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Letters to the Editor  |   November 2008
Chronic Psoas Syndrome Caused by the Inappropriate Use of a Heel Lift
Author Affiliations
  • Harold I. Magoun, Jr, DO
    Greenwood Village, Colo
Article Information
Neuromusculoskeletal Disorders / Pain Management/Palliative Care / Low Back Pain
Letters to the Editor   |   November 2008
Chronic Psoas Syndrome Caused by the Inappropriate Use of a Heel Lift
The Journal of the American Osteopathic Association, November 2008, Vol. 108, 629-630. doi:10.7556/jaoa.2008.108.11.629
The Journal of the American Osteopathic Association, November 2008, Vol. 108, 629-630. doi:10.7556/jaoa.2008.108.11.629
To the Editor:  
I wish to add a brief response to the discussion of sacral base imbalance that began with the September 2007 case report by Christopher M. Rancont, DO.1 
In his July letter to the editor, Dale E. Alsager, DO, PhD,2 notes several errors that he found in that case report,1 in which standing postural radiography was used to determine leg length discrepancy. 
Despite the errors pointed out by Dr Alsager,2 I believe that Dr Rancont1 provided an excellent and detailed osteopathic structural evaluation for the patient described. Nevertheless, Drs Alsager2 and Rancont1 both fail to mention the most important point of all: for standing postural radiographs to provide an accurate picture of leg length discrepancy, any dysfunction in the pelvis must be corrected before the radiographs are made. 
Preradiograph correction is important because a number of iliosacral and sacroiliac dysfunctions that cause functional changes in leg length would appear on standing postural radiograph images as a short leg problem. In such cases, the use of heel lifts could aggravate the problem. 
I have seen a number of cases with associations between pelvic dysfunction and changes in leg length during my 57 years in practice. The most common pelvic dysfunction I have seen in such cases is a posterior innominate, which shortens the leg that is on the side of the dysfunction, and also everts the leg at an angle of more than the usual 15 degrees. The most thorough evaluation of the associations between pelvic dysfunction and changes in leg length was reported by Fred L. Mitchell, Sr, DO.3 
Moreover, standing postural radiographs are an unnecessary technicality that result in an unnecessary exposure to radiation for patients. If an osteopathic physician has any diagnostic ability at all, a careful clinical evaluation will provide all the information that is needed for a quick and accurate diagnosis. The DO should observe the patient walking, noting the angle of the feet and the relative height of the hips and shoulders. Next, the DO should evaluate the standing patient from behind, again noting the angle of the feet, the height of the trochanters and iliac crests, and the position and motion of the superimposed spine. 
If the patient's trochanters are level and the iliac crests are asymmetric, a functional change is most likely present and in need of correction. As corrective treatment is being administered, the DO should keep in mind that, in chronic cases, ongoing treatment and reevaluation of the patient will be necessary. 
If both trochanters and iliac crests are asymmetric, a short leg problem is indicated. In such cases, nature attempts to level the sacral base, almost invariably producing a posterior innominate, an inferior sacral shear on the side of the long leg, or both. The body's natural compensatory adjustments result in the shortening of that leg. 
The present letter is not intended to address all the associated details of leg length discrepancy, however. I simply wish to relay a strategy I have found very effective in my practice. This strategy allowed me to stop using standing postural radiographs 30 years ago. 
An osteopathic physician who is treating a patient with leg length discrepancy should make any corrections that are possible, then clinically reevaluate the patient, and, if appropriate, apply a heel lift. 
Rancont CM. Chronic psoas syndrome caused by the inappropriate use of a heel lift [case report]. J Am Osteopath Assoc. 2007;107:415-418. Available at: http://www.jaoa.org/cgi/content/full/107/9/415. Accessed October 1, 2008.
Alsager DE. Something wrong with this picture [letter]. J Am Osteopath Assoc. 2008;108:350-351. Available at: http://www.jaoa.org/cgi/content/full/108/7/350. Accessed October 1, 2008.
Mitchell FL Sr. Structural pelvic function. In: 1965 Yearbook. Vol 2. Indianapolis, Ind: American Academy of Osteopathy; 1965:178 .