward the
outer reaches of a stretch or action no extreme yoga poses necessary)

And if you overload the body, you will simply recruit other movement muscles rather than the
stabilizers to do the action and fail to work effectively with the stabilizers.

The multifidus muscles are worked best by small extension movements of the spine
(small versions of back bending / slight extension of the spine that does not overly kink
the spine at any particular point).
When you challenge the body to maintain its balance particularly in hands-andknees versions the body is forced to recruit the transverse abdominals to stabilize
the trunk while the spine is being extended.

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Structural Leg Length Difference often manifests

as the Short Right Leg Syndrome, and usually involves the
following:

low right femoral head

lumbar convexity to the short leg side (side
bent to the left and rotated to the right)
pelvic rotation

lumbar
convexity

L
low right femoral head

pelvic rotation

There can be variations in the bodys

response to a structurally shorter leg

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Defying Expectations
The Leaning Tower of Pisa principle: would lead you to
expect that when the right leg is short, the weight would
lean or shift toward the short right side, putting more
weight on the short leg.

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Defying Expectations
The Leaning Tower of Pisa principle: would lead you to
expect that when the right leg is short, the weight would
lean or shift toward the short right side, putting more
weight on the short leg.

But the Tower of Pisa does not have a central nervous

system:
some individuals may unconsciously resist this gravitational
pull by shifting the body weight to the left side.
and motor dominance overrides the Pisa Principle of tilting
the weight toward the low side; instead, the spine tilts
away from the low side.
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Short Leg Symptoms

Along with these shifts and side-bends, there can be
variations in which leg is more weight-bearing
Those with short right legs who bear more weight to the short right side usually
report greater SI joint pain in the right hip and low back.

tests usually reveal that the right sacral base is rotated forward (deep),
the ilium is rotated forward and stuck (fixated), and
the iliolumbar and sacroiliac ligaments are tender.

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Short Leg Symptoms

Along with these shifts and side-bends, there can be
variations in which leg is more weight-bearing
Those who side-shift over the left leg (often because of motor
dominance) usually experience greater left-sided SI joint pain.

Usually the left ilium is posteriorly rotated and stuck.

symptoms get worse during prolonged walking or running, as

overstretched abductors rub against the greater trochanter in the

left hip, creating
bursitis
Superior
gluteus medias tendinosis and
Posterior
piriformis syndrome.

L
R
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Patterns Of The Hips Showing Up In The Feet

Usually when one hip point is lower (from forward tilt of the
pelvic bone), there is a corresponding drop in the arch of the
foot (pronation), along with an internal rotation of the thigh
at the knee and lack of tone in the quadricep.
When the opposite hip point is higher (from posterior tilt
of the pelvic bone), the foot usually supinates, bringing the
weight to the outer heel. The thigh is often externally
rotated, with greater tone in the quadricep.
The effect of these tendencies on the hips will depend upon
the degree of shift of the hips, both forward-backward and
side-side

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Awareness of Weight-Bearing Patterns in the Feet

Tibialis
Posterior

The center point in the sole of the foot directly underneath the talus can be the central point
of focus for the lift of the arch, which comes mainly from tibialis posterior.
Making a bridge of the feet by standing on the two blocks will help to stimulate the lift of the arches
and center the hips over the feet.
and will also make you more aware of where you tend to bear weight in each of your feet:

toward the big toe mound and inner edge of the foot, or
toward the outer heel and outer edge of your foot

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CHARACTERISTICS OF A FLAT FOOT

Medial column hypermobility
The medial column the inner edge of the foot has too much motion
when the muscles from the base of the big toe fail to take their share of the
weight, allowing the arch of the foot to collapse.

A Tight Calf Muscle

Symptoms of Flat Feet:

extra pressure is placed on the tendon of tibialis posterior,

overstretching the tibial nerve

compression forces on the outside of the ankle joint, which can

wear out the outside of the ankle joint leading to ankle arthritis.

Overload on the base of the 2nd toe, because the base of the big
toe does not take its share of the weight, can lead to overload the
2nd toe, leading to metatarsalalgia or even stress fractures in the
2nd metatarsal.

Compression
Forces on the
Outer Ankle

Stress on
the Second
Toe

Overstretching of tibial nerve

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CHARACTERISTICS OF A HIGH ARCH

Medial Column Stiffness
A high arch foot is known in medical terms as a subtle cavus foot. People
with high arch feet tend to be very stiff through the midfoot, with very little
movement through the main midfoot joints (ex. the talo-navicular joint). The
heel tends to be pointed inward in what is known as a varus position.

Symptoms of High Arches:

The excess loading on the base of the big toe can predispose people
to develop sesamoiditis and sesamoid fractures.

Stress on the outer ankle can lead to tendinitis in the peroneals.

The foot is more susceptible to

Compression is greater on the inner ankle, which can lead to ankle

arthritis from damage to the inner (medial) aspect of the ankle joint.

ankle sprains
fractures on the outside of the little toe
pain directly under the big toe (sesamoiditis)
With a genuinely high arch, the inner
heel remains grounded, though the
Achilles Tendon may still show some
bowing.
Compensation for a fallen arch simply
rolls the weight to the outer edge of
the foot; the inner heel is not
grounded.
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The Paradox Of The Shorter Leg Syndrome

When the right leg is shorter the body tries to accommodate, and often shifts the
patterns in the feet.
The following patterns are fairly predictable:
On the Long (Left) Leg:
The body tries to make the leg shorter by pronating or flattening the foot.
The leftward shift of the hips tends to bring the weight toward the outer
heel, while the foot flattens at the same time, trying to shorten the leg. This
can lead to exhaustion in the foot.
The knee tends to flex on the long leg.
circumduction of the long leg the leg swings around to the front while
walking
On the Short (Right) Leg:
The body tries to make the leg longer by supinating the foot
knee hyperextension on the short side, rotating the knee inward and putting
strain on the inside of the knee
as the foot attempts to supinate, it turns the shin outward, while the thigh bone
is rotating inward; this can cause tibial torsion at the knee

Arch support for the shorter leg is not always effective

because of the twisting actions of pronation and supination
taking place in the feet especially in response to the hips!

Foot Supinates to

Foot Pronates to

make the short leg

longer

make the long leg

shorter

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SCOLIOSIS

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General Effect of Tilts on the Lumbar Spine

Lumbar Curve
Flattens on the Left
Side

Lumbar Curve
Increases
(Lordosis) on the
Right Side; tightness
in the left
quadratus as well
as lordosis on the
right can show up
in poses like
Trikonasana,
misaligning the
pose as well as
creating pops in
the spine during
sidebending

Lumbar Spine
Sidebends to the Left
Compensates for Left Rotation of
the lower lumbar (turning with the
Sacrum) by Rotating to the Right in
the Upper Lumbar: Scoliotic C
Curve
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Other Scoliotic Compensations

Shortening of
Quadratus Lumborum
on the Long Leg Side

Shortening of:
Scalenes
Levator Scapulae
Sternocleidomastoid
Upper Trapezius
on the Short Leg Side

Recognizable patterns during walking:

shoulder tilting to one side
unequal arm swing
pelvic tilt
foot supinated on the short side and pronated on the long side
ankle plantarflexed on the short side (toe pointed, or walking on toes) and/or
knee flexed on the long side
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What to Address: Shifts and Tilts First

L
R

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some suggestions concerning lateral poses

In lateral standing poses, use

resistance against the wall to help
activate gluteus medius on the
convex side to open the hip while
working the quadratus lumborum.
Convex Side
rib hump

Convex
Side

Concave
Side

Concave Side

Dont go down so far as to collapse small

lateral movements are better: the exercise is
for strengthening the side, not stretching it.

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Functional Leg Length Assessment

Too much emphasis is put on supine (reclining) leg length assessment:
Commonly, one leg will appear shorter when checking the medial
malleoli (inner ankle) when, in fact, the leg lengths are actually equal or
just the opposite of how they appear when standing.

For example, in the presence of a true (structural) short right leg, the
right hip point will be dropped while standing; however, when lying
down (supine, removed from vertical compression from gravity) the
left leg may test shorter than the right.

One of the most common reasons for this is the length/strength

imbalance in deep intrinsic postural muscles such as the quadratus
lumborum. When it is short and tight on one side, the QL can pull
the left hip upward when there is no weight on the leg, making the
left leg shorter than the right.

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Prone Leg Length Assessment

In prone leg length assessments, when lying facedown, both
hip points are pinned to the floor, preventing ilial rotation

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The Deerfield Maneuver Testing in Dhanurasana Leg Position

The head should be in a neutral position.
Place your thumbs on the medial malleoli, and slightly point the toes while
slowly bending the knees to 90, looking for any changes in heel height.
Three possible things may happen:
1.

The short leg stays short: the leg that appeared short in the
beginning, if it is anatomically short, will not change in length as you
bend the knee to 90.

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2.

The short leg gets shorter: muscular tightness in the sacroiliac and
lumbar region can shorten the leg in appearance as the knee is
flexed. Use techniques for derotating the pelvis to correct sacroiliac
and lumbar spine asymmetry.

Adjustment for Anterior Tilt (right

side), using the gluteal. Combine
with quadriceps stretching on the
right side.

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3. The short leg gets longer - as the long leg gets shorter: a posteriorly rotated and stuck Ilium (usually
the left one) shortens the (left) leg (making the left leg the initially shorter leg).

When this is combined with an adhesive right anterior hip capsule, the pull of the quadriceps
(rectus femoris) shortens the right leg, causing the left leg to appear as long as or longer than the
right a seeming cross-over effect in which the legs switch length.

Light or passive Anjaneyasana for the right hip capsule; hip adjustment for posteriorly rotated left
ilium.

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