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Most of us have slight sideways curvatures of the spine that create no problems and are nothing to worry about, but for others scoliosis is a painful condition. The cause of scoliosis is not well understood. What if the cause has been right in front of our noses the whole time and we have been wrongfully discounting it?

Janet Travell, a visionary massage therapist and medical doctor who wrote the book “Myofascial Pain and Dysfunction: The Trigger Point Manual, thought that far more people than is currently believed have either an anatomical leg length discrepancy, a smaller pelvis on one side or both. If one leg is shorter, in standing the pelvis will be tilted to one side, so the sacrum or base of the spine is starting its journey up to the head on a tilt. Just as the trunk of a tree aims up to the light, the spine will curve as it needs so that by the time it gets to the head the eyes can be level. A pelvis that is smaller on one side will create the same effect in sitting. I don’t feel her work, which is currently being taught by Paul St. John, has been given enough consideration when it comes to pain and especially scoliosis.

The argument one hears is that anatomical leg-length discrepancies are rare – only about 4%, and as a result I believe that many manual therapists don’t look for them, or if they think they might see one, they figure they must be wrong because they believe they are so rare. I personally have not seen the source for the 4% number, but there are other studies that suggest that it is not rare at all – that about 90% of the population has some anatomical leg-length inequality with the average being 5.2mm according to Knutson. Friberg found that those that have a leg that is shorter by 10-14mm are twice as likely to have low back pain, and those with a 15+mm leg-length discrepancy are almost 5.5 times more likely to have back pain. The biggest problem caused by a leg-length discrepancy appears to be a wearing of the hip joint usually on the long leg side, potentially requiring hip replacement. Knee osteoarthritis is also linked to leg-length inequality. Please feel free to examine the studies below.

Whether or not a lower-leg inequality or hemi-pelvis inequality causes pain would depend on the amount of time and load put through body as well as the person’s ability to stabilize the spine and pelvis and dissipate forces away from the joints. So, if you have a leg-length inequality and you spend 8 hours a day standing, moving or lifting things, you are more likely to feel pain as a consequence. Many other people have large leg-length discrepancies and have no pain at all. If someone has a painful scoliosis or musculoskeletal pain anywhere in the body, it makes sense to see if leg-length inequality or hemi-pelvis inequality is involved. Anatomical-leg length discrepancies will invariably cause a scoliosis in the spine, and if they are caught early enough and a full sole lift is used (not a heel lift), the scoliosis is unlikely to progress and will probably even improve. Even if leg-length differences are caught and treated late, the pain they cause can be greatly helped.

Frequently manual therapists use the heel pads or the ankles as the marker to decide whether or not the pelvis is level. The problem with that methodology is it is based upon the assumption that the legs are the same length. What if the person on the table is within that “rare” 4% or “common” 90% depending on which studies you are relying on? If you are a manual therapist, I invite you to experiment with levelling the pelvis without using the legs as your measuring tool. Apart from gently tugging the heels to ensure the patient is lying straight on the table, measure your progress at the pelvis itself. Do your techniques that you use (massage therapy, muscle energy, atlas correction, chiropractic – whatever) to level the pelvis until the ASIS’s (pokey-outy bits on the front of the pelvis) are level, one side of the pelvis is not turned towards the midline (inflared) more than the other, and the entire pelvis is not rotated to one side. I use the first two strategies shown here to level a pelvis.

Only once you are satisfied that the pelvis is level is it time to check the heel pads. If they are level too, that’s great! If not, check the fibular heads (bone just below the knee on the outside of the leg). If they are level and the heel pads are not, there is a short lower leg. If the fibular heads are not level either, look at the greater trochanters on the upper leg to determine which bone is short. By doing it this way, you have taken the pelvis out of the equation and you can examine the legs in isolation. (I personally find that the tibial tuberosities can sometimes be different sizes due to injuries or the favouring of one leg over the other. Although this can also be true for the fibular heads, there seems to be less variation and therefore they are a more reliable measure in my opinion.)

Probably more impactful for causing scoliosis is a difference in size of the two sides of the pelvis. When we are standing we can keep our pelvis neutral by sticking the longer leg out to the side a bit. Much harder to instinctively adjust for a smaller hemi-pelvis while seated, so if the person in question spends a lot of time sitting on a tilted pelvis, the adjustments higher up the spine may be more dramatic. If this is a very longstanding pattern, the person will often not be able to straighten the lateral shifts in the spine in standing, even if the legs are the same length and the pelvis is level. This drawing illustrates a smaller left hemi-pelvis, which tilts the pelvis left. The ribs compensate by shifting (shearing) left while tilting and rotating right on the pelvis, and the head tilts and rotates back to the left on the ribs, potentially creating neck and shoulder pain.

To look for a smaller hemi-pelvis, once the client’s pelvis is levelled in supine (lying on one’s back) have them carefully sit up on the table, legs over the side, and weight-bear evenly through both sit bones. Check the PSIS (sticky-outy bits at the back of the pelvis) and the top of the iliac crest for level. If both tilt in the same direction there is a strong possibility that the low hemi-pelvis is smaller. This can be tricky because even though one can be successful at levelling the pelvis while lying on the table, frequently the patient is so unstable that just moving to the seated position knocks the bones out of place again, so probably a good idea to recheck in supine and seated again.

A small hemi-pelvis is treated by having the person always sit the small side on a “butt pad” of the needed height to level the pelvis. Once the underlying cause of the scoliosis is addressed, then other massage and exercise techniques will be far more effective at improving the faulty posture.

Janet Travell’s book goes into detail on this and is an invaluable resource with respect to assessment, confirmation X-ray, and treatment. Or learn Integrated Neurosomatic Therapy from Paul St. John and his staff at Neurosomatic Educators to get clear on how to measure this. It’s great stuff!

If you have a painful scoliosis or other chronic musculoskeletal pain and you have not been checked for a leg-length or a pelvis discrepancy, ask your therapist or chiro to check for you. Or contact Neurosomatic Educators in Florida to find an Integrated Neurosomatic Therapist who has been trained in how to find these anatomical discrepancies. In the Vancouver area, you are welcome to contact me.

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Related tips:
Tail wagging the head, or head wagging the tail?
Posture, leg-length discrepancies, musculoskeletal pain and organ function
It’s all in your head – I mean neck!
Walking, sacroiliac joint dysfunction and hip pain

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