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.

How are your hammy’s?

Another tool for you, in addition to making sure the gluten are on line, to improve ankle rocker and hip extension.

“This study concludes that neural mobilization techniques are a useful adjunct to static stretching, without any risk of adverse events or injuries. Athletes or trainers can consider using one or both types of neural mobilization techniques to enhance muscular flexibility. Dosage of the neural mobilization as well as the proposed working mechanism behind the increase in hamstring flexibility can be found in the full text of the article.”

http://www.ncbi.nlm.nih.gov/pubmed/26482098

Phys Ther Sport. 2016 Jan;17:30-7. doi: 10.1016/j.ptsp.2015.03.003. Epub 2015 Mar 17.
Short term effectiveness of neural sliders and neural tensioners as an adjunct to static stretching of hamstrings on knee extension angle in healthy individuals: A randomized controlled trial.
Sharma S, Balthillaya G2, Rao R, Mani R .

What’s wrong with this picture? (Besides the fact that you probably shouldn’t run with your dog on asphalt) 

There’s been a lot of incongruency in the media as of late. This particular gal, with your head rotation to the right is going against the harmony of neurology and physiology. Let me explain…

 This particular gal, with her rotated to the right is going against the way the nervous system is designed to work.

In a post  in the last week or so (the massage cream one and  incongruent movement) we talked about tonic neck responses. When the head is rotated to one side, that upper and lower extremity should extend while the contralateral side should flex. This poor gal is fighting her own neurology! 

 Also note that she really doesn’t have that much hip extension on the right and increases her lumbar lordosis to compensate. Gee whizz. You’d a thought they would have done better…

 So much for the photo op : -) 

The Elusive Iliocapsularis

As with many things, one thing often leads to another. I had a patient with anterior hip pain and what i believed was iliopsoas dysfunction, but I wanted to know EXACTLY which muscles attached to the hip capsule, to make sure I wasn’t missing anything.

I turned up some great info, including a nice .pdf lecture, which I am including the link to along with a second paper that began my journey.

I had thought the iliopsoas attached to the hip capsule, but it turns out it doesn’t, but the iliocapsularis does along with a host of others, including one of my favs, the gluteus minimus, which was believed to be part of the psoas, but actually is a completely separate muscle.  Did I mention that these are  FREE, FULL TEXT articles?

Anyway, I began reading, with great interest, about the iliocapsularis and I found yet another great review paper on it, along with mechanical hip pain. This last paper has some real clinical pearls and I recommend reading it the next opportunity you have a bit of time.

I began thinking about when the iliopsoas fires in the gait cycle (terminal stance to mid swing). So, it is firing eccentrically at pre swing (perhaps limiting or attenuating hip extension?), then concentrically through early and mid swing, when it becomes electrically silent. During running gait, the activation pattern is similar. This muscle is also implicated in femoroacetabular impingement (FAI), or more correctly anterior inferior iliac spine subspine impingement (AIIS Impingement) or iliopsoas impingement (IPI). They all can cause anterior hip pain and they should all be considered in your differential.

The iliocapsularis muscle has its proximal attachment at the anterior-inferior iliac spine and the anterior hip capsule and does not attach to the labrum . Its distal insertion is just distal to the lesser trochanter. It can sometimes inset into the iliofemoral ligament and/or the trochanteric line of the femur. It is innervated by a branch of the femoral nerve (L2-4). It is believed to act to raise the capsule of the hip and be an accessory stabilizer of the hip. 

OK, there you have it. the iliocapsularis. Another muscle you didn’t know you could access. It pays to know your anatomy!

https://www.mcjconsulting.com/meetings/2012/asm/ePosters/files/ISHA_Poster_202.pdf

 http://pubs.rsna.org/doi/full/10.1148/radiol.12111320

Great, FREE FULL TEXT article on the hip.

an EXCELLENT review with some great rehab tips at the conclusion like this

“Once isolated contraction of the deep external rotator muscles
is successfully achieved, progression can be made to the
rehabilitation of secondary stabilisers and prime movers of the
hip, particularly the gluteus maximus, initially using nonweight
bearing exercises and progressing to weight bearing
exercises once motor control and strength allows. Pre-activation
of the deep external rotators may make these exercises
more effective. Deficits in flexibility and proprioception
should also be addressed at this stage. Once adequate hip muscle
strength and endurance is achieved, functional and sports
specific exercises can then be implemented. ”

Can local muscles augment stability in the hip?: A narrative literature review T.H. Retchford, K.M. Crossley, A. Grimaldi , J.L. Kemp, S.M. Cowan J Musculoskelet Neuronal Interact 2013; 13(1):1-12

http://www.ismni.org/jmni/pdf/51/01RETCHFORD.pdf

image from: https://www.researchgate.net/…/258427127_fig12_Fig-11-Anato…

The Mighty Quadratus Femoris

Ishial tuberosity pain that looks like a hamstring but is not responding? Think QF.

We have always have found the quadratus femoris is one of, if not the, 1st hip muscle to become dysfunctional in hip pain patients. Perhaps it is due to it being the southern most stabilizer of the deep 6. Long known as an adductor, but also external rotator, we find it is employed eccentrically when the foot the planted and people rotate to the same side as weight bearing, or people take a “sudden stumble” while running. It often mimics an insertional hamstring strain with regards to location. We were happy to see it is getting some of the attention it deserves : )

The Mighty Quadratus Femoris

“The Deep 6” and their “not so talked about” role in the gait cycle.

Excerpted from a recent Dry Needling Seminar in, listen to this brief video and you will never look at these muscles the same way again.

It talks about the lesser known, eccentric role of the deep 6 external rotators during gait. This is really important from a rehab perspective, as these muscles are often neglected in the rehab process.

Do yourself and your clients/patients a favor and watch this informative short so you don’t miss out : )