Exploring the Links Between Human Movement, Biomechanics & Gait
Why does this gal have so much limited external rotation of her legs?
We have discussed torsions and versions here on the blog many times before. We rarely see femoral antetorsion. She came in to see us with the pain following a total hip replacement on the right.
Note that she has fairly good internal rotation of the hips bilaterally but limited external rotation. This is usually not the case, as most folks lose internal rotation. We need 4 to 6° internal and external rotation to walk normally. This poor gal has very little external rotation available to her.
Have you figured out what’s going on with hips yet? She has a condition called femoral ante torsion. This means that the angle of the femoral neck is in excess of 12°. This will allow her to have a lot of internal rotation but very little external rotation. She will need to either “create” or “borrow” her requisite external rotation from somewhere. In this case she decreases her progression of gait (intoed), and borrows the remainder from her lumbar spine.
So what do we do? We attempt to create more external rotation. We are accomplishing this with exercises that emphasize external rotation, acupuncture/needling of the hip capsule and musculature which would promote external rotation (posterior fibers of gluteus medius, gluteus maximus, vastus medialis, biceps femoris). A few degrees can go a very long way as they have in this patient.
confused? Did you miss our awesome post on femoral torsions: click here to learn more.
You can only “borrow” so much before you need to “pay it back”
How can feet relate to golf swing?
This 52 year old right handed gentleman presented with pain at the thoracolumbar junction after playing golf. He noticed he had a limited amount of “back swing” and pain at the end of his “follow through”.
Take a look a these pix and think about why.
Hopefully, in addition to he having hairy and scarred legs (he is a contractor by trade), you noted the following
Top left: note the normal internal rotation of the right hip; You need 4 degrees to walk normally and most folks have close to 40 degrees. He also has internal tibial torsion.
Top right: loss of external rotation of the right hip. Again, you need 4 degrees (from neutral) of external rotation of the hip to supinate and walk normally.
Top center:normal internal rotation of the left hip; internal tibial torsion
3rd photo down: limited external rotation of the left hip, especially with respect ti the amount of internal rotation present; this is to a greater degree than the right
4th and 5th photos down: note the amount of tibial varum and tibial torsion. Yes, with this much varum, he has a forefoot varus.
The brain is wired so that it will (generally) not allow you to walk with your toes pointing in (pigeon toed), so you rotate them out to somewhat of a normal progression angle (for more on progression angles, click here). If you have internal tibial torsion, this places the knees outside the saggital plane. (For more on tibial torsion, click here.) If you rotate your extremity outward, and already have a limited amount of range of motion available, you will take up some of that range of motion, making less available for normal physiological function. If the motion cannot occur at the knee or hip, it will usually occur at the next available joint cephalad, in this case the spine.
The lumbar spine has a limited amount of rotation available, ranging from 1.2-1.7 degrees per segment in a normal spine (1). This is generally less in degenerative conditions (2).
Place your feet on the ground with your feet pointing straight ahead. Now simulate a right handed golf swing, bending slightly at the waist and rotating your body backward to the right. Now slowly swing and follow through from right to left. Note what happens to your hips: as you wind back to the right, the left hip is externally rotating and the right hip is internally rotating. As you follow through to the left, your right, your hip must externally rotate and your left hip must externally rotate. Can you see how his left hip is inhibiting his back swing and his right hip is limiting his follow through? Can you see that because of his internal tibial torsion, he has already “used up” some of his external rotation range of motion?
If he does not have enough range of motion in the hip, where will it come from?
he will “borrow it” from a joint more north of the hip, in this case, his spine. More motion will occur at the thoracolumbar junction, since most likely (because of degenerative change) the most is available there; but you can only “borrow” so much before you need to “Pay it back”. In this case, he over rotated and injured the joint.
What did we do?
we treated the injured joint locally, with manipulation of the pathomechanical segments
we reduced inflammation and muscle spasm with acupuncture
we gave him some lumbar and throacolumbar stabilization exercises: founders exercise, extension holds, non tripod, cross crawl, pull ups
we gave him foot exercises to reduce his forefoot varus: tripod standing, EHB, lift-spread-reach
we had him externally rotate both feet (duck) when playing golf
The Gait Guys. Helping you to store up lots “in your bank” of foot and gait literacy, so you can help people when they need to “pay it back”, one case at a time.
Holy Twisted Femurs, Batman. What is going on here?
So, this is what femoral antetorsion looks like!
Remember that ante torsion occurs during development and is when the neck of the femur makes greater than a 12 degree angle with the shaft. We did a great post on this a while ago, click here to read it.
If you remember that the femur heads point anteriorly in a standing position, this would accentuate that, so they stand with an increased progression angle (ie feet toed out; see 1st picture).
With the increased femoral neck angle, these folks have a greater range of internal rotation of the femur, and decreased external rotation. Can you see this in the pictures above? We have rotated her legs fully internally and externally.
A few questions for you:
if you look carefully at the 1st picture, you will note she has external tibial torsion. Why?
this condition can develop in utero, but more commonly occurs postnatally with”W” sitting (sitting with knees together and legs abducted, with buttocks between the legs or feet. Think about that constant internal force on the femurs and external rotatory force on the lower tibia! Have your kids sit differently!
What type of shoe should this person be in?
The condition itself does not dictate the type of shoe thay should be in. This individual has a rigid, cavus foot BUT has an uncompensated forefoot varus with a great deal of forefoot pronation. In addition to exercises to strengthen the external rotators of the thigh, and inverters of the foot, a shoe with some motion control features is indicated in this instance
The Gait Guys…..Twisted? Yes! And still bald, middle aged and geeky as well.
A bit confused? Dig into our blog more, or watch our youtube channel. Maybe it’s time to push your knowledge base to the next level and take the National Shoe Fit Program. email us at email@example.com
Photo: Where is your knee joint hinge point ? Say that 4 times fast.
Here is a photo of 4 elite runners. We suspect it is an 800m race because #100 is Ahmed Bile who is the son of Olympian and world champion Abdi Bile.
In this photo you can see that Ahmed #100 has a significantly large foot progression angle (large foot turn out) and this likely represents external tibial torsion or femoral antetorsion while #454 has a neutral foot turn out as does #232. #46 has a modest foot progression angle. Grossly, #46 also has the patella right over the foot and so tibial torsion is not likely. Now, move up to observe their knee progression. All of them have a forward (sagittally) oriented knee progression. How can that be? Well, it is simple if you know your torsional issues. After all, the knee is a hinge and if you are running forward your knee pretty much should hinge forward as well. Now, there is much room for conversation here and debate but we are just trying to make and observation and a point. To a large extent the knee rules the roost in the lower limb in terms of sagittal progression because it is the joint with the least number of tolerances. The knee only hinges in flexion and extension where as the hip and ankle/foot have frontal and axial planes they can notably tap into when the sagittal is challenged. Again, look at #100 and our point is made.
Look at the 2 fellas in the middle (454 and 232). they have a internally (medially) postured knee/thigh yet their foot progression angle is mostly neutral and the knees are hinging forward. Does #454 have internal tibial torsion? It could be (hint, look at his right trailing leg, specifically the patella and foot postures) but the left limb looks cleaner although adducted suggesting he might like the cross-over gait or it is more external tibial torsioned. Where as the 2 outer fellas, 100 and 46, are more neutrally oriented knees/thighs (one could make the case that #100 has a more externally oriented femur) yet increased progression foot progression angle in an environment of a forward hinging knee.
So what gives ? Torsions. Yes, we are soapboxing on torsions again. Torsions in the tibia, torsions in the femur. Versions are normal expressed angles, tibial torsions are abnormal.
Now, as life would have it, look over the right shoulder of #100. See the fella in the red headband? Ya, that guy losing. He has the cleanest lines of the bunch. How is that for cruel irony ? Sometimes it ain’t what you got, it is what you do with what you got. Unless of course he is actually wincing in pain and trailing behind because he got spiked by #100 and that hideously frontal plane splayed foot !
Lastly, this wouldn’t be an official Gait Guys post if we did not preach to remember that “what you see is not the problem, what you see in a gait analysis is the person’s compensatory strategy around their deficits”. And here we see deficits. Our observations today are merely just that, observations. Now someone has to get them on a table and examine them and confirm our observations, prove them wrong and/or discover the joint, muscular and motor pattern deficits that created these observations. Or, someone has to confirm that all parts are working and that they were at the end of the line when the straight long bones were first handed out.
Today’s Lesson: Get in line, and get in line early. (just kidding of course)
The Gait Guys. Calling it they way we see it, but reserving the right to plead the 5th or change our minds after an examination. We would suggest to everyone, when it counts and when your reputation is on the line, plead the 5th, until you have completed your hands on clinical examination. ”Seeing may be believing” but that still doesn’t always make it so.
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Hmmm. We are fully internally rotating this gentleman’s lower leg (and thus hip) on each side. What can you tell us?
Look at the upper picture. Does the knee go past midline? NO! So we have limnited internal rotation of the hip. What are the possible causes?
femoral retro torsion
tight posterior capsule of hip
OA of hip
tight gluteal group (max or posterior fibers of medius)
Now line up the tibial tuberosity and the foot. What do you see? The foot is externally rotated with respect to the leg. What are the possible causes?
external tibial torsion
fracture/derangement causing this position
Now look at the bottom picture. Awesome forearm and nice choice of watch. Good thing we didn’t wear Mickey Mouse!
Look at upper leg. Hmm. Same story as the right side.
Look at the lower leg and line up the tibial tuberosity and the foot. What do you see? The foot is internally rotated with respect to the leg. What are the possible causes?
internal tibial torsion
fracture/derangement causing this position
So this individual will have very different lower leg mechanics on the right side compared to the left (external torsion right, internal left). We refere to this as “windswept” biomechanics, as it looks like the wind came in from the right and “swept” the feet together to the left.
What will this look like? Most likely increased pronation on the right and supination on the left. What may we see?
calcaneal (rearfoot) valgus on right
calcaneal (rearfoot) varum on the left
bilateral knee fall to midline
knee fall to midline on right occurring smoother than on left (the patient has an uncompensated forefoot varus bilaterally; he is already partially pronated on the right, so it may appear to be less abrupt)
toeing off in supination more pronounced on the left (due to the internal torsion and forefoot varus)
The Gait Guys. Increasing your foot and gait IQ with each and every post.
What can we learn from a trip to the museum and ancient pachyderms?
Lessons from the Denver Museum of Science and the “Mammoths and Mastodons” exhibit.
Leave it to gait nerds to notice stuff like this. These are the things that keep us up at night.
Look carefully at the last 2 pictures, especially the femurs. Besides their grandious size, what do you see. Femoral anterversion! The angle of the femur head with the shaft of the femur is quite large. We remember from our discussion of anteversion previously (see here); that femoral anteversion allows a greater amount of internal rotation of the head of the femur in the acetabulum (ie the ball in the socket).
Now look at the top picture. Besides a cross over gait that Dr Allen was quick to point out. What do you see? Ok…tremendous glutes : ). What else? Look at the second picture for a hint. You got it! Internal rotation of the legs.
Think about how pachyderms are put together compared to say, reptiles, specifically lizards. The legs are UNDER the body in the former and STICK OUT from the body in the latter. Watch them walk. The latter swing their tails and the former have the legs under their center of mass.
Extrapolate this to human gait (We know, it’s a stretch, but you have a great imagination). Some people have their weight under their body (ie, they have sufficient internal rotation of the hips to allow this; many of these folks have more anteverision than retroversion. also remember that we are speaking versions, NOT torsions here). Think about retroverted folks. Wider stance, wider gait, just like reptiles.
Ok, maybe this was a stretch, but it was cool, no?
The Gait Guys. Comparing pachyderms to humans….reallly.
all material copyright 2013 The Gait Guys/The Homunculus Group. All rights reserved.
Take a look at these pics for a moment, then come back and read.
Ready? Lets see how much you remember about torsions and versions. Take a look at this child that was brought in by their parent (legs were too short to drive themselves : ) ) They were wondering if the child needed orthotics. What do we see?
top left photo: legs are in a neutral position. note the position of the knee (more specifically the tibial tuberosity and patellae can sometimes fake you out. ( OK, maybe not you, but they can sometimes fake SOME people out). The plane of the 2nd metatarsal is LATERAL to the tibial tuberosity, This is EXTERNAL TIBIAL TORSION; it appears greater on the (patients) right (look also at the left lower leg in the center picture as well, it has less torsion). Note also the lower longitudinal arches bilaterally (they are typically higher in non-weightbearing but in children this young they are typically lower in the early stages).
top right photo: I am fully internally rotating the right lower leg and hip. Note the position of the knee; it does not rotate as much as you would expect (normally 40 degrees) when compared to the distance the foot seems to have travelled. This hip is RETRO-TORSIONED (remember we are born anteverted about 40 degrees, which decreases approximately 1.5 degrees per year to puberty, resulting in an 8-12 degree angle in the adult. If you need a review, go back and read the February 27th post). Go back and read our 5 part series on Versions and Torsions (“Are you Twisted ?”).
Center photo: I am fully externally rotating the right leg. Note that range of motion is much greater than internal rotation and exceeds 40 degrees. This supports the previous paragraph, retro-torsion.
Bottom left: I am fully internally rotating the left lower leg. It appears normal with about 40 degrees (or more) of internal rotation. This femur is NORMAL or has NORMAL FEMORAL VERSION.
Bottom right: I am externally rotating the left leg. Motion appears to mimic internal rotation and is approximately equal. This supports the previous paragraph as NORMAL FEMORAL VERSION.
External tibial torsion, R > L
flattened longitudinal arches
Right femoral retrotorsion
Left femoral version, NORMAL
Well, what do you think? Are orthotics going to help this kiddo? No, probably not, they may even make the problem worse, by slowing derotation of the talar head, forcing them into more permanent varus of the forefoot.
How did you do? Can you see now why torsions and versions (the degree of “twistedness” of a limb is so important? They help you understand skeletal development and help you to make clearer decisions.
The Gait Guys. Twisted in a good way. Versioned but not torsioned.
all material copyright 2013 The Gait Guys/The Homunculus Group. all rights reserved. please don’t use our stuff without asking : )
Hopefully you have been keeping us with us. If you missed the 1st 3 of this series, go back 3 weeks and start reading again, or do a search on the blog page for “torsion”.
The final chapter of developmental versions involves the femur. The degree of version is the angle between an imaginary line drawn through the condyles of the femur and an imaginary line drawn through the head and neck of the femur. This is often referred to as the femoral neck angle or FNA.
Beginning about the 3rd month of embryological development (Lanz and Mayet 1953) and reaches about 40 degrees (with an average of 30-60 degrees) at birth. It then decreases 25-30 degrees by adulthood to 8-20 degrees with males being at the lower and females at the upper end of the range.
The FNA angle, therefore, diminishes about 1.5 degrees a year until about 15 years of age. Femoral neck anteversion angle is typically symmetrical from the left side to the right side.
What causes torsion in the first place? By the sixth month in utero, the lumbar spine and hips of the fetus are fully flexed, so perhaps it is positional. Other sources say it coincides with the degree of osteogenesis. There is a growing consensus that muscular forces are responsible, particularly the iliopsoas or possibly the medial and lateral hip rotators.
Additional changes can occur after birth, particularly with sitting postures. “W” sitting or “cross legged” sitting have been associated with altering the available range of motion and thus the FNA, with the range increased in the direction the hip was held in; W sitting causing increased internal rotation and antetorsion and cross legged causing external rotation and retro torsion.
As discussed previously, there are at least 3 reasons we need to understand torsions and versions, They can alter the progression angle of gait, they usually affect the available ranges of motion of the limb and they can alter the coronal plane orientation of the limb.
1. fermoral torsions often alter theprogression angle of gait.In femoral antetorsion torsion, the knees often face inward, resulting in an intoed gait and a decreased progression angle of the foot. This can be differentiated from internal tibial torsion (ITT) by looking at the tibia and studying the position of the tibial tuberosity with respect to the foot, particularly the 2nd metatarsal. In ITT, the foot points inward while the tibial tuberosity points straight ahead. In an individual with no torsion, the tibial tuberosity lines up with the 2nd metatarsal. If the tibial tuerosity and 2nd met are lined up,and the knees still point inward, the individual probably has femoral ante torsion. Remember that a decreased progression angle is often associated with a decreased step width whereas an increased angle is often associated with an increased step width. See the person with external tibial torsion in the above picture?
2. Femoral torsions affect available ranges of motion of the limb. We remember that the thigh leg needs to internally rotate the requisite 4-6 degrees from initial contact to midstance (most folks have 40 degrees) If it is already fully internally rotated (as it may be with femoral retro torsion), that range of motion must be created or compensated for elsewhere. This, much like internal tibial torsion, can result in external rotation of the affected lower limb to create the range of motion needed.
Femoral retro torsion results in less internal rotation of the limb, and increased external rotation.
Femoral ante torsion results in less external rotation of the limb, and increased internal rotation.
3. femoral torsions usually do not effect the coronal plane orientation of the lower limb, since the “spin” is in the transverse or horizontal plane.
The take home message here about femoral torsions is that no matter what the cause:
FNA values that exist one to two standard deviations outside the range are considered “torsions”
Decreased values (ie, less than 8 degrees) are called “retro torsion” and increased values (greater than 20 degrees) are called “ante torsion”
Retro torsion causes a limitation of available internal rotation of the hip and an increase in external rotation
Ante torsion causes an increase in available internal rotationof the hip and decrease in external rotation
Femoral ante torsion will be perpetuated by “W” sitting (sitting on knees with the feet outside the thighs, promoting internal rotation of the femur)
Femoral antetorsion will be perpetuated by sitting cross legged, which forces the thigh into external rotation.
Stay tuned for a case tomorrow to test your learning over the last few weeks.
We remain: Bald, good looking and intelligent…The Gait Guys
All material copyright 2013 The Gait Guys/ The Homunculus Group. All rights reserved. Please ask to use our stuff!
What do you see ? How does the alignment look ? Are they developing normally ? At what point should you intervene to ensure proper alignment and development occurs in this child ? Can we standardize our visual screen to fit all cases in all children ? So many questions !
* this case goes very nicely with a prior case on the blog published on July 15th.
Click back and forth between the two photos above on the blog. Youcan see that in the first photo that when the feet are parallel, the patellae point inward (normal compensation).
In photo 2, we can see that when we put the patellae in the saggittal plane (pointing forward) the foot progression angle is severely positive (externally postured or out-toed).
This is a severe case of FEMORAL ANTETORSION with compensatory EXTERNAL TIBIAL TORSION. The external tibial torsion is an external spin along the long axis of the shaft in a response to try to correct alignment. You can see that in this case there is no happy medium. The torsion in the long bones is so extreme that either the knees are positioned inwards when the feet are normally aligned or the feet are spun outwards when the knees are properly aligned. Regardless, there is much abnormal stress on the hip and knee joints and the labrum of the hip and menisci of the knees not to mention the challenges into the foot mechanics and gait.
Taking this into a gait perspective:
Patients with antetorsion are forced to externally rotate the limbs to bring the knee forward to a normal alignment from an internally rotated position.
This takes up some, occasionally all, of the lateral (external) rotation needed for the hips to function normally during gait causing compensatory rotation of the spine during single leg stance; the spine being really the only place the rotation can be achieved.
Normally, during gait the hip rotates laterally from toe off through to heel strike and is present during the initial loading response.
When this rotation does not occur in the hip, it must occur as a compensatory motion somewhere else in the kinetic chain and this is usually the pelvis or lumbar spinal joints.
Furthermore, the abnormal alignment of the femoral head in the acetabulum can repetitively irritate the hip joint and labrum let alone place abnormal torque on the tib-femoral joint (knee).
Antetorsion patients who compensate and realign the feet to a normal progression angle via tibial external torsion will force the femoral head anteriorly into the anterior hip capsule and this is a common source of pain. It is a “hammocking effect” into the anterior capsule and it can leave the femoral head and it’s cartilage uncovered and uncompressed thus advancing arthritis degeneration.
This is a similar symptom phenomenon as in “anterior femoral glide syndrome” as described by Shirley Sahrmann. It is not uncommon to see a sway back lumbar posture in these clients.
These patients may have anterior contractile tissue deficits, namely stretch-weak iliopsoas as described by Kendall.
Remember to check for limb length symmetry in these clients who’s anteversion is not symmetrical.
Watch for a future series on torsions and versions
We may be twisted, but the last time we looked, we are still …… The Gait Guys