L-7 Scoliosis and short leg

• Study notes on scoliosis and Short Leg Syndrome

Scoliosis

• It is a lateral curvature of the vertebral column.
• The convex side is the side of the curve.
• The concave side is the side of the bend.
• It most often affects adolescents.
• 10 in every 200 adolescents develop scoliosis by age 10-15.
• 1 in every 200 people have clinical symptoms of scoliosis.
• Symptoms include pain and cardiopulmonary complications.
• Females are 3-5 times more likely to experience progression of scoliosis.
• Named for the direction of convexity, Levo- is Left, and Dextro- is Right.

Severity

• Mild scoliosis is 5-15°.
• Moderate scoliosis is 20-45°.
• Severe scoliosis is >50°.
• Respiratory function gets compromised at >50°.
• Cardiovascular function gets compromised at >75°.

Causes

• Idiopathic is 70-90% of scoliotic curves.
• Congenital scoliosis is 75% progressive.
• Acquired scoliosis may be caused by trauma.

Types of Scoliosis

• Structural scoliosis means the spine has a physical curve.
• Functional scoliosis means the spine appears curved, but is due to another condition.
• These include the possibility of progression to structural scoliosis, muscle hypertonicity, short leg syndrome, compensation, and weak musculature.

Reversibility:

• Sidebending does not correct structural scoliosis, which is likely genetic or hereditary.
• Functional scoliosis is an attempt at symmetry.
• Sidebending opposite to the presenting curve partially or completely straightens Functional scoliosis, which is likely due to somatic dysfunction.

Types and Location

• The double major type of scoliosis is the most common.
• Single thoracic scoliosis is usually right/dextro.
• Other types are: Single lumbar, Junctional thoracolumbar, and Junctional cervicothoracic.

Osteopathic Considerations

• The body strives to keep the eyes level by forming compensatory curves to maintain balance.
• Scoliosis produces structural changes, where structure and function are interrelated.
• The vertebra rotates into and sidebends away from convexity.
• Example: T4-8 levoscoliosis includes rotation into the left, sidebending away to the right, and a neutral sagittal plane with the final diagnosis as T4-8 Neutral, Rotated left, Sidebent right.
• Disc spaces narrow on the concave side.
• There’s a Right convexity and Right vertebral rotation.
• There is a Left vertebral sidebending.
• Ribs on the convex side separate and move posterior. Example T4-8 levoscoliosis has left ribs that INHALE BH.
• Ribs on the concave side move closer together and anterior Example: T 4-8 levoscoliosis has right ribs that EXHALE BH.

Screening

• Mass screenings are no longer indicated.
• Look for lateral curve/feel for lateral curve.
• Check for rib hump with forward bending.
• Check for conditions resulting in apparent short leg.
• Use Radiologic measurements to classify severity.

Cobb Angle

• Used to measure scoliotic curves.
• If the curve is <10°, reevaluate in 6-12 months.
• If the curve is >10°, follow every 4-6 months, and treat patients with curves that progress >5°.
• Patients with curves >30° on initial presentation should be treated.
• Curves <20° in a skeletally mature adult will not usually progress.

Treatment Goals

• Obtain spinal flexibility and improve balance.
• Determine and treat primary cause.
• Prevent progression and postpone fusion.

Treatment: OMT

• Goal is to Increase muscle balance on both sides of the curve.
• Optimize function of existing structures.
• Remove any somatic dysfunction.
• Stretch lumbosacral tissues.
• Exercise to reduce the lumbosacral angle, and strengthen the psoas and abdominal muscles.

Additional Treatments

• Braces (Milwaukee, and Boston).
• Surgery is usually reserved for curves >45 degrees.

OMT for Scoliosis Techniques

• Use Soft tissue, Myofascial release, Muscle energy, Counterstrain, Facilitated positional release, Balanced ligamentous tension, and Cranial manipulation.
• Areas to treat include the Head, Cervical spine, Thoracic spine, Lumbar spine, Pelvis, Sacrum, Lower extremities, Upper Extremities, and Ribs.

Short Leg Syndrome Biomechanics

• Sacral Base Unleveling is the most clinically relevant element.
• The spine compensates by changing its spinal curvatures most commonly resulting in functional rotoscoliosis.
• Innominates rotate to compensate and may side shift.

Suspecting Short Leg Syndrome

• 50% of an unselected population have radiologic leg length inequality of more than 3/16" (5 mm).
• Perform a Standing pelvic x-ray.
• Look for TART findings including Pelvic rotation, and pelvic side shift, Recurrent somatic dysfunctions, Other asymmetries, and Tissue texture changes/restrictions of motion.

Assessing for Short Leg Syndrome

• Assess Levelness of horizontal planes from the Mastoid process or occipital base, Acromioclavicular joints, Inferior Angle of the scapulae, Iliac Crests, and Greater Trochanters.

Compensation

• Sacral base tilts to side of short leg (Right).
• Ilium rotates forward on side of short leg (Right).
• Spinal convexity toward side of short leg (Right).
• Head and shoulder will be depressed OPPOSITE the side of the pelvic depression: Left shoulder is depressed.
• May eventually get secondary thoracic curve to opposite side.

Guiding Principles for Progressive Compensation

• Postural changes occur to coordinate visual, vestibular, and kinesthetic input while distributing the stresses, keeping eyes level.
• Changes commonly occur in lumbopelvic region because of the issues proximity to the center of gravity.
• Innominate on the short side rotates anteriorly to lengthen that extremity.
• Innominate on the long side rotates posterior to shorten that extremity.
• The pelvis will side shift and rotate away from the side of sacral base declination.
• The long leg will internally rotate and the foot/ankle will pronate.
• Lumbosacral angle increases 2-3 degrees.
• The vertebrae of the most caudal scoliotic curve sidebend away and rotate toward the short leg.
• Degenerative arthritis of the hip joint on the long leg side develops along with tenderness over the greater trochanter.

Diagnosis Difficulties

• Definitive diagnosis based on structural findings alone is often difficult and inaccurate.
• Various factors affect diagnosis including Spinous processes, iliac crests which are poor indicators of sacral base unleveling, ASIS or hip to ankle measurements, Measurement of supine medial malleoli, Greater trochanter levelness in the standing position, and Somatic dysfunction/tissue hypertonicity.

Diagnostic Clues for Diagnosis

• Recurrent somatic dysfunctions.
• Example: Right innominate anterior rotation, L1 to 5 Neutral Rotated right, Sidebent left, Sacrum: right unilateral flexion, Left talus everted, and Left tibia internally rotated.
• Iliolumbar ligament on the side of the convexity becomes stressed.
• Sacroiliac ligaments are Stressed/Tender on the side of convexity with Referred pain down the lateral side of the leg.
• Long leg will cause Unilateral sciatica and hip pain, and Pain over the greater trochanter.
• Postural muscles get strained → segmental facilitation
• Visceral dysfunction: increased sympathetic hyperactivity between T1 and L2.
• OMT should first be applied to correct any somatic dysfunctions if there is a suspected short leg.
• After OMT, take standing postural x-rays to measure coronal plane values accurately, with Ensure shoes are OFF.

Radiologic Measurements & Significance

• Measure iliac crest heights, femoral head heights, sacral base unleveling, and degree/type of scoliotic compensation.
• Less than 5 mm generally is not treated unless patient has clinically relevant factors or is symptomatic.
• As little as 1.5 mm difference may cause low back pain.

Treatment

• Use a Trial of OMT for Functional short legs that resulted from stresses on the body.
• OMT prepares somatic tissues to accept the realignment after placing a heel lift for Anatomic short leg from growth or trauma.
• Formula for the required lift: L < [SBU]/[D + C]
• L = Lift required; SBU = Sacral base unleveling; D = Duration; C = Compensation.
• Duration allotted as (1) = 0-10 years; (2) = 10-30 years; (3) = 30+ years.
• Compensation allotted as (0) = none observed; (1) = rotation of lumbar vertebrae into convexity of compensatory side-bending; (2) = wedging of the vertebrae, altered size of facets, horizontal osseous developments from endplates, and/or spurring.

Other Guidelines for Lift Therapy

• If the spine is flexible with no more than mild to moderate strain noted in the myofascial system, begin with a 3 mm heel lift or half the total lift desired, and lift no faster than 1.5 mm per week or 3 mm every two weeks.
• In Fragile Patients who are arthritic, osteoporotic, aged, and/or having significant acute pain, begin with a 1.5 mm heel lift and increase it no faster than 1.5 mm every 2 weeks.
• Lift the FULL fractional amount that was lost in the case of a Sudden loss of leg length on one side and the patient had a level sacral base prior to developing a short leg.
• Example occurrences include following a fracture or recent hip prosthesis.
• This may have to be modified for frail patients.

More Guidelines for Lift Therapy

• Due to the presence of magnification, measurement error, and compensatory changes, The final lift height in chronic short leg syndrome may only be 50-75% of the shortness in that leg measured by the standard standing X-ray method
• Diagnosis and treatment are generally based on the patient's experience with symptoms and resolution.
• The standing flexion test should become negative when the proper lift has been reached and there are no pelvic or lower extremity somatic dysfunctions.
• A repeat X-ray should be performed with shoes on and the lift in place.
• The goal should be to Level the sacral base.

Structural Short Leg

• A structural short leg is can be congenital or traumatically induced.
• The Sacral base is not the the problem.
• The goal s to Fill in the gap through adding 'length' to the leg.