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Saturday, March 26, 2011

Short Leg Syndrome and Shoulder Pain: Email Advice

Dear Dr. Blake,


I really hope you can give me some direction as I have struggle with pain for a number of years now and it is keeping me from doing work and play. Here is my history:

I have had a low right shoulder for as long as I can remember but have only really had pain for the last 4 years, I am now 39. My first visit was to an orthopedic surgeon who gave me 3 injections of cortizone and prescribed 2 different physical therapists over a years time. I had no relief. I tried a recommended chiropractor but no relief. I finally got substantial relief from a neuro muscular massage threrapist. He got my muscles out of spasm and the pain subsided. He then also noticed that I was way out of alignment(hips going one way, spine going other way with low shoulder, neck going the other way and head then leaning the opposite way, a big zig zag all the way up.) By trial and error with foot lifts he found that when 10mm lifts were put under foot my left foot everything straightened out. This was good for about 9 mos. I had different pains as muscles adusted but all worked out except for a sharp hamstring pain that we could not get to subside. I then looked for help from my gp and he sent me to a new chiropractor, he determined that the hamstring was overworked because of the lift. He believes that my short leg is functional and with excericise and manipulation it will correct. After some time my hamstring subsided but now my shoulder dropped again and I am once again getting shoulder and neck pain. I don't know where to go next. Any advice would be greatly appreciated. I am from New Jersey and if you know of anyone in the New Jersey or New York City area I would be willing to travel to see them.

Thank you,

George
 
George, Thank you for your patience with my answering this email due to my vacation. It sounds like the typical adult pattern of long right leg with dropped right shoulder. The short left leg would cause the head to lean to the left. The body deals with this by creating a scoliosis. The upper 1/2 of the spine brings the head back over the center thus dropping the shoulder of the side of the long leg. This seems plausible for you since the lift under your left foot did get rid of your shoulder pain. So, at initial glance, sounds like we need to get you back into your lift.

     Let's discuss why you got the hamstring pain that did not allow you to continue wearing the lift. I apologize for not asking you if the hamstring pain was on the right or left side or both. I am assumming it was on the side of the left lift. If not, let me know. When you use lifts to correct for a short leg, you can create some instability by lifting the foot out of the shoe (especially if only heel lifts were used for the lifts, or it the lifts were on very soft material). The hamstrings in this case work harder to stabilize the leg and can become painful. As you use lifts you may also straighten the knee some putting a stretch on the hamstrings (more stretch than what they are used to experiencing). If you add already tight hamstrings (like me), that extra stretch can be painful. The sciatic nerve off the back is can get painful as it runs through the hamstrings, and is often misdiagnosed as hamstring strain. The same treatment for sciatica (as it is called) is totally different than hamstring strain. The sciatic nerve could get irritated for multiple reasons, including using a lift inappropriately (say on the wrong side).

     So, as this is pieced together, and you can hopefully see it is detective work, you should be able to find a solution. As I have mentioned in my posts, when there is differing opinions on what side is short, and whether it is trully functional or structural or combination, I would get the Standing AP Pelvic Xray barefoot. You stand with the knees straight and feet in normal position. If one arch is alot flatter than the other, and you wear orthotics to correct that, you would want to wear shoes and orthotics. But, if your feet are fairly symmetrical, barefoot is perfect. That one xray will answer once and for all if you have a short leg, then treatment is not so much guess work. There is radiation with xrays, so docs try to avoid this xray unless forced into it. I think you should have the xray. Ask your GP to order for you.

     Every profession has biases. Podiatrists are biased certain ways. Chiropractors think most short legs are functional. Orthopedists generally feel that under 13 mm short legs do not cause much problems. GPs generally think lifts are a big pain to deal with so they don't even want to get started on short leg treatment. This is why the chronic pain syndromes caused by short legs can go on forever.

     I am hoping when you read this that you were just using heel lifts under the left side, and once you change to full length lifts (as described in various posts), your shoulder pain will again disappear and your hamstrings will remain calm. That is actually what I would do if you were sitting in my office right now. If that did not help, I would get the xrays (although I would also do the standing LLD exam that my blog even has videos on).

     So, in summary (with questions):
  • Has anyone done the standing LLD measurements outlined by my blog?
  • Was your hamstring pain on the left or right?
  • Were your lifts in the heel only or were they full length (at least going to the toes)?
  • Did the doctor who was the most helpful feel that the shoulder pain was coming from your neck?
  • Did they try to differentiate the hamstring pain from possible sciatica?
  • I would recommend one of the following podiatrists in no particular order. They are all outstanding sports medicine podiatrists, but you will have to call there offices and see if they deal with short leg syndrome. They are Karen Langone, DPM (Southampton, NY), David Davidson, DPM (Amherst, NY), and John McNerney, DPM (Westwood, NJ). They may have a great physiatrist or osteopath in their area that deals with this issue that they co-treat patients with. They may also recommend a great doc in your area that they are more familiar with. Please ask them to read this post so that they understand what we are trying to accomplish. Please feel free to send a comment to this post of answers to my questions and other thoughts, or progress report when something happens ---like no pain!!! Hope this helps, and thank you for your patience. Rich Blake

   

5 comments:

  1. This is Dr Rich Blake. I am posting George's response and will comment soon on this comment.

    Dr. Blake,
    Your post was great. Thank you. I wish I had come upon your blog a long time ago. Here are a few answers to your questions:
    - The neuro-muscular therapist did a standing LLD and found the short left leg. That is when we experimented with the lifts to see what height straighten me out. This length also put my hips into alignment as they were rotated otherwise.
    -My left hamstring is the problematic one, the same side as the lift; as you suspected.
    -My lifts are full foot lifts. Since it was 10mm, I could not use inserts; instead I sent the shoes out to be lifted. The soles were removed,10mm of rubber was added, and the soles were glued back on over the rubber. The flexability of the rubber seems to be good.
    -Both my neck and sciatica were checked by the orthopedic and the chiropractor. Both determined they were non-issues.

    Since I first wrote you, on my own I decided to adjust the height of the lift to see if a measurement could be found that would cause as little pain as possible. I have done this by adding full foot adjustable height inserts made by GW Heel Lifts into my right shoe. I have found that when I use 3mm in my right shoe when wearing my 10mm left shoe, I experience the least amount of pain. For now this works well but I am going to call the doctors that you recommended to see which one specializes in LLD and then make an appointment. Thank you again for the advice and guidance. If you have any more suggestions I would be greatly appreciative, otherwise I will keep you posted with updates after seeing the doctor.
    Regards and many thanks,
    George

    ReplyDelete
  2. Dr. Blake,
    A google search on similar symptoms directed me to your blog. I am a 42 year old male and recently got on an exercise kick to try to lose some weight. For as long as I can remember, I have had lower back pain - never debilitating - just nagging, end-of-the-day soreness, tightness. But as I began this walking/running program, the pain significantly worsened. I made an appt with an orthopedic doctor. Long story short... he believes I have a short left leg, though the pain was concentrated in my lower RIGHT back and hip. He gave me a 3/8 inch heel lift for my left shoe and sent me for physical therapy. On my first appt with the PT guy, he had me stand barefooted in front of him, with my left foot on a book which he increasingly thickened until he thought, by placing his fingers on my hipbones, that my hips were level. (Really scientific there!) He said the difference was 1 inch. He recommended that I keep using the heel lift but also have a shoe repair shop add an additional 3/8 of material to the bottom of my left shoe. I continued with PT for about a month - traction, massage, exercises, etc. The pain improved but never completely went away. I have continued using the heel lift but have not had shoes altered. I have not resumed the walk/run program I started.

    My questions - how is it possible that I could have never noticed a difference like that? Is it reasonable to expect that if that entire difference is corrected that it really could alleviate the pain? It just sounds farfetched. Any advice would be appreciated.

    Thank you!
    Lee

    ReplyDelete
  3. Lee, Definitely your symptom response to lifts with back pain depends on many factors. I would recommend the Standing AP Pelvic Xray barefoot in normal standing position to give you the exact measurement. That way you can gradually get use to the lifts and have them placed in or on the outside of most shoes. You could just limit the number of shoes you wear for several monthes to see how the lifts work. If you read the various posts on short legs you will see that there can be confusion over treating the leg length vs the sacral base vs the pelvic tilts. The physical therapist will have to get the muscles strong or flexible as needed. If there is a pinched nerve or bulging disc, this may need to be addressed also. But, definitely starting with the most basic and correcting for the leg length in most shoes seems the right thing to do for most. Most patients come in with symptoms relalted to a short leg in their 40s or 50s or even later for the first time. Your body must be able to compensate for it when you are younger. Hope this helps. Rich

    ReplyDelete
  4. Dear Dr Blake

    I am 21 now and I have been having shin spints for 4 years, along with plantar fasciitis. In the past year I have developed quite severe hip pain. It is clear to see that my back is not straight and that one hip is higher than the other. Is it possible that my hip misalignment could also be causing the shin spints, and plantar fasciitis? also i have some pain in the neck/shoulder. is it possible that it could be causing that pain as well? This pain in the neck also radiates down my ulnar nerve to my elbow and wrist. I am trying to solve this puzzle and my chiropractor told me one leg is shorter than the other. Could this really be the cause of all of my injuries? Also what specialist would be most helpful to correct my hip misalignment? Thank you very much

    Jonny

    ReplyDelete
  5. I just passed this into a colleague who was doing a little research on that. And he actually bought me lunch because I found it for him smile So let me rephrase that. DenverOrtho

    ReplyDelete

Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.