18/09/2020
Lack of hip internal rotation?
What first comes through in your mind when you see this problem? I have mentioned the importance of hip internal rotation for lower back stability and mobility in my last post. Do not get me wrong.
Restricted hip internal rotation can contribute to the development of knee and foot pain as well. For instance, I have seen people with knee and medial foot pain. They commonly report that squatting hurts their knee and foot so have not done it for a while. BUT the thing is that everyone does unconsiocously squat everyday. What am I talking about? Yes! Think of sitting from standing and vice versa. We squat everyday, right? It can not be eliminated in daily life. Get it? I have had doctors who believe that squatting actually damages knee joints. Well, really? If squatting is harmful, then do not walk, sit to stand but rest in bed. Easy, isn’t it?
The bottom line is that squatting is not a problem. However, lack of range of motion of each segment of the body is the problem. For example, if your hips are stiff, then you can not flex through the hips but more your lower back. That puts a lot of load to the lower back which can be a contributing factor to lower back pain or groin pain. When squatting down, restricted hip internal rotation can cause knee valgus or/and foot overpronation. Something has to compensate for the restriction of the hip internal rotation.
How would you improve it?
Yes! Some soft tissue release may be beneficial. However, can it make a long term effect tho? Humm half half i guess. I would not feel confident in his recovery if I kept providing the same passive treatment. Why is that? Most patients feel better after passive treatment. First, who would not like massage? It is relaxing. Second, lying in bed during massage is an unloading position to his body. So, it is not being physically stressed. Therefore, he feels great afterwards. I believe that satisfying a patient’s expectation is important depending on what they think good before coming to see you. Mostly, they expect some type of relaxing passive treatment to alleviate their pain.
However, I also believe that applying hands on treatment should not be a stand alone solution. Why is that? Again, he feels great afterwards. However, once getting out of the clinic, he starts loading his body. As soon as heel strike occurs, his body begins to transfer load. If there is a poor load tolerance or/and lack of joint ROM, then there will be a suboptimal load transfer which can eventually develop pain.
Anyways, how to improve hip internal rotation?
Stretching? It can be helpful for a short period of time. However, stretching can not be an injury prevention. Why is that? According to research, static stretching before playing sports actually decrease sports performance by 30%. We still do not know its exact reason. I hypothesise that whatever sports we play, they require good load tolerance. This means that you may need more tension that absorbs stress/ground forces than lengthened muscles. Forcible hip ROM exercises can aggravate hip pain too.
Then what would you do?
Let me share my patient’s case. He presented with L anterior hip pain during full leg squat. Long story short, I found lack of hip internal rotation in supine. This indicates that his knee could compensate for it. In the literature, 10-50 degs of anterior pelvic tilt can significantly decrease hip internal rotation. BUT how do you know if he has severe anterior pelvic tilt? Does this directly cause anterior hip pain? Not always. That’s why, you cannot diagnose your patients. Why is that? For instance, 60% of soccer players with a hip labral tear do not have hip pain. Therefore, having an anterior pelvic tilt does not mean you should have lower back pain or hip pain if it makes sense.
What I usually do is collecting all physical assessment findings and trying to connect “dots”. For example, there was a clear anterior pelvic tilt on his stance. I then used that info to see if this was relevant to his anterior hip pain. This pelvic posture can lengthen glutes and hamstrings but shorten your quads, right? So, check their muscle length. As the literature shows, it can significantly reduce hip internal rotation, right? So, check hip internal rotation then. Obviously, it can decrease hip flexion as well. If +Ve to all those tests, then you may question about what if changing the pelvic position can improve the restricted hip ROM?. Do not just question yourself only but implement what you think may change it.
How would you change it then?
Yes! Youve already read what muscles may be lengthened in the anterior pelvic tilt posture. What are they? Yes! Hamstring/glutes and what else? Yes! Do not forget about core muscles, especially obliques whose job is to depress and retract the ribcage. Think of people with severe anterior pelvic tilt. That altered pelvic posture can outflare your ribcage as its picture shows down below.
This can overstretch your core muscles big time. This means difficulty to engage them. For instance, 60% of post partum women do not know how to perform activation of core and pelvic floor muscles. Why is that? In 10 months of pregnancy, the anterior abdominal fascia and other connective tissues get stretched out. That’s why, post-partum rehab is very important. Anyways, simply put, get them to activate core muscles during hip flexion or internal rotation to see if it improves pain or ROM. If not, then move on something else that may lead to their pain. There is no such thing as a right answer cuz everyone is different and needs to be individually assessed.
