Treatments for leg length discrepancy, pelvic tilt, pelvic incidence-lumbar lordosis mismatch, and walking difficulties
Ross A. Hauser, MD., Danielle R. Steilen-Matias, MMS, PA-C., Brian Hutcheson, DC
In this article, we look at the problems of leg length discrepancy in the adult patient, its role in back and hip pain, and, in walking difficulties. We will also discuss how these problems can be treated.
We realize that you have probably made your way here to our article because conventional and conservative care for your challenges has not worked that well for you and you are now exploring more options.
Before we get started, let’s go over some definitions and explanations:
What is pelvic incidence?
Pelvic incidence is a measurement. It is not a diagnosis or condition. There was a 2016 paper published in the medical journal Spine (1) which gives a good introductory explanation of what Pelvic Incidence is and what it could mean to you.
“Medical textbooks present the pelvis and the spine as distinct entities-an unfortunate practice that does not reflect the crucial and critical role that the pelvis plays in regulating spinopelvic alignment.”
What the researchers noted was the work of other researchers and previous studies who suggested that the pelvis be thought of as another vertebra or extension of the spine and that analysis of the spine requires simultaneous analysis of its relationship to the pelvis. To understand this pelvis-spine relationship better – the concept of pelvic incidence angle was introduced to understand who this pelvic angle helps regulate the curvature of the spine.
In other words, if your pelvis is tilted, it can disrupt the natural curvature of the lower spine.
What are we seeing in this image? If your pelvis is tilted, it can disrupt the natural curvature of the lower spine. An understanding of the symptoms of pelvic tilting and lumbar lordosis mismatch causing muscle spasms and low back pain and hip pain
As you will read below, some of the people that contact us report that one of their symptoms is stiffness and pain when they stand after sitting for some time. If you have stiffness and pain after sitting, this may account for it. In this image we see:
Anterior (the front) and posterior (the back) tilting of the pelvis and its effect on the kinematics (movement) of the lumbar spine. This image is divided into an A, B, C, D segment
- In the A image (anterior pelvic tilt with lumbar extension) and the B image (a close-up image of the vertebrae and intervertebral lumbar extension) the anterior or frontal tilt of the pelvis when the person is sitting puts pressure on the lumbar spine by increasing Lordosis or spinal curve (you start bending backward). In the B closeup we see that when the lower spine is bending backward, it increased pressure on the front of the vertebrae causing the disc innards, the nucleus pulposus to bulge the disc outward. To the rear of the vertebrae, this pressure causes a narrowing of the intervertebral foramen. We have a situation where the disc is bulging in the front and possibly pinching nerves in the rear.
In the C image (anterior pelvic tilt with lumbar extension) and the D image (a close-up image of the vertebrae and intervertebral lumbar flexion), we see that a rear tilt of the pelvis inwards towards the front curves the spine towards the front. This will decrease the lordotic curve of the spine. Stress is now placed on the spinal ligaments, the connective tissue that strains to keep the vertebra in proper alignment. In the D illustration, we see a stretching of the posterior ligament or ligamentous complex which includes the capsular ligaments of the spinal joints, the spinous and interspinous ligaments (the ligaments that attach the rear of each vertebra to the vertebra above and below it). The disc bulge occurs now in the rear, forcing the front of the vertebra to move towards a collision with the vertebra below.
Bulging discs, herniated discs, and a situation mimicking a stenosis/sciatica
In this illustration above we see many things happening. All these things lead to pain and loss of function. When this happens you get stories that go something like this:
Hip arthritis, leg length discrepancy
- I have hip arthritis, low back problems, and leg length discrepancy. My x-ray and MRI are bad. My main problems are I am walking with an uneven gait, I have stiffness when I stand after sitting. Fortunately, I can still function and perform daily normal movements.
Sciatica, hip, difficulty walking
- I am a former athlete, I have issues with the same side sciatica, hip, and leg pain. One leg is slightly shorter with some pelvic tilt. My doctors tell me that my pain is coming from degenerative disc disease and spinal compression on the nerves. I have walking issues. X-ray shows bone on bone knee and pelvic tilt. Physical therapy helps a little.
Sacroiliac joint dysfunction
- I have been diagnosed with Sacroiliac joint dysfunction, leg length discrepancy, and my foot pronates. I also have piriformis syndrome/gluteus medius tendinopathy, but I am able to function and be active. I would like to stay that way without surgery.
What these three stories have in common is that there is a degenerative element to what is happening to these people. For some, these problems did not gradually develop because of spinal instability and wear and tear that comes with age-related conditions such as slipped vertebrae or spondylolisthesis. These people may have had a long history of spinal problems such as scoliosis developed during childhood that has become progressively worse into adulthood. Others had adult spinal deformity brought on them by spinal surgery and the problems of adjacent segment disease noted in failed back surgery syndrome. Each person is of course unique and their successful treatment will present unique challenges.
Which came first, developing lower spine curve deformity or leg length discrepancy and pelvic tilt?
The complexity of your problem with leg length discrepancy and pelvic tilt and why the diagnosis may be challenging was revealed in a 2015 study in the Journal of Physical Therapy Science. (2)
How leg-length inequality would affect the pelvic position and spinal posture
In this study, researchers created a computer-guided model to investigate how an artificially created leg-length discrepancy would affect the pelvic position and spinal posture. What they found were some significant changes in the pelvic position as a result of an artificially created leg-length discrepancy.
Increasing leg length discrepancy was not translating into increasing spinal deformity
The pelvic tilt is an indicator for observing pelvic changes in the coronal plane (looking at the body straight on from the front and observing if the left side pelvis is higher than the right side pelvis or vice versa, the tilt to one side to another).
However, what the researchers found was that in some models, while leg-length discrepancy increased, this did not translate to creating a significant difference in spinal posture resulting from the leg-length inequalities. (So the increasing leg length discrepancy was not translating into increasing spinal deformity), so leg length discrepancy would not come first in this model. The spinal deformity would.)
There appeared to be no significant changes in the trunk resulting from the temporal (over time) leg-length inequalities, but spinal changes were observed with different leg lengths for short periods of time in healthy adult male and female groups. The temporal changes in the pelvis and the trunk resulting from leg-length inequalities seem to show more of a compensation mechanism in the pelvis than in the trunk. (So the leg length discrepancy could come first in problems of pelvic tilt).
So what does this mean? Alleviation of symptoms related to leg length discrepancy may not be solved by spinal surgery.
If you had leg length discrepancy and you were given the choice of one surgery to solve it, it should not be a spinal surgery. Look at the hip first.
The hip joint joins the leg to the pelvis. Unfortunately for most people, both legs are not exactly the same. They may look the same, but from a biomechanical standpoint, they are not the same. One leg may be rotated either in or out, or one leg may be shorter than the other. The latter is especially common if one leg was broken during childhood. Because the hip joint connects the leg to the pelvis, the hip joint will sustain the brunt of any biomechanical abnormality that may occur.
So a leg length problem starting with the legs is a problem that may only confine itself to problems in the pelvis and hip pain. If you show spinal deformity, one may suggest a connection, but the connection is not clear and alleviation of symptoms related to leg length discrepancy may not be found in spinal surgery.
Doctors recommend long fusion surgery as a means to prevent reoperations because of adjacent segment disease.
An August 2021 study in the journal World Neurosurgery (3) focused on pelvic incidence-lumbar lordosis mismatch as the possible cause of adjacent segment disease in spinal fusion patients and as the cause for the need for revision spinal fusion surgery.
What the researchers of this study set out to do was examine the clinical outcomes of 47 patients aged 40+ years who underwent repeat posterior lumbar interbody fusion after single-segment posterior lumbar interbody fusion due to adjacent segment disease. What they were looking for is what made these patients have a greater risk for revision surgery. What did they find? “Pelvic incidence-lumbar lordosis mismatch and thoracic kyphosis before repeat posterior lumbar interbody fusion were identified as predisposing factors for subsequent long corrective fusion.” Further, “Once the Pelvic incidence-lumbar lordosis mismatch occurs after initial posterior lumbar interbody fusion, it will be difficult to resolve the Pelvic incidence-lumbar lordosis mismatch during the second posterior lumbar interbody fusion.”
What are we seeing in this image?
Lumbar instability above fusion causes nerve compression. Narrowing of the intervertebral foramina at the L3 and L4 levels is seen on the extension view but open on the flexion view. This is diagnostic lumbar instability causing this person’s symptoms of lumbar radiculopathy.
Leg length discrepancy and degenerative joint forces straining the hip.
- If one leg is shorter than the other, the hip joints will be stressed as the leg-length discrepancy will cause an abnormal gait or walking motion. This is evidenced by the waddling gait of someone with a hip problem. This waddling gait helps remove pressure on the painful hip. The gait cycle is most efficient when the iliac crests are level, you have a straight pelvis, not a tilted pelvis. Unequal leg lengths cause the pelvis to move abnormally, this will cause stress on the pelvis and can include problems of Pelvic Floor Dysfunction, Pubic symphysis in Men, and Pelvic Girdle Pain.
Many people come in with a tilted pelvis. However, for many of these patients, that is not what is causing their pain.
In this brief video Danielle R. Steilen-Matias, MMS, PA-C. Caring Medical Florida explains.
The summary transcript:
- What is interesting about the diagnosis of the tilted pelvis is that we see a lot of patients without that diagnosis and they in fact do have a tilted pelvis. So the question is, is the tilted pelvis the cause of their hip and back pain or not?
This seemingly obvious connection between leg length discrepancy, walking problems, and hip and back pain is still a controversial subject.
In a recent study, doctors in Israel published findings in the medical journal Gait and Posture (4) that sought to determine if there is a relationship between the magnitude of leg length discrepancy and the presence of gait deviations.
- The first thing the researchers noted was that controversy still exists as to the clinical significance of leg length discrepancy in spite of the fact that further evidence has been emerging regarding the relationship between several clinical conditions and leg length discrepancy.
- Despite the controversy, the researchers found a significant relationship between anatomic leg length discrepancy and gait deviation. The evidence suggests (something of the obvious) that gait deviations cause more pain and instability in the joints as the discrepancy increases.
Even a small deviation in leg length could impact joint stability and degenerative disc and joint disease
University researchers in Australia and Spain combined to publish research in the Journal of Manipulative and Physiological Therapeutics (5) that evaluated the correlation between mild leg length discrepancy and degenerative joint disease or osteoarthritis.
They looked at 235 adults, (121 women and 134 men) who went to the chiropractor for back pain. The researchers found a strong connection between leg length discrepancy and degenerative disc disease at the L5-s1 spinal segment and the L4-L5 spinal segment.
The researchers concluded that patients with hip and lower back pain should be evaluated for leg length discrepancy.
In Finland, doctors writing in the medical journal Acta Orthopaedica went back 29 years to show how different leg lengths affected patients over this near 30 year period. (6)
- Of note: The researchers suggest that 7% of the population have leg-length inequality of 12 mm (almost a half-inch or greater) but display no symptoms or problems.
- It has been suggested that leg-length inequality of 5 mm (about 1/5th of an inch) can be associated with an increased risk of osteoarthritis of the knee and hip.
- The Finnish team followed the records of 193 individuals for 29 years. They all started with no leg-length discrepancy.
- When the patients were first observed they had no clinical histories or signs of leg symptoms. The initial standing radiographs of their hips revealed no signs of osteoarthritis.
- After 29 years :
- 24 (12%) of the subjects still had no discernible leg-length difference,
- 62 (32%), had a leg-length difference of 1-4 mm, (less than 1/5th of an inch)
- 74 (38%) of 5-8 mm, (less than 1/3rd of an inch)
- 21 (11%) of 9-12 mm, (almost a half inch)
- and 12 (6%) of over 12 mm (More than a half-inch)
- 16 (8%) of the subjects had undergone hip replacement arthroplasty for primary osteoarthritis. Half of the group had both hip and knee replacements.
- Another note: 10 individuals had undergone a joint replacement of the longer leg and only 3 of the shorter leg. In the group of equal leg length, 3 had had an arthroplasty of hip or knee.
- Interpretation – Hip or knee arthroplasty due to primary osteoarthritis had been done 3 times more often to the longer leg than to the shorter.
Treatment of pelvic tilt and leg length discrepancy
As mentioned above the diagnosis and treatment options for pelvic tilt, leg length discrepancy and a possible connection to adult spinal deformity can be challenging. Surgery may be called for. But what kind of surgery? Will the surgery help or make the problem worse? For many people, spinal surgery may be of great benefit. These are typically not the people we see in our office. Moreso, we may see patients following a hip replacement that caused greater leg length distortion and these people have shoe inserts to help straighten their pelvis.
Understanding and treating pelvic incidence-lumbar lordosis mismatch – Muscle spasms and low back pain
Many patients we see have terrible back pain and muscle spasms because of the struggles their musculoskeletal frame goes through trying to keep their body balanced and their head in its correct position. That is the head is upright and in vertical alignment with the pelvis.
In your visits to your doctors, you may have heard terms such as “sagittal misalignment,” or “sagittal malalignment.” You may have been told you have “adult spinal deformity.” What you clearly have is pain and limitation in movement, and probably a suggestion to have multi-level spinal fusion surgery.
What are we seeing in this next image? Muscle spasms and low back pain
In this illustration, we see the muscles that help balance the pelvis and keep our body in proper alignment. It is typically these muscles that spasms and cause pain when there is spinal instability in the lumbar spine caused by lumbar ligament damage, weakness, and laxity.
- The erector spinae is comprised of three muscles, the Iliocostalis, the longissimus, and the spinalis. This muscle complex attaches the base of the skull to the pelvis. As the name implies, the Erector spinae keeps the spine erect.
- The abdominals are the four main muscle groups sometimes referred to as part of the “core muscles.”
- The transversus abdominis stabilizes the trunk and is often the key to helping back pain patients in physical therapy.
- The rectus abdominis or “six-pack,” muscles. These muscles connect the rib cage to the pelvis.
- The external oblique muscles and internal oblique muscles –the muscles of the abdominal core that provides twisting motion
Again, will spinal surgery address the problem?
In September 2020, researchers wrote in The Spine Journal (7) of how surgical correction strategies for adult spinal deformity may or may not improve daily quality of life problems such as those created by pelvic tilt and lumbar lordosis.
The researchers suggested that: “Surgical correction strategies for adult spinal deformity relies heavily on radiographic alignment goals, however, there is often debate regarding the degree of correction and how static alignment translates to physical ability in daily life.”
In other words, the success of the surgery is based on what the post-surgical x-ray reveals. Are things lined up correctly? But these doctors have expressed concern that even if things are lined up correctly in the surgery, does this offer any benefit to the patient’s daily quality of life?
What the researchers then examined were various factors that they considered important in determining the surgical treatment success so they could assess “clinically meaningful estimates of dynamic changes in spinal alignment during activities of daily life.” For one thing, they looked at how the patient walked.
This is what they found:
Patients with severe adult spinal deformity had significantly larger dynamic maximum and minimums for sagittal vertical axes, T1 pelvic angle, lumbar lordosis, and pelvic tilt compared with Mild adult spinal deformity patients. However, adult spinal deformity patients exhibited little difference in dynamic alignment compared with healthy subjects. Only pelvic tilt had a significant difference in dynamic range of motion compared with healthy control subjects.
Conclusions: Mild and Severe adult spinal deformity patients exhibited similar global dynamic alignment measures during gait and had a comparable range of motion to healthy subjects except with greater pelvic tilt.
In other words, problems of walking and quality of life in patients with adult spinal deformity were more impacted by pelvic tilt than spinal problems. The answer for some of these people may be in correcting the pelvic tilt.
Did spinal surgery cause the problem? “Not aligned” patients had also a significantly higher pelvic incidence.
Here is a May 2021 study in the journal Advances in Orthopedics (8). The focus was on understanding how crucial it was to return a post-fusion surgical patient to a somewhat normal lumbar lordosis by lordosis repartition. What the results revealed was that in adjacent segment disease patients, postoperative malalignment was associated with a lack of distal (between L4-S1) lordosis restoration. “Not aligned” patients had also a significantly higher pelvic incidence. Specific attention must be paid to restore optimal distal lumbar lordosis in order to set the amount and the distribution of optimal postoperative lumbar lordosis.
The problem of pelvic tilt in Femoroacetabular impingement
We have a very extensive article on Femoroacetabular Impingement. We will summarize some of the learning points of this article here.
Femoroacetabular Impingement or sometimes diagnosed simply as Hip Impingement is a condition where abnormal contact and rubbing of the ball and socket portion of the hip bones creates joint damaging friction. For some people, the rapid degeneration of the hip joint causes the formation of bone spurs. The bone spurs are there because the body is trying to create stability in a joint that has become unstable. The loss of stability can be traced to a weakening of the ligaments and tendons of the hip, low back, groin, and hamstring areas, and hip labrum degeneration.
Femoroacetabular Impingement may only be one part of a bigger problem – such as the problems of leg length discrepancy, pelvic tilt, pelvic incidence-lumbar lordosis mismatch, and walking difficulties
As in the many conditions we see, Femoroacetabular Impingement is not a condition or diagnosis that sits in isolation. It is typically part of a bigger picture of hip instability. For some people, exercise programs that get the hip back into its natural and optimal position will work very well. For those it does not, we will present the information below on regenerative medicine injections that can accelerate the healing process.
A February 2021 study in the European Spine Journal (9) found that adult spinal deformity patients compensating with knee flexion have altered hip orientation which can lead to posterior femoroacetabular impingement, thus limiting pelvic retroversion (the natural movement of the pelvis behind the spine in part due to loss of the natural curve or lordosis of the lumbar region). This underlying mechanism could be potentially involved in the hip-spine syndrome.
What are we seeing in this image? The answer for some of these people may be in correcting the pelvic tilt by treating the spinal, hip, and pelvic ligaments
In this image, we see the front of the pelvis and the many ligament attachments that hold the two halves of the pelvis together and connect the pelvis to the spine. Above we cited research that suggested that the pelvis be treated as an extension of the spine. When you look at the pelvic/spinal ligaments you can see how the spine and pelvic and spinal instability should not be treated in isolation. In this image, we see how the intertransverse ligament, anterior longitudinal ligament, anterior sacroiliac ligaments, iliolumbar ligaments, and the pubofemoral ligaments all interact to provide a “firm girdle.”
A patient case history: The patient is Ross Hauser, MD
In this video Brian Hutcheson, DC, and Danielle Matias, PA-C discuss one of their patients, Caring Medical medical director Ross Hauser, MD.
Here we have a pelvic and hip x-ray of our mentor and medical directory Ross Hauser, MD.
Summary learning points:
He has a tilt.
- In this x-ray of Dr. Hauser, we see that he has a problem: There is a reduction in the space between his ischium (the bone that forms the base of the pelvis) and his ileum (the bone that forms the upper part of the pelvis). When we compare this space reduction to his right side, his left side displays a bit of a lowering. In common terms. He has a tilt. The right side is higher than the left side.
Sciatica like symptoms and right knee pain
- Dr. Hauser noted that he was having sciatica-like symptoms on his left side. H was also suffering from a nagging pain in his right knee.
- Dr. Hauser’s symptoms are very common in patients we see. People will come in with back pain, hip pain, or knee pain and their pelvis are off. The patients will tell us that they already know that one of their hips rests higher than the other side, or they will tell us that their legs are two different lengths and that they have a leg-length discrepancy.
- Many patients assume that their legs are in fact two different lengths. But when we measure the legs, we find that is both equal and length and that their leg length problems are originating in their pelvis.
- Leg length discrepancy, pelvic tilt, a higher hip, can be caused by many different things. It can be a lumbar problem or spinal instability tugging and pulling the pelvic bones out of position, it could also be a problem with one of the femurs where they connect to the acetabulum (hip socket). One of the femurs can be jammed in the hip socket and the other one could be sitting in the correct position. So we’ll have to adjust or treat in that area also.
- In patients like Dr. Hauser, the knee will be a problem and if we look further down that chain, the ankle pain can be a symptom of this problem or a cause of sciatica-like symptoms and hip pain.
What are we seeing in this image? A lot of tilt
In this image, we see an x-ray of a patient. The x-ray is of Dr. Ross Hauser’s pelvic tilt. Dr. Hauser suffered from the sudden and acute onset of lower back pain on his left side. He also displayed symptoms of sciatica. The x-ray revealed on his left side a decrease in the distance from the ischial tuberosity to the top of the iliac crest. This means that there would be an increase in tilt between the left and right sides. This is displayed in the increase in distance from the sacroiliac joint to the midline compared to the right side. For Dr. Hauser, Prolotherapy treatments to his left iliolumbar, sacroiliac, and sacrotuberous ligaments resolved his pain and pelvic distortions.
With leg-length discrepancy, either hip joint can cause pain, and usually both hip joints hurt to some degree. To propel the leg forward, the hip joint must be raised which strains the gluteus medius muscle and connective tendons and the posterior hip ligaments. Leg-length problems are also associated with recurrent lower back problems because they cause the pelvis to be asymmetric.
Whether it is a low back problem, pubis problem, pelvic floor, or hip problem, leg length discrepancy can cause significant and disabling problems down the road.
Prolotherapy Injections for correcting spinopelvic instability and pelvic tilt
Prolotherapy is an injection treatment that stimulates the repair of connective tissues such as tendons and ligaments. It causes a mild inflammatory response which initiates an immune response. This mimics what the body does naturally to heal soft tissue injuries.
The most common pelvic instability is sacroiliac instability, caused by injuries to the stabilizing ligaments of the sacroiliac joint. These ligaments are typically injured through the combined movements of spinal flexion and rotation.
Prolotherapy: Treating the ligaments in sacroiliac joint dysfunction
We treat the whole low back area to include the sacroiliac or SI joint.
Summary and Learning Points of Prolotherapy to the low back
- Prolotherapy is multiple injections of simple dextrose into the damaged spinal area.
- Each injection goes down to the bone, where the ligaments meet the bone at the fibro-osseous junction. It is at this junction we want to stimulate repair of the ligament attachment to the bone.
- We treat the whole low back area to include the sacroiliac or SI joint. In the photo above, the patient’s sacroiliac area is being treated to make sure that we get the ligament insertions and attachments of the SI joint in the low back.
- Why the black crayon lines? This patient has a curvature of her spine, scoliosis, so it is important to understand where the midpoint (center) of her spine is. In this patient, we are going to go up to the horizontal line into the thoracic area which is usually not typical of all treatments.
- After treatment we want the patient to take it easy for about 4 days.
- Depending on the severity of the low back pain condition, we may need to offer 3 to 10 treatments every 4 to 6 weeks.
Ligaments are bands of fibrous tissue that connect bones to each other, like the vertebrae to each other and the sacrum to the pelvis.
In a December 2019 study, (10) doctors made these observations concerning Prolotherapy and Platelet Rich Plasma (PRP) Injections. Platelet Rich Plasma (PRP) Injections are considered a type of Prolotherapy when applied in a similar manner. These injections are explained further below.
“SI joint pain can be generated from extra-articular elements including ligaments and capsules. (The SI joint pain does not necessarily have to come from the joint itself). Prolotherapy involves the injection of hyperosmolar dextrose or platelet-rich plasma (PRP) into the area where repairing and strengthening are thought to be needed. The application of prolotherapy for SI joint pain consists of making injections in the periarticular and intra-articular areas to treat pain and sacral ligament laxity. Some studies reported the positive clinical outcomes of prolotherapy for SI joint pain and even a superior effect and longer duration for relief of SI joint pain compared to the injection of a steroid into the joint. In recent studies, a significant reduction in the pain scores of SI joint pain was observed in patients receiving intra-articular PRP injections compared to those receiving steroid injections.
In this video, Ross Hauser, MD explains the use of Platelet Rich Plasma in treating this patient with problems of the sacroiliac instability caused by sacroiliac ligament damage.
The actual treatment begins at 3:15 of the video
Summary learning points:
- Platelet Rich Plasma or PRP involves the application of concentrated platelets, which release growth factors to stimulate recovery in non-healing injuries.
- At 3:15 of the video, the pain is numbed and the injections begin
- Prolotherapy is used to treat the ligaments. PRP is used to more specifically treat the attachments of the SI Joint and Pelvis. The treatment is designed to correct SI joint instability by addressing the damaged and weakened ligaments of the SI / Pelvic region.
Summary and contact us. Can we help you?
We hope you found this article informative and it helped answer many of the questions you may have surrounding your leg length discrepancy, pelvic tilt, pelvic incidence-lumbar lordosis mismatch, and walking difficulties challenges. If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff
Brian Hutcheson, DC | Ross Hauser, MD | Danielle Steilen-Matias, PA-C
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This article was updated August 10, 2021