Scoliosis and Short Leg – An Osteopathic
Manipulative Medicine Approach
Jonathon R. Kirsch, D.O., C-NMM/OMM
Associate Physician
Neuromusculoskeletal Medicine/OMM
Marshfield Clinic Stevens Point Center
4100 N. Hwy 66
Stevens Point, Wisconsin, 54482
Presenting at WAOPS Fall Seminar, Sept. 25-26, 2015
Learning Objectives
1. Describe postural strain, its effects on the body,
its diagnosis and treatment.
2. Classify and Differentiate various types of
scoliosis, and discuss its clinical significance.
3. Discuss management and OMT for scoliosis.
4. Describe diagnosis, implications, and
appropriate heel lift protocol for anatomical
short leg.
5. Discuss gait, postural mechanics, and related
clinical presentations for the sacrum and pelvis
regions.
Learning Objectives
1. Describe the use of radiographic studies in
postural diagnosis and management.
2. Discuss and interpret the “Cobb Angle”
measurement from an AP radiograph of the
thoracolumbar spine.
3. Discuss and interpret sacral base unleveling
measurement from an AP radiograph of the
pelvis.
4. Discuss and interpret lumbosacral angle and
pelvic index measurements from a lateral
postural x-ray.
Learning Objectives
1. Discuss strategies for osteopathic manipulative
treatment in functional scoliosis.
2. Perform structural exam of spine, noting
asymmetry and lateral curvature.
3. Observe and document changes in asymmetries
with the use of a heel lift before and after OMT.
4. Diagnose and treat somatic dysfunction in the
pelvis, sacral, lumbar, and thoracic regions.
Materials Needed for This Lab
• 12 pieces of 20lb copy paper
• Your hands
Construct a Heel Lift
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Start with 12 pieces of standard copy paper (20lb)
Take 3 pages and stack them together.
Fold in half
Fold in half again
Fold in half a third time
Tape the open edges closed with scotch tape.
You now have a 1/8 inch heel lift for this lab!
Stack 2 of these together for ¼ inch lift.
Stack 4 together for ½ inch lift (total of 12 pages)
The Consequences of Unlevel
Foundations…
Postural Homeostasis
• Postural changes take
place in order to
coordinate visual,
vestibular, and
kinesthetic input
• Each person responds
to asymmetric postural
stress uniquely
• Changes occur in a
more predictable
pattern in the
lumbopelvic region
Effects of Postural Strain Bone and Joint
• Wolff’s law
– Wedging of vertebral body and exostoses (spurs).
– Can result in modified function and increased calcium
deposition
• Increased functional demand + asymmetry
 joint degeneration
• Long term radiographic postural studies: progressive
postural decline
• Lateral curves more likely to evolve if leg-length
difference > 10 mm.
Postural Observation
• Asymmetry
– Body position and
alignment
– Spaces or gaps from one
side to the other
– Key landmarks
• Rotoscoliosis screening
– Levelness of key landmarks
• In static position
• In dynamic position (when
patient bends forward)
Ideal Posture: Sagittal Plane
• Center of gravity should pass
through following points:
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•
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Just anterior to lateral malleolus
Just posterior to mid-knee
Femoral head
Anterior third of sacral base
Middle of body of L3
Humoral head
External auditory meatus
Iliolumbar Ligament Strain
• Anterior Sacral Rotation
– Strains portions labeled
“1”.
• Posterior Innominate
Rotation
– Strains portions labeled
“2”
Iliolumbar Ligament – Postural Effects
• One of the first
structures involved in
postural
decompensation
• Exhibits tenderness,
edema, pain
• Groin pain
• Hip pain
Scoliosis-defined as a
pathological or
functional lateral
curve; an appreciable
lateral deviation in the
normally straight
vertical line of the
spine. (Dorland).
SCOLIOSIS
Demographics
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10 in 200 children by age 10-15 are diagnosed
1 in 200 children have clinical symptoms
Curves progress during rapid growth
Boys and girls are affected equally initially, but
in girls is 3-5 times more likely to progress
• It usually stabilizes after the child stops
growing.
• If the child stops growing with less than a 40
degree Cobb angle, adult progression is rare.
Naming by Side
Named according to the Convexity
Dextroscoliosis-curve that is sidebent left,
scoliosis/convexity is to the right.
Levoscoliosis-curve that is sidebent right,
scoliosis/convexity is to the left.
Classification By Cause
• Idiopathic (70-90% scoliotic curves)
– Unlevel sacral/cranial base
– Sagittal plane biomechanics
– Other unknown causes
• Congenital
– 75% are progressive
• Acquired
– Short leg syndrome, Psoas syndrome, Osteomalacia,
Inflammation, Irradiation, Sciatic irritibility, Healed leg
fracture, Following hip fracture
Classify by LOCATION:
Double Major Scoliosis
(most common)
• Balanced curve
• Subject to Degeneration
at Cross Over Areas of
Curve
Single Thoracic Scoliosis
•Cosmetically
noticable
•Heart and Lungs in
jeopardy with
progression of
scoliosis
Single Lumbar Scoliosis
•Associated with
Arthritic change
Junctional thoracolumbar
scoliosis
• Less Common
• Associated with Arthritis
often (due to long length
of curve)
Classification By
Reversibility
• Functional vs. Structural
• Functional curves go
away with side bending,
rotation, or forward
bending
• Structural curves are
fixed and do not reduce
with side bending,
rotation, or lift therapy
Classification By Severity
• Mild Scoliosis (less than 20 degrees).
• Moderate Scoliosis (between 20 and 45
degrees).
• Severe Scoliosis (between 45 and 70 degrees).
• Very Severe Scoliosis (Over 100 degrees).
Cobb Angle
•Angle of Lines across the top of
the superior vertebral segment,
and
•Across the bottom of the inferior
vertebral segment of a spinal
scoliotic curve
•The perpendicular lines intersect
to form an angle (“Cobb angle”)
FOM
Management in Mild Scoliosis
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•
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Periodic Monitoring
OMT
Physical Therapy
Orthotics / Lift Therapy
Education
OMT for Scoliosis - Overview
• Treat lumbar and pelvic somatic dysfunction.
• Assess for anatomic leg length difference.
• Long restrictor muscle stretch for side of
concavity (Hypertonic m. stretching)
• Postural exercises for retraining
• Possible heel lift for anatomical short leg.
Management in Moderate Scoliosis
(between 20 and 45 degrees)
• Bracing – consider in
curves 20 to 50 degrees
• OMT, Exercise, Physical
Therapy
• Orthotics
• Education
• Electrical stimulation
(debatable efficacy)
Management in Severe Scoliosis
(between 45 and 70 degrees).
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•
•
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OMT
Exercise, Education
Orthotics
Bracing
Electrical stimulation (debatable efficacy)
Surgery as possible last resort (1 in 1000 cases)
– Curves greater than 45 degrees
– Prevents heart and lung complications
• At >75 degrees the distortions may also cause
dangerous changes in the heart or lungs
SPONDYLOLISTHESIS
DEFINITION
• Forward displacement of one
vertebra over another
– usually L5 over S1
Clinical Presentation:
•Back pain plus or minus leg pain and tight hamstrings
•Radicular pain more common in adult
•Painful extension
•L5 nerve deficits
Classification Types
• Type I: Dysplastic
Insufficiency of articulatory process
• Type II: Isthmic
– Defect in Pars Interarticularis
• Or Fracture
• Type III: Degenerative
– Changes in apophyseal joints
• Type IV: Traumatic
– Fracture other than in pars
interarticularis
• Type V: Pathologic
– Secondary to Disease
Meyerding Grading System
• For each one quarter that the upper vertebra
is displaced forward on the vertebra below
– I (1-25%)
– II (25-50%)
– III (50-75%)
– IV (more than 75%)
• Progression
– Fastest ages 9-15
– Rare progression over age of 20
Risk of Cauda Equina
• Can occur in isthmic spondylolisthesis above
grade II (50% anterior movement)
• Can occur in dysplastic spondylolisthesis
above grade I (25% anterior movement)
Postural Etiology
• Hyperlordosis transfers
weightbearing from the
vertebral bodies onto
the articular facets
• Higher incidence is
seen in gymnasts
due to increase in
backward bending.
Microtrauma Etiology
• Repetitive lumbosacral
motion
– Ex. Weight lifters,
soldiers carrying
backpacks, and college
football linemen
• Frequent postural
stress, especially during
growth spurt,
contributes to the
syndrome
Diagnosis
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Diagnostic Testing
Radiography (Ferguson’s Angle)
History (½ of patients asymptomatic)
Physical examination
Spinal palpation
• Neurologic testing
Palpatory Findings
• Anteriorly located spinous process
• Sacral base motion exhibits laxity in anterior
motion
• Paraspinal tissues – tissue texture changes and
tenderness
• Iliolumbar ligament = bilateral tension and
subjective tenderness
• Patient may present with lateral thigh and/or
groin pain
Radiographic Findings
• Lumbolumbar or lumbosacral lordotic angles
are objective measurements of lumbar
lordosis
• Hyperlordosis is significant in patients with
sagittal plane postural problems
Lumbosacral Angle
(AKA Feguson’s Angle or Sacral Base Angle)
Reference line
1. Is a measure of
lumbosacral lordosis
2. Angle between the
top of the sacral
base, and the
horizontal plane.
3. Normal is 30-40
degrees.
Line A
Line B
Conservative Management
• Treatment addressing the underlying
instability, spinal mechanics, and patient
homeostasis.
• Stretch hamstrings, improve lumbar and
abdominal strength, and flexibility
• Promote anti-lordotic posture
• Boston Brace for antilordosis (9-12 mo.)
• OMT, orthotics, patient education
• Exercise - stabilize the lumbosacral region,
diminish the lumbar lordosis, flexion-type only
Goals of OMM in Spondylolisthesis
• Reduce Lumbar Lordosis and somatic
dysfunction
• Help promote lympathic drainage
• Promote optimal stability of
weightbearing posture
– Directed at support structures, eg.
Pelvis
– Correct Sacral Base Unleveling with
heel lift orthotic
– Thoracic spine and thoracolumbar
junction
• Quadratus lumborum and the
iliolumbar ligament
• Avoid HVLA**
SHORT LEG SYNDROME AND LIFT
THERAPY
Anatomic versus Functional
• Anatomic Short Leg- One leg is anatomically
shorter than the other.
• Functional Short Leg- one leg appears shorter
than the other but is secondary to pelvic
dysfunction or other structural imbalance or
scoliotic curve.
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
• Lumbar spine has convexity on
short leg side (sidebending
away from short leg)
Lateral Curves
over Time
• Sacral base unlevels in
coronal plane
• Curve forms in one spinal
region - C-shaped curve
• Over time, other spinal
curvatures develop
– S-shaped curve
– Thoracic curve may
develop with convexity
opposite the lumbar
spine
Sacral Mechanics with Short Leg
• In short leg there will be
lumbar sidebending, affecting
sacral mechanics through the
L5-Sacrum mechanical
relationship.
• Lumbar sidebending to the left
(see figure) if chronic, will be
associated with a left oblique
axis sacral somatic dysfunction
• Lumbar sidebending convexity
is usually on the side of the
short leg (DiGiovanna)
Sacral Motion in Gait
• Left rotation
on a left
oblique axis
• Left oblique
axis is
engaged
• L5 RR
• Right
rotation on
a right
oblique axis
• Right
oblique axis
is engaged
• L5 RL
• Example: When the left leg is weight bearing, then the left axis of the sacrum is engaged.
• Spinal column sidebends to the left (the weight bearing side)
• The weight pins the upper pole of the sacrum on the weight bearing side.
• As free lower extremity swings forward, it carries the free pole of the sacrum anteriorly, creating
rotation of the sacrum about the Oblique Axis.
• We call this a left rotation on a left oblique axis. This is normal.
Sacral Base Unleveling – Associated
Findings
• If sacral base is inferior on one side in the
coronal plane, and
• If this is due to leg length inequality,
• Then the following are typically inferior on the
side of inferior sacral base:
– Greater trochanter of femur
– PSIS
– iliac crest
Innominate Dysfunction in Short Leg
• Innominate rotation dysfunction
can give rise to functional short
leg, as acetabulum is anterior to
mid-line of bone.
– Anterior rotation  contralateral
short leg
– Posterior rotation  ipsilateral
short leg
Anatomic short leg can give rise to
compensatory innominate rotation
dysfunction.
Short right leg  Right anterior
innominate
Short left leg  Left anterior innominate
Anterior
Innominate
ASIS inferior
PSIS
superior
Short Leg Diagnosis
• Check for sacral and innominate shear.
• OMT should be directed to all related
somatic dysfunctions prior to diagnosis
• Observe iliac crest height, femoral head
height, sacral base leveling, degree of
scoliotic compensatory curvatures, angle of
the scapula, etc…
• Obtain standing postural x-ray
AP Postural Xray Interpretation
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•
Vertical lines are drawn from
femoral heads
A sacral base line is
constructed across the top of
the sacrum, to femoral head
lines
• Intersection of sacral base
line and femoral head lines
gives femoral head height
differential (C and C’ in
diagram)
Treatment Short leg Syndrome
• OMT directed to the spine, pelvis, LE’s, all
associated musculature, ligaments and fascia.
• If leg length discrepancy is apparent after
somatic dysfunction addressed, order
standing postural x-ray series.
• If the Standing Postural Series reveals a
femoral head discrepancy of >5mm., consider
heel lift therapy.
Lift Therapy
• Initiated to help body return to better
structural alignment and function
• The patient’s postural mechanisms are
reeducated toward ideal posture
• Paraspinal muscle tension and other
spinal physiologic parameters become
more symmetrically normalized
• Level foundation of vertebral column
“Flexible Spine”
Mild to Moderate Strain
• Spine is flexible
• No more than mild to moderate strain is noted
in the myofascial system
• Begin with 1/8-inch lift and lift at a rate no
faster than 1/16 of an inch per week, or 1/8 of
an inch every 2 weeks.
“Fragile Patient”
• Arthritic, osteoporotic, aged, having significant
acute pain, etc.
• Begin with 1/16-inch lift and lift no faster than
1/16 of an inch every 2 weeks.
Sudden Loss of Length
• Recent sudden loss of leg length on one side,
(eg. following fracture or a recent hip or knee
replacement surgery)
• Patient had a level sacral base before the
fracture or surgery
• Lift the full amount that was lost.
Lift Therapy in Children
• Monitor children with lifts closely
• Wolf’s Law may cause longer leg to
grow faster
• Check bone length on X-ray if possible
and monitor leg lengths
• Fryette found that in his pediatric
patients the short leg would grow to
equal the long leg with lift therapy,
over time.
Heel Lift Therapy
• Final lift is ½- ¾ amount of total discrepancy,
unless is immediately after a surgery where
height was lost, and full amount of change can
be corrected.
• A maximum of ¼ inch should be lifted inside
of shoe, if greater, lift outside of shoe.
• If need to lift > ½ inch, should also lift sole of
shoe to prevent compensatory inominate
rotation.
Perform a structural exam with attention to
coronal plane asymmetry and lateral curves
• Gait evaluation
• Standing postural
asymmetry examination
• Seated postural
examination
– did anything change?
• Have your instructors
check your findings
Standing Sidebending
Test
•Slide hand down thigh toward
knee
•Look at curve in thoracolumbar
spine
•Smooth curve?
•Abrupt changes in curve?
Gross Spinal Flexion Test
•With standing forward flexion,
observe thoracic spine for any
rotational humping on one side.
•This indicates a lateral curve
•For eg., a hump on the left signifies
a lateral group curve in the spine,
which is sidebending right, with
rotation left.
Rotoscoliosis
STANDING FLEXION TEST
• The patient stands
- feet are hip’s width apart
- knees extended
• The physicians's
- fingers on the iliac crest
- thumbs 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 the same side.)
Sidebending: Mid-Thoracic Region (T4 to
T8)
• The hands of the examiner
are placed on the shoulders
over the acromion process.
• A downward and medial
pressure is exerted,
depressing the shoulder on
one side and then on the
other.
• Check for asymmetry in
ease of shoulder movement
in the inferior direction, on
each side.
Rotation - (T8 to T11)
• Place hands are on the
shoulders
• Rotate the trunk to both
sides.
• Check for symmetry or
asymmetry.
Note: The lower thoracic spine has greater rotation than the upper due
to rib attachments that restrict the upper region.
Hip flop
• Patient supine
• Knees up, feet on table,
lift buttocks off table,
then down again, and
straighten legs
66
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
67
ASIS Levelness
Pubic Tubercle Levelness
ASIS Compression Test
• Have the patient lie supine. The patient
is then asked to raise his/her bottom up
off the table and then set it back down
again.
• Doctor Stands with head and shoulders
centered over the patient.
• Contact the ASIS
– Stabilize one ASIS while applying
pressure at a 45 degree angle to the
other ASIS
• Positive test - restricted movement of
the Sacroiliac joint -> rock like motion
• Negative test - a sense of give or
resilience => bounce or spring like
motion
SLR (hamstring tension)
71
Setting the Pelvis (Prone)
Quad tension and Psoas tension
73
PSIS
Ischial Tuberosity
• Gluteal curve- where thigh joins gluteus
muscle.
• Palms approximately 4” apart.
• Push superiorly, slightly laterally until you run
into a very firm bone (ischial tuberosity).
• Is the ischial tuberosity superior or inferior on
the lateralized side?
Lumbosacral Spring Test
• Patient Prone
• Physician at Side of Table
• Place Heel of Hand over
Lumbosacral Junction (L5-S1)
• Keep arms straight, and lean
with body
• Spring Several Times –
• Negative Test is a Mobility to
Springing (motion is felt at joint)
• Positive Test is Restriction to
Anterior Springing
SPHINX TEST
Decreased Sacral Base Asymmetry indicates a Negative Test
Increased Sacral Base Asymmetry indicates a Positive Test
Sacral Motion Testing
• Motion testing over the 4 Corners of the Sacrum
• Place thumb on the right sacral base. Keep arms
extended. Spring anteriorly
• Place thumb on the left sacral base. Keep arms extended.
Spring anteriorly
• Place thumb on the right ILA. Keep arms extended. Spring
anteriorly
• Place thumb on the left ILA. Keep arms extended. Spring
anteriorly
• Record (+), (-), or (+/-).
– + means a sense of resiliency, springs back
– - means little to no motion, bricklike
– +/- means some motion
• Record your findings on your Sacral Motion Testing
Worksheet.
Make Your Diagnosis of Somatic
Dysfunction
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•
•
•
•
•
•
Psoas/Hamstring
Femoroacetabular
Innominate
Sacrum
Lumbar
Thoracic
Short Leg Syndrome?
– Functional
– Anatomic
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
Scoliosis and Lateral Curves
TREATMENT SECTION
OMT for Scoliosis - Overview
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•
•
•
Treat sacral and innominate dysfunction.
Assess for anatomic leg length difference.
Thoracic and lumbar type 2 dysfunctions
Thoracic and Lumbar treatment of type 1 group
curves.
• Long restrictor muscle stretch for side of
concavity (Hypertonic m. stretching)
• Postural exercises for retraining
• Possible heel lift for anatomical short leg.
Pre-OMT
APPLICATION OF HEEL LIFTS
Exaggerate the lateral curves
• Add 1/8 inch lift under the heel of the side
with the high iliac crest
• Observe what happened
– Did the asymmetry increase ?
– Did the compensatory curves change ?
• Add ¼ inch lift and repeat observations.
Use lifts to level the iliac crests and
sacral base
• Place lifts under the heel of the side with the
low iliac crest, place enough lift to level iliac
crest.
• Observe what happened
– Did the asymmetry increase ?
– Did the compensatory curves change ?
– Observe what happened to the primary and
secondary curves
OMT PART ONE: INNOMINATE / HIP
Hamstring Stretch – For
Shortened Hip Extensors,
4613.11A
Iliopsoas Stretch
Muscle energy for posterior
innominate technique
Muscle energy technique for anterior
innominate technique
OMT PART TWO: LUMBO-SACRAL
For Non-Neutral Dys.
Lumbar HVLA – for Neutral Dys.
11. A high velocity, low
amplitude thrust is
applied antero-superiorly
to the pelvis while
providing counterforce
through the patient's
shoulder
12. Recheck
Dx: L3-5NSlRr
KIM 213A
TX: Unilateral Sacral Flexion (Sacral Shear) DX: Left
unilateral sacral flexion
KIM 213A
KIM 216A
RECHECK SYMMETRY
• Repeat the standing
postural
examination on
your partner
– Did your findings
change?
– What changed
– Is your partner a
candidate to be
evaluated for possible
lift therapy?
Use lifts to level the iliac crests and
sacral base
• Place lifts under the heel of the side with the
low iliac crest. Place enough lift to level the
iliac crests.
• Observe what happened
– Did the asymmetry decrease?
– Did the compensatory curves change?
What is next?
• Does your partner still have a low iliac crest on
standing, after OMT?
• Did you successfully treat all the somatic
dysfunctions that could be contributing to the
high/low iliac crest/sacral base?
• Is it an acute or chronic problem? (recent
lower extremity surgery, or long term?)
• Is further work-up for short leg indicated?
Sources
• Steinberg, Akins, Baran, Orthopaedics in Primary Care, 3rd ed.,
LWW, Philadelphia, 1998, Pg. 154-156
• Kuchera and Kuchera, Osteopathic Principles in Practice, 2nd ed.,
revised. Greyden Press, Columbus, Ohio, 1994.
• Ward, editor, Foundations for Osteopathic Medicine., 2nd ed., LWW,
Philadelphia, PA 2003
• Chila, Foundations for Osteopathic Medicine, 3rd Ed., 3rd ed., LWW,
Philadelphia, PA 2010, pg. 437-480.
• The Muscle Energy Manual, Mitchell, Fred L., Volume 3, pg. 33-52.
• An Osteopathic Approach to Diagnosis and Treatment, DiGiovanna,
pp. 300-301
• Kimberly, P., Outline of Osteopathic Manipulative Procedures, “The
Kimberly Manual”, 2006 ed., (2008 update), Walsworth Pub Co,
Marceline, MO., 2008.