19/09/2025
Medial Rotation of the Right Femur, TMJ Dysfunction, Second Cardinal Sign, SRLS - The Question of Dysfunction Working Up or Down the Body
I keep seeing medial rotation of the right femur being used to explain a dropped right hip in a compensating scenario where TMJ dysfunction is attributed for a reaction working down the body. I argue that the dropped right hip is attributed to structural leg length discrepancy working up through the body. Associated with the Second Cardinal Sign of Short Right Leg Syndrome is thickening and tightening through Adductor Magnus due to Kidney deficiency. This is a consequence of impingement of the Bladder meridian in the lumbro-sacral region. Adductor Magnus adducts and medially rotates the femur and its activation in this scenario is initiated by postural distortion from leg length discrepancy impacting energetic Qi flow in the Bladder meridian.
From a practical perspective, both images are uncommon and rare presentations. The first shows perfectly symmetrical alignment with even leg length. The last instance of this sighted in my clinical practice was three years ago. Even leg length is rare. The second presenting an inferior right hip, right convexity through the thoracic, elevated left hip and right shoulder is the most common presentation of SRLS. To be accompanied by high range medial rotation of the right femur is uncommon. This is rarely sighted. What is missing is the more common presentation similar to the second picture with the same right leaning tilt at hips, right convexity through thoracic, etc., without any significant medial rotation of the femur. To argue medial rotation of the femur is the primary cause for the dropped right hip and right leaning tilt of the pelvis completely overlooks the fact the right leg is structurally short in the first place. It is only in more advanced cases where blocked Kidney meridian effects and rigidity about the right hip from the Second Cardinal Sign have escalated combined with other lower limb anomalies are we likely to sight instances of medial rotation of the right femur.
Note: Other contributory factors can be a collapsed arch pronating the foot and/or cartilage wear or damage at the medial meniscus of the knee motivating us to shift loading through the knee to the lateral aspect of the joint.
Examining structural leg length in my clinical practice for over a decade, in the vast majority of cases the right leg is 15mm to 20mm shorter than the left. Even or near even leg length is rare. Short left legs almost never occur...sighting only one natural instance in a decade. Until this is taken into account, the theory a condition is working down from the jaw needs to be reviewed. There is strong evidence it is the other way around and effects are working up the body from the legs. Right leaning pelvic tilt encouraging mild scoliosis with right convexity through thoracic, elevating right shoulder, tilting head to left, straining right TMJ. I have observed an instance where chronic pain at the right TMJ was resolved simply by insertion of a 5mm heel lift under the right foot.
Exception cases of left convexity through the thoracic where the spine flops from rightward to leftward at the juncture of lumbar and thoracic are less common but not rare. These elevate left shoulder and strain left TMJ. Interestingly, these cases still have the short right leg and right leaning tilt through the pelvis. I do not know how proponents of TMJ and neck issues working downwards account for this contrary outcome. If all things were equal, one might expect medial rotation of the left femur in these exception cases where effects are hypothetically working downward. I have not seen that possibility argued because the reality of what happens under the influence of the short right leg is very different at the left hip.
In lieu of rigidity at the Iliac Crest blocking Bladder meridian Qi impacting the Kidney meridian, the left hip rotates in the Sagittal plane about the SIJ, anatomically pulling up the structurally longer left leg, reducing pelvic tilt to some degree, making us feel more comfortable and protecting the lumbar spine. This also binds the left SIJ, shortens the hip flexor Iliacus and is less affected by gait which is responsible for the Bladder/Kidney meridian nexus sighted at the right hip. The most prominent effects at the left hip are tightness in the left hip flexor, dysfunction at the left SIJ and the potential for thickening and tightening through the connective tissue down the backline of the left lower limb. These effects down the backline can be subtle only detected by a therapist with good palpation skills. It can escalate to acute pain and injury under the influence of loading. A tight Adductor Magnus and medial rotation of the femur is not a part of this scenario. This is described by the First Cardinal Sign of SRLS and the Left Lower Limb Mechanism.
Of course, there are instances where injury to jaw and neck do have some degree of downward effect but the number of upward patterns from the feet and legs far outweigh them. My observation of these downward influences are largely restricted to brachial plexus issues impacting neck, shoulder and arm.
The development of acute TMJ symptoms from the upward pattern are not common but the underlying postural alignment I am describing is universal. Similarly, instances of high range internal rotation of the femur due to the tightening of Adductor Magnus may not be common yet its thickening and tightening is present in every case of SRLS examined. This is one aspect of the Second Cardinal Sign of SRLS generating rigidity at the right hip. This rigidity is easily demonstrated tractioning the right lower limb from the ankle in supine. The right hip is wooden while the left is softer and giving.
Examining the mechanism for medial rotation of the femur in the presence of a structurally short right leg. The effects of distortion and strain from this postural anomaly on the convoluted passage of the Bladder meridian through the lumbro-sacral region and hips leads to Kidney deficiency. The Bladder feeds the Kidneys energetically in the TCM model. Hence a common side effect of SRLS is anxiety and other Kidney deficiency symptoms of constipation, insomnia, aching lower back, dry mouth, reduced vitality and endurance. Where energetic Qi flow is blocked, a thickening and tightening through the connective tissue occurs that is not responsive to direct treatment until Qi flow resumes. The degree of blockage is variable and the impact on muscle tone and internal health function will fluctuate in concert with it. Lower range cases may experience intermittent symptoms. Advanced cases demonstrate chronic and acute conditions.
I describe this energetic aspect of the condition as the "Pelvic Block.” When eliminated through treatment improves Kidney, Digestive and Reproductive function. It probably does not stop there. This is supported by TCM theory and known to some TCM practitioners. It is not taught in their university training. Incidentally, should meridian blockage be complete and total, death can be expected within days or weeks. This was employed by assassins who undertook advanced physical and energetic training aided by herbal supplementation to develop the ability to gently touch the chest and insert an energetic barb blocking the Heart meridian. So strongly embedded there was no means of clearing it before the target of the assassination died some days later.
More pertinent to explanations for TMJ dysfunction and associated effects, is the result of the blocked energetic Qi flow in the Bladder meridian on musculature along the energetic pathway of both the Bladder and Kidney meridians in the lower limbs. A characteristic of the Short Right Leg Syndrome I describe as the Second Cardinal Sign is rigidity about the right hip. Primarily due to gait effects from the short leg leading to chronic tightening through the right Iliac Crest. Advanced cases experience pain and tightness at both primary and secondary Bladder meridian choke points descending the backline of the lower limb. Another is tightening through the right Adductor Magnus where energetic Qi flow is blocked and deficient. This is directly related to the blocked descending Bladder meridian having a consequent effect on the ascending Kidney meridian. The Kidney meridian passes through Adductor Magnus which in addition to adduction, also has the action of medial rotation of the femur. Every case examined demonstrates this rigidity about the right hip where the left will be softer and giving under traction. Every case exhibits greater tightness in the right adductors than the left. There are few exceptions to this and they are usually Yoga gurus or dancers able to maintain ultimate flexibility through dedicated practice.
Where medial rotation may be sighted at the right femur because of the Second Cardinal Sign of SRLS impacting Bladder and Kidney meridian energetic Qi flow, the primary underlying contributory factor is leg length discrepancy generating distortion and strain through the pelvis and lumbro-sacral region. The bones of the right leg are structurally shorter than the left and the compensating effects through left and right hips, stance, gait, energetic Qi flow, comfort, mobility and internal health is complex in its entirety. I have read explanations for hip, pelvis, spine and jaw conditions that come to conclusions without considering the input of the structurally short right leg that is present in the majority of cases. It is a dominant genetic trait and must be taken into account.
