Exploring the Links Between Human Movement, Biomechanics & Gait
Tag: femoral ante torsion
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.
Last week we posted on measuring tibial torsions (click here to read that post). This week we are posting on measuring the other, often over looked torsion: “femoral torsion”.
Perhaps you have read some of our posts on femoral torsion, particularly this one.
We remember that as hip (thigh) flexion increases, the amount of internal rotation of the femur decreases. This is due largely to the direction of the hip capsule ligaments (ishiofemoral, iliofemoral and pubeofemoral ligaments) “spiraling” from their attachment from the femur to the innominate. This may seem like a subtle detail until you thing about how much hip flexion occurs when we do a squat, and what exactly, is the position of our feet.
We start life with the hips anteverted (ie, the angle of the neck of the femur with the shaft of the femur is > 12 degrees; in fact at birth it is around 35 degrees) and this angle should decrease as we age to about 8-12 degrees). When we stand, the heads of our femurs point anteriorly; it is just a matter of how much (ante version or ante torsion) or how little (retro version or retro torsion) that is. If you are a precise person and would really like to geek out on the difference between versions or torsions, check out this post here.
Measurement is important, because the more retro torsion you have (ie, the smaller the angle is), the less internal rotation of the femur you will have available to you. An important fact if you are planning on squatting.
An easy way to do this is by approximating the angle of the femoral neck by performing “Craig’s Test”. Have your patient/client/athlete lie prone with their knee flexed 90 degrees. Palpate the greater trochanter (the bump on the side of the hip that the gluteus medius muscles attach to) with one hand while using the other hand to grasp around the ankle and internally and externally rotate the femur (we like to use the right hand on the right trochanter for the patient/client/athletes right leg). Note the position of the tibia when the greater trochanter is parallel to the table (see diagram above from Tom Michaud’s most excellent text: Human Locomotion: the conservative management of gait related disorders, available by clicking here). The smaller the angle, the more retro version/torsion present).
This is also a convenient way to estimate the amount of internal and external rotation of the femur available. One source states that internal rotation of greater than 70 degrees and external rotation of less than 25 degrees means that there is excessive femoral ante torsion present (1).
Craig’s Test: a convenient way to measure torsions of the femur. Important if you squat! Brought to you by The Gait Guys: Uber Gait Geeks Extrodinaire.
(1) Staheli LT. Rotational problems in the lower extremity. Orthop Clin North Am, 1987; 18:503-512
Subtle clues. Helping someone around their anatomy
This patient comes in with low back pain of years duration, helped temporarily with manipulation and activity. Her exam is relatively benign, save for increased lumbar discomfort with axial compression in extension and extension combined with lateral bending. Believe it or not, her abdominal and gluteal muscles (yes, all of them) test strong (no, we couldn’t believe it either; she is extremely regular with her exercises). She has bilateral internal tibial torsion (ITT) and bilateral femoral retro torsion (FRT). She has a decreased progression angle of the feet during walking and the knees do not progress past midlilne. There is a loss of active ankle rocker with gait, but not on the exam table; same with hip extension.
We know she has a sweater on which obscures things a bit, but this is what you have to work with. Look carefully at her posture from the side. The gravitational line should pass from the earlobe, through the shoulder, greater trochanter and through or just anterior to the lateral malleolus.
In the top picture, can you see how her pelvis is anterior to this line? Do you see how it gets worse when she lifts her hands over her head (yes, they are directly over head)? This can signify many things, but often indicates a lack of flexibility in the lumbar lordosis; in this case, she cannot extend her lumbar spine further so she translates her pelvis forward. Most folks should have enough range of motion from a neutral pelvis and enough stability to allow the movement to occur without a significant change. Go ahead, we know you are curious, go watch yourself do this in a mirror and see if YOU change.
Looking at the bottom left picture, can you pick out that she has a genu valgus? Look at the hips and look at the tibial angle.
In the bottom left picture, did you note the progression angle (or lack of) in her feet? This is a common finding (but NOT pathognomonic) in patients with internal tibial torsion. Notice the forefoot adductus on the right foot?
So what do we think is going on?
ITT and FRT both limit the amount of internal rotation of the thigh and lower leg. Remember you NEED 4 degrees of each to walk normally. Most folks have significantly more
if you don’t have enough internal rotation of the lower extremity, you will need to “create” it. You can do this by extending the lumbar spine (bottom picture, right) or externally rotating the lower extremity
Since her ITT and FRT are bilateral, she flexes the pelvis and nutates the pelvis anteriorly.
the lumbar facet joints should only carry 20% of load
she is increasing the load and causing facet imbercation resulting in LBP.
What did we do?
taught her about neutral pelvic positioning, creating more ROM in the lumbar spine
had her consciously alter her progression angle of her foot on strike, to create more available ROM in internal rotation
encouraged her to wear neutral shoes
worked on helping her to create more ankle rocker and hip extension with active drills and exercise (ie gait rehabilitation); shuffle walks, Texas walk, toes up walking, etc
why didn’t we put her in an orthotic to externally rotate her lower extremity? Because with internal tibial torsion, this would move her knee outside the saggital plane and create a biomechanical conflict at the knee and possibly compromising her meniscus.
Cool case, eh? We thought so. Keep on learning so your brain keeps expanding. If you are not growing your brain, you are shrinking it!
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.
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