Treatments for leg length discrepancy, pelvic tilt, and a misaligned spine

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, its role in back and hip pain, and, in walking difficulties. We will also discuss how these problems can be treated.

Many people we see with problems of back and hip pain have been diagnosed with Adult Spinal Deformity. If you are reading this article it is likely you or a loved one has, and, as it has probably already been explained to you at your doctor’s office, a diagnoses of adult spinal deformity means that your spine is misaligned or not lined up right. It means that you are suffering from a loss of the natural spinal curve and this loss of curve is one of the causes of your  lower back, hip, and pelvis pain.

It may have taken you many doctor’s visits and examinations to get this diagnosis

It may have taken you many doctor’s visits and examinations to get that diagnosis even though you may have displayed the more obvious physical signs on x-ray of a spine tilted or curved to the left or right or as having a forward-bending posture and the developing or increasing of a hunch back in the upper spine. The reason as it may have been explained to you was to eliminate other causes and to confirm or deny the need for a surgery.

For others, adult spinal deformity did not gradually develop because of spinal instability and wear and tear that comes with age related conditions such as slipped vertebrae or spondylolisthesis. For these people they 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.

Which came first, developing spinal 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.(1)

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.

So what came first?

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 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.

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 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 (2) 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 Journal of manipulative and physiological therapeutics (3) 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.(4)

  • 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 replacement.
  • 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.

In this illustration, we demonstrate that top to bottom, from cervical neck pain to foot pain, joint instability impacts walking and gait. This includes hip pain, pelvic malalignment and adult spinal deformities including increased lordosis.

In this illustration, we demonstrate that top to bottom, from cervical neck pain to foot pain, joint instability impacts walking and gait. This includes hip pain, pelvic malalignment and adult spinal deformities including increased lordosis.

In this illustration we demonstrate the positioning and importance of the pelvic, hip, and spinal ligaments and how by administering treatments that strengthen these ligaments, we can treat and alleviate problems related to pelvic tilt discrepancy and leg length discrepancy.

In this illustration we demonstrate the positioning and importance of the pelvic, hip, and spinal ligaments and how by administering treatments that strengthen these ligaments, we can treat and alleviate problems related to pelvic tilt discrepancy and leg length discrepancy.

Again, will spinal surgery address the problem?

In September 2020, researchers wrote in The spine journal (5) 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 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 was 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 patients exhibited similar global dynamic alignment measures during gait and had 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 the spinal problems. The answer for some of these people may be in correcting the pelvic tilt.

The answer for some of these people may be in correcting the pelvic tilt by treating the spinal, hip, and pelvic ligaments

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 symptoms is very common in patients we see. People will come in with back pain, hip pain, or knee pain and and their pelvis is 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 are both equal and length and that their leg length problems are originating in their pelvis.

Leg-length discrepancy

  • 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 his 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 with.
  • 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.
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 left and right side. 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.

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 left and right side. 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 to the sacroiliac and hip joints will correct the asymmetries in the majority of cases. The leg-length discrepancy disappears as a result of the leveling of the pelvis. Often a shoe insert or heel lift will be added to help correct the problem.

Do you have a question? You can get help and information from our Caring Medical staff

1 Kwon YJ, Song M, Baek IH, Lee T. The effect of simulating a leg-length discrepancy on pelvic position and spinal posture. Journal of physical therapy science. 2015;27(3):689-91. [Google Scholar]
2 Murray KJ, Molyneux T, Le Grande MR, Mendez AC, Fuss FK, Azari MF. Association of Mild Leg Length Discrepancy and Degenerative Changes in the Hip Joint and Lumbar Spine. Journal of Manipulative and Physiological Therapeutics. 2017 Jun 30;40(5):320-9. [Google Scholar]
3 Khamis S, Carmeli E. Relationship and Significance of Gait Deviations Associated with Limb Length Discrepancy: A Literature Review. Gait & Posture. 2017 May 31. [Google Scholar]
4 Tallroth K, Ristolainen L, Manninen M. Is a long leg a risk for hip or knee osteoarthritis? A 29-year follow-up study of 193 individuals. Acta Orthopaedica. 2017 Sep 3;88(5):512-5. [Google Scholar]
5 Mar DE, Kisinde S, Lieberman IH, Haddas R. Representative Dynamic Ranges of Spinal Alignment During Gait in Patients with Mild and Severe Adult Spinal Deformities. The Spine Journal. 2020 Sep 20. [Google Scholar]

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