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they were more adaptive, healthier and better able the utricle but the entire vestibular system. The
to ward off stress and disease. utricle is considered the most influential organ
Effects of spinal decompensation in the four of the vestibular system. Its duty is to supply a
transitional zones and resulting altered diaphrag- steady stream of updated data concerning position
matic function is discussed in greater detail in the and movement of a person’s head. Other vital in-
following two chapters. ner ear sensing structures include the semicircular
canals – anterior, posterior and lateral which lie
Counterintuitive Possibilities anatomically in different planes with each intri-
cately placed at right angles to the others. Thus,
The central theme in Myoskeletal Zone Thera- the combined functioning of this elaborate vestib-
py® focuses on the influence cerebral lateralization ular apparatus efficiently deals with various head
– due to predictable fetal positioning during the movements: up and down, side to side, and tilting
third trimester – has on embryologic development. from one side to the other.
Eighty percent of vertex births are in a left fetal
lie. In this position, the head is flexed and turned Interestingly, cerebral lateralization appears
left. During the walking cycle, as the mother’s to be a primary influential factor in addressing
belly moves anteriorly (maternal acceleration), the perplexing, but fascinating question of limb
fetal inertia forces the left side of the baby’s head length discrepancies observed in our offices each
posteriorly. It is theorized that repeated left-sided day. An in-depth discussion of these theories is
stimulation affects the baby’s utricle which, in presented in the Myoskeletal Zone Therapy chap-
turn, perpetuates early development of not only ter but an introductory overview is also necessary.
Cervicocranial
SRR L
Cervicothoracic
SRR R
Thoracolumbar
SLR R
Lumbosacral
SRR L
8b
Personal Perspectives on Muscle extended top leg toward the ceiling while in a
Substitutions Patterns sidelying position), gluteus medius and minimus
should fire first followed by tensor fasciae latae,
In an attempt to combine many of my favorite
piriformis, quadratus lumborum, and ipsilateral
researchers’ postural models (Zink, Janda, Previc,
lumbar erectors.
Geschwind, Pope, Greenman, etc.) into some
sort of reasonable therapeutic protocol, I have To test the firing order in hip abduction,
come to recognize certain predictable substitu- simply assume a left sidelying position and raise
tion patterns that develop from vestibular and (abduct) the fully extended right leg toward the
motor dominant neurological adaptations. In my ceiling. The gluteus medius/minimus should fire
opinion, the pelvic muscles that hold the greatest first followed by their synergistic muscles listed
liability for creating and perpetuating dysfunction above.
during vestibularly-driven left pelvic sideshifting However, during weight-bearing, the gluteus
are…the gluteus medius and minimus. My respect medius/minimus perform a completely different
for these often neglected muscles has grown with function. During the normal walking cycle, the
increased observation and study. I now place them right gluteus medius/minimus must fire during
on a level with the other distinguished antigravity the stance phase to “cock” or lift the contralat-
structures such as: (Fig. 6) eral pelvis (right pelvic sidebending) so the left
• Transversus abdominis: Through its leg can swing through (Fig. 7). It is imperative
intimate connection with the thoracolumbar that the right gluteus minimus/medius be the first
fasciae, multifidus and sacrospinous liga- muscles recruited to elevate the contralateral hip
ments, the transversus should not only brace so the synergistic stabilizing muscles can per-
the lumbar spine during forward bending, but form their specific duties.
also help lift the ribcage off the pelvic girdle
with each step.
• Hip flexors/extensors: Allow the lower
quadrant to spring forward when hip Tensor
extension firing order patterns are Fascia
functioning properly. Optimum hip exten-
Latae
sion firing order during the walking cycle
should be: rectus femoris (extend the knee),
ipsilateral hamstrings, ipsilateral gluteus
maximus, contralateral lumbar erectors,
and ipsilateral erectors. Anterior hip capsule
adhesions often inhibit the antigravity Fig. 9. TFL and
Iliotibial Tract.
function of these muscles resulting in
A common substitution
disruptive firing order substitution patterns. pattern for stretch-weak-
The proclamation concerning the importance of ened gluteus medius/mini-
mus is the TFL. The brain
gluteus medius/minimus as primary antigravity frequently recruits TFL to
structures deserves further explanation. help in abduction efforts.
However, the TFL eventu-
Abduction Firing Order ally overpowers the glu-
teals, becomes hypertonic
Substitution Patterns and short, and begins an
As discussed in an earlier chapter on firing unmerciful pull on the IT
band occasionally leading to
order patterns, during hip abduction (raising the IT-band friction syndrome.
146 Short Right Leg Syndrome
Conversely, on the left side a prevalent hip abduc- During the left sidelying hip abduction test,
tion substitution pattern develops as the brain is frequently the gluteus medius/minimus, TFL and
forced to recruit the QL muscle to fire first due to piriformis will all fire together, indicating that
an extremely stretch-weakened gluteus medius/ they are combining forces due to weakness in the
minimus muscle group. This pervasive and devas- gluteus medius/minimus. During the right sidely-
tating pattern causes further ipsilateral posterior ing hip abduction test, look for the quadratus to
innominate rotation, flattening of lumbar lordosis, fire first (indicated by dipping in the 12th rib area)
left sidebending of the lumbars, tractioning of the followed by either TFL or the inhibited gluteus
12th rib, and eventual back pain. These folks are medius/minimus. This substitution pattern is a
easily recognized as they sidebend their torso left major pain generator and suggests gluteal weak-
to allow the right leg to swing through. Therapists ness from excessive weight bearing during the
often mis-assess this pattern since it appears that stance phase.
the right side is doing all the work of pulling up The observations described above are only
the right hip and leg. If the trunk does not left meant as an overview of a particular muscle
sidebend during the left stance phase of gait, it is imbalance pattern I have found interesting to
possible that they are lifting with their right side. work with in my practice and I remain unaware
Try the sidelying hip abduction test to deter- of any studies performed to verify these find-
mine if you are one of many who are left ves- ings. Therefore, these conclusions may or may
tibular dominant and follow the common com- not prove to be accurate in all cases, e.g. clients
pensatory pattern. Then have someone skilled presenting with fixed scoliotic patterns, sacraliza-
in measuring anatomic landmarks check your tions, hemipelvis, etc. Test your clients using hip
structure while in a supine position to see if you hyperextension and hip abduction tests presented
fit the common compensatory pattern which is in Myoskeletal Alignment Techniques Volume I
reflected in a short right leg and anterior/inferior and see what correlations (if any) you find using
ipsilaterally rotated ilium. this neuromyoskeletal theory.
words when you have a right-handed person with With all the new research surfacing on pre-
a short left leg – the muscular component over- dictable patterns, it is now possible to begin com-
rides the anatomic. In these cases the short left bining various formulas to help develop a clearer
leg is probably either congenital or secondary to picture of common postural asymmetries. This
trauma. On other occasions you will find a normal synergy greatly enhances visual and hands-on
pelvis radiographically, i.e. level sacral base and evaluations.
equal leg lengths, and the patient will display a
functional short right leg when supine. This again
shows muscular dominance and is typical for
right-handed (CCP) people. The main reason for PLUMB LINE
the exceptions is either fixed scoliosis or a cranial
asymmetry (usually lost vertical dimension on
one side of the bite).”
The key phrase for me was: “The ilium on
the “functionally” short side is anteriorly rotated
which places the femoral head in a more cephalad
position in an off-weighted position.” Although
this was precisely the picture I had in my mind
concerning positioning of the femoral head and
acetabulum, I was unable to verify these findings
using palpatory evaluations, I simply had to see it.
Working from an
Assessment Baseline
One assessment protocol I have found help-
ful when performing pain management structural
work is to first develop a baseline of aberration.
Working from a baseline simply means that I
strive to view the body as a whole while maintain-
ing certain expectations of what patterns I am
inclined to see. For example, I ask myself:
Fig. 13. Short Right Leg Sideshifts the Pelvis,
• What predictable structural patterns are Resulting in Compensatory Scoliosis.
represented; The most common postural compensation for leg
length discrepancy is a functional scoliosis. A gen-
• Which alternate patterns typically accompany eral rule has been suggested which summarizes
the aberration I am seeing; the type of scoliosis present in relation to the limb
length discrepancy. If the leg length discrepancy
• Is there a “key” neuromyoskeletal disorder is less than 1cm, a ‘C’ curve will be present with
triggering the primary dysfunction; the shoulder on the short side being the higher of
the two. Conversely, an ‘S’ curve will be observed if
• Am I seeing an upper or lower crossed or the limb length discrepancy is more than 1cm. This
common compensatory pattern; and increased leg length inequality causes the shoulder
on the shorter side to appear lower. Typically, the
• What fascial, skeletal, or diaphragmatic tissue
pelvis will be more inferior on the short side and the
is responsible for their primary decompensa- thoracic spine will have a type I group curve convex
tion? left with the shoulder and arm hanging lower on the
long leg side (left).
Short Right Leg Syndrome 151
Searching for the “Tie That Binds” 2. Functional: Develops as a result of altered
Based on research from innovators such as mechanics of the lower extremities (foot
Janda, Rolf, Zink, Greenman, Mitchell, Previc, hyperpronation) or pelvic obliquity due to
Pope, and others, I often begin my visual and upper quadrant muscle imbalances such
hands-on analysis with a preconceived notion of as tonic neck reflexes, poor trunk stabiliza-
certain predictable muscle/joint strain patterns tion, protective lumbar muscle guarding,
and then record non-adapting or decompensated deep fascial strain patterns, etc.
patterns. I find this approach more interesting, For efficient locomotion, a symmetrical and
less confusing and more practical than myopically well aligned body is necessary. If symmetry is
investigating a single area and then attempting to distorted, particular by limb length discrepancies,
relate it to the rest of the structure. Although the then gait and posture are disrupted. Consequently,
process demands an open mind and heart, it is a diversity of symptoms can prevail, and without
still exciting to search for early embryologic and adequate treatment, often manifests as chronic
CCP clues attempting to determine where the cli- sources of pain and dysfunction.
ent either follows or departs from the norm. When
clients come in hurting, I always ask myself: The Body’s Innate Compensatory
“What key dysfunction is driving this aberrant Capability
posturally-initiated pain pattern and does the root Simply stated, innate compensations occur to
cause of this disorder seem to be based in ge- lengthen the short leg and shorten the long leg.
netic influences, early embryologic development, Typically, the body’s innate wisdom immediately
trauma, habitual patterns, gravitational exposure, begins the pelvic-balancing correction process
psychosocial, or vestibular/motor dominance?” using information gleaned from proprioceptors
Unless I am dealing with acute injuries, such embedded in fascia, muscles and joints located
as tennis elbow, ankle or knee sprains, etc., I typi- on the bottom of the feet. Millions of these highly
cally observe for common dysfunctional postural sensitive receptors sense weight imbalance and
patterns (upper and lower crossed, common com- body sway (Fig. 11). Over a period of weeks, it is
pensatory) rather than focus evaluation on each intriguing to observe how the brain slowly raises
individual body segment. Sometimes it works; (supinates) the medial arch on the short leg side in
and other times I simply get lost in all the overlap- an attempt to balance the anterior/inferior rotated
ping embedded aberrant strain patterns. At this innominate. Regrettably, prolonged supination
point, I begin at square one and untangle the mess often strains and sometimes fractures the meta-
until familiar patterns begin to emerge. tarsals, talus or calcaneus bones due to excessive
lateral arch weight-bearing. As the brain succeeds
Back to the Basics… in elevating the anterior/inferior ilium, the foot is
Short Right Leg forced to function in an equinus position to pre-
vent dorsiflexion.
Limb length discrepancy is simply defined as
a condition where one leg is shorter than the other. The opposite pelvic-balancing pattern typi-
When a substantial difference exists, disruptive cally occurs on the long-leg side as the brain
effects on gait and posture can occur. hyperpronates or flattens the medial arch in an
effort to lower the high ilium. Excessive medial
As discussed earlier, leg length discrepancy
wear on the client’s left shoe is a dead-giveaway
can be divided into two etiological groups;
that hyperpronation is at work. Long-term hyper-
1. Structural: True shortening of the skeleton pronation not only diminishes the body’s natural
from congenital, traumatic, or diseased antigravity springing system, but is also a precur-
origins. sor to foot, ankle, knee, and hip pain.
152 Short Right Leg Syndrome
In the lower limbs, compensations at each torsioning slowly sinks its insidious tentacles into
level can be summarized as follows; associated spinal joint structures setting off neu-
roreflexive muscle guarding responses.
• Ankle instability due to foot supination on
the short side; That Hitch in your Get-Along
• Knee hyperextension on the short side and the The presence of a limb length discrepancy is
knee flexed on the long side; usually easily recognizable during gait by observ-
• Externally rotated leg on the short side; and ing for:
• Circumduction of the long limb. • Shoulder tilting to one side;
• Unequal arm swing;
Trunk and head compensations
• Pelvic tilt;
Compensatory scoliosis is commonly reflected
as a low shoulder on the high ilium side. Since the • Foot supinated on the short side and pronated
head typically will not tilt to maintain the eyes on the long side;
parallel to the horizon, a short “C” curve is com- • Ankle plantarflexed on the short side; and
mon in the cervical vertebrae. Elbow and hand • Knee flexed on the long side.
positions may appear shorter on the shorter leg
Note: During running, it has been suggested that
side, with the opposing arm swinging more on the
limb length discrepancy makes no real differ-
shorter leg side.
ence due to the fact that only one foot strikes the
As mentioned earlier, some authors suggest ground at any given time. However, Blustein and
that there is a rotation of the pelvis towards the D’Amico’s extensive research finds that leg length
long leg side, possibly due to hyperpronation and discrepancy is the third most common cause of
medial leg rotation.6 They describe a typical gait running injuries. 7
where the short leg steps down and the long leg
compensates by “vaulting” This pattern of walk- Posture and Limb Length Discrepancy
ing on toes on the short side and flexing the knee The most common postural compensation for
of the long side seems to be a fairly consistent leg length discrepancy is a functional scoliosis.
compensatory gait. Unfortunately, as the center Scoliotic patterns that are noted in both standing
of gravity unevenly shifts, the smooth sinusoidal and flexion indicate the presence of a structural or
motion during the walking cycle is disrupted. fixed scoliosis (Fig. 13).
Thus, cosmetic effects of gait can also contribute
A general rule has been suggested which sum-
to compensation mechanisms and eventual tissue
marizes the type of scoliosis present in relation
injury. For example walking on the toes may lead
to the limb length discrepancy. If the leg length
to a contracture of the Achilles and calf muscles
discrepancy is less than 1cm, a “C” curve will be
leading to conditions such as Achilles tendinitis
present with the shoulder on the short side being
and plantar fasciitis.
the higher of the two. Conversely, an “S” curve
Other muscle compensations of the CCP will be observed if the limb length discrepancy
include left-sided QL shortening (long left-leg is more than 1cm. With this increased leg length
Short Right Leg Syndrome 153
distortion, the shoulder on the shorter side should tural relationships, and have fun when assessing
appear lower.8 and treating asymmetrical leg length patterns and
Typically, the pelvis will be more inferior on resulting compensations.
the short side and the thoracic spine will have a
type I group curve convex left with the shoulder
and arm hanging lower on the long leg side (left). References: