The timing of heel lift therapy

Posted 05/17/22 by Malcolm Hiort and filed under:

I saw a client again today after a year. She was wearing a heel lift, glued down in her right boot. Her prime symptom was a chronically sore right rear hip, with the pain spreading out laterally and inferiorly from her right sacroiliac joint.

Suprisingly to me, Diane had independently followed up on what I had mentioned to her during our session a year ago. I had assessed her right leg as being anatomically short, which is a very common and under-recognised situation in my opinion. That was for information-only purposes, as she was not ready for heel lift therapy at that stage. She needed more loosening and balancing first.

Diane had arranged to have her leg lengths scanned to see if indeed there was a leg length discrepancy (LLD). This objective two-dimensional test showed a 7mm difference.

So far so good, it seems. Tests confirmed the asymmetry and she was wearing a heel lift in her boot under the correct leg. She was unsure as to the thickness of the lift that had been supplied and I could not examine it.

But importantly for her, the pain had not changed. The idea of the short leg and a heel lift to correct the discrepancy had become the focus. Although arguably logical on the surface of things, it didn’t work. The cause of her pain was sidelined in the quest for a deeper solution.

So what went wrong? Why had this strategy not worked? The tactics were wrong. The problem that prevented the heel lift from working as planned was that Diane had had no bodywork since I saw her.

Nobody had attempted to address the sacroiliac joint or otherwise release her pelvis. The fixated sacroiliac joint was sabotaging the aim of the heel lift and she was not able to decompensate. All heel lift and no manual therapy had kept Diane in pain.

Her hip pain was there before the heel lift was fitted and was still there causing her grief. On examination with her lying supine, it was blazingly obvious that her right sacroiliac joint was monumentally stuck, immobile and causing problems and compensations.

When should a heel lift be deployed? Bodywork first, heel lift after! Spoiler alert: I am not talking here about so-called ‘functional short leg’, which is entirely correctable with good manual therapy. (Assessing clients after a treatment will lead to clearer findings)

While this did not impair the accuracy of measuring her bone lengths with a scan, the whole ‘correction’ procedure with the lift was faulty. Her compensated, distorted posture was ignored as she was scanned, then assessed and fitted with the heel lift.

Re-assessments of her standing posture, including a careful look at how the heel lift was affecting the rest of her body would have been profoundly compromised. I speculate that this never happened and it may have been a case of “you are 7mm short, here is your 7mm (?) heel lift, case closed, goodbye”. At some point I will look at her standing posture from behind, before I dig the heel lift out from her boot. I will be a bit surprised if I think it is the correct thickness for her but we will see.

Don’t make this mistake. Manual therapy is vital. Do it first, keep assessing, get the client’s pelvis as loose and balanced as you can. That is the main work. Think of a heel lift as the prevention of recurrence after your treatment. The assessments are simple enough, it is your interpretations and critical thinking that are more important.