Why are you putting your internal hip rotation into your low back (pain).

Why are you putting your internal hip rotation into your low back (pain).

On October 12th, 2018 I wrote about utilizing the gluteals in internal hip rotation. You will have to go back and search FB for that article and video.
Assessing Internal hip rotation (in various ranges of hip flexion, extension, abduction and adduction) is a basic exam principle I examine on nearly every patient and athlete that comes to see me, regardless of their complaint. Other than breathing, walking is the next most under appreciated movement we undertake, and take for granted.
Lack of adequate internal hip rotation, in my clinical experience (20+ years), is all too often a fundamental parameter in hip, knee and low back pain. It is necessary to have unrestricted internal hip rotation during gait. Adequate internal hip rotation in the mid to late stance phases of gait is critical and is also paired with hip extension, in fact, one has to pass through adequate internal hip internal rotation to get to adequate hip extension. Without one, we do not get the other. And, if the internal rotation is not imparted in the hip when the hip is supposed to be the one internally rotation, that demand is going to move up or down, caudally or rostrally, low back or knee. Of interesting note, taking things deeper, the opposite arm is also going to go through internal rotation and extension at the same time. Impair one limb, and we can make a case, often enough, that the contralateral upper or lower limb is also challenged. This fundamental fact is one of the fascinating reasons Dr Ivo and I get so geeked out by gait and human movement. Because, it is very complicated. And if one is not looking close enough, paying enough attention with enough fundamental knowledge, things are going to get overlooked and missed when solving for "X" in a client's pain/problems/movement. Compensation will ensue, all too easily. Build strength on said compensations and we are off to the races in driving neuronal pasticity into potential asymmetries. If one is strength training a client without examining them and making specific corrections along the way, well, we reap what we sew. Ok, enough soap-boxing. -Dr. Allen
Here, don't take our word for it, . . . . .

"Correlation between Hip Rotation Range-of-Motion Impairment and Low Back Pain. A Literature Review."
Ortop Traumatol Rehabil. 2015 Oct;17(5):455-62. doi: 10.5604/15093492.1186813.
Sadeghisani M1, Manshadi FD1, Kalantari KK1, Rahimi A1, Namnik N2, Karimi MT3, Oskouei AE4.

"There is a hypothesis which suggests that a limited range of hip rotation results in compensatory lumbar spine rotation. Hence, LBP may develop as the result. This article reviews studies assessing hip rotation ROM impairment in the LBP population.

"Asymmetrical (right versus left, lead versus non-lead) and limited hip internal rotation ROM were common findings in patients with LBP. Reduced and asymmetrical total hip rotation was also observed in patients with LBP. However, none of the studies explicitly reported limited hip external rotation ROM."

CONCLUSION: "The precise assessment of hip rotation ROM, especially hip internal rotation ROM, must be included in the examination of patients with LBP symptoms."

Photo credit: courtesy of Pixabay

The turned out foot. How far ahead (and how fast) can you think ? 

There are many causes of the turned out foot. The above slide is just one of many logical and possible chain of events.  

There are also reasons above the neck that cannot be ignored in creating the externally rotated foot (and in resolving it). Things are not always biomechanical in origin so remember this when you are continually doing activation and rehab interventions to get more glute or drive more internal limb spin and your results are met with a non-response.  

Most of us like a biomechanical line of thinking when it comes to apparent biomechanical aberrancies from the norm.  However, more often than you probably think (go back and listen to podcast 58 on Cortical Brain Mapping of injuries), several more purely neurologic reasons are plausible.  For example, changes in input/output in unilateral activity within the pontomedullary reticular formation (PMRF) of the brain can lead to inhibition of the posterior chain muscles below the T6 spinal level (And anterior muscles above T6. And what is awesome is that there are ways to test this kinda stuff on a physical exam !  However, this blog post is not the place to teach these neurologic examination procedures.  But, if this sounds like Janda’s Upper and Lower Crossed Syndromes you are thinking soundly. Just remember though, if you are fixing what you see, you may not be fixing the problem, fix the cause that drove what you are seeing.  If you know your functional neurology you will know where these things come from, they are a cortical phenomenon).  

Of the posterior compartment muscles below T6, the gluteus maximus is probably the largest of this group and when it is inhibited there is loss of control of its ability to stabilize single leg stance.  One strategy around a stability challenge would be to turn the foot/leg into the frontal plane (toe out) via external limb rotation.  Now we can use the remaining muscles in both the sagittal and frontal planes ! We are always more stable when we can engage two or more cardinal planes at the same time.

There are  many more reasons for the externally rotated limb/foot, for example vestibular dysfunction, cerebellar dysfunction, core dysfunction, impaired normal arm swing and the list goes on. We have talked about many of these reasons on many of our blog posts and podcasts.

Mental gymnastics when it comes to the brain are important, Keep your gait and human movement game sharp, work through scenarios in your head regularly because it is what is necessary when you are working up a client.  

Shawn and Ivo

the gait guys