Correlating various foot problems to hip function and limitations. This is something we have been shouting about for years now.
One of the very first things we do after watching one’s gait on any patient visit is to have them supine on the table and check passive external and internal hip rotation (IR) ranges. At this time paying particular attention to the topic of INTERNAL HIP ROTATION, we do this particularly with the limb straight (lying flat on the table) to mimic what the range might be with them standing in midstance phase of gait/running (ie. the pelvis and body mass directly over the foot). We do this supine because checking IR in variations of hip flexion does not make much sense when it comes to gait pathology. We compare the ranges left and right. They should be symmetrical and sufficient. According to Michaud’s work, 4-6 internal rotation degrees is necessary, 45 is normal.
As we move through midstance the stance limb is converting from external hip rotation to internal rotation as the contralateral hemipelvis transitions forward during that leg’s swing phase. A major key for normal biomechanics moving downwards through the kinetic chain is that sufficient hip internal rotation is present. If there is a deficit functionally (and sometimes that is different from what the books say is necessary), the internal rotation has to occur somewhere. Quite frequently it occurs through more aggressive and faster internal tibial rotation which will challenge the amount of foot pronation that occurs (it usually causes more). [* please keep in mind if your solution for this local increased pronation at the foot is an orthotic to block the excess motion keep in mind that the body now has to find another place to put this internal spin and sadly it quite often has to go back to the hip and this can cause the hip labral problems that we have talked about all week. *Now you see why we set the week up this way preempting this discussion with the pathologies.]
Continuing our thoughts a bit further, if internal hip rotation is not sufficient as the body moves over the limb then the next succession, hip extension, is going to be compromised. This sets up a whole cascade of problems. here we go with some (but not all) …….
- If you cannot get sufficient internal hip rotation you have to ask for it from tibial spin and thus possible increased pronation and arch collapse…..this could lead to a plethora of foot and ankle pathologies such as plantar fascitis, metatarsal pain syndromes, tendonopathies etc etc.
- lack of subsequent hip extension will cause weakness of the gluteals, which will further compromise hip stability but also hip propulsion. This can cause a compensatory challenge to the calf muscles to do more in the department of forward propulsion which often has complications. Furthermore, if the calf becomes more dominant than it should, and we thus lose the relationship symmetry between the calf and the anterior compartment of the lower leg, then ankle rocker will be impaired. And loss of ankle rocker (dorsiflexion) has a whole host of pathologies that go with it (see numerous prior postings on this blog).
- if the glutes are compromised then the glute-abdominal relationship is challenged and thus pelvic stability problems can occur. This disrupted relationship can allow anterior pelvic posturing which usually is accompanied by lower abdominal weakness. And you should know that the lower abdominals are the anchor for internal hip rotation (review the postings earlier this week).
And so …. if you follow this whole lineage, you will see a completion of a vicious cycle. So now, the entire gait pattern is disrupted. From internal hip rotation, to hip extension, to glute mediation, to pelvic instability, to impaired limb spin, to impaired pronation-supination cycle and thus …… gait pathology. And in time, but hopefully not, hip labral and knee meniscal pathologies to go with the gait pathology.
Remember what they always say…….. FORM FOLLOWS FUNCTION.
But here at The Gait Guys, we like to say……..FORM FOLLOWS DYSFUNCTION.
we ain’t no Gait Fools !