Why are you putting your internal hip rotation into your low back (pain).

Why are you putting your internal hip rotation into your low back (pain).

On October 12th, 2018 I wrote about utilizing the gluteals in internal hip rotation. You will have to go back and search FB for that article and video.
Assessing Internal hip rotation (in various ranges of hip flexion, extension, abduction and adduction) is a basic exam principle I examine on nearly every patient and athlete that comes to see me, regardless of their complaint. Other than breathing, walking is the next most under appreciated movement we undertake, and take for granted.
Lack of adequate internal hip rotation, in my clinical experience (20+ years), is all too often a fundamental parameter in hip, knee and low back pain. It is necessary to have unrestricted internal hip rotation during gait. Adequate internal hip rotation in the mid to late stance phases of gait is critical and is also paired with hip extension, in fact, one has to pass through adequate internal hip internal rotation to get to adequate hip extension. Without one, we do not get the other. And, if the internal rotation is not imparted in the hip when the hip is supposed to be the one internally rotation, that demand is going to move up or down, caudally or rostrally, low back or knee. Of interesting note, taking things deeper, the opposite arm is also going to go through internal rotation and extension at the same time. Impair one limb, and we can make a case, often enough, that the contralateral upper or lower limb is also challenged. This fundamental fact is one of the fascinating reasons Dr Ivo and I get so geeked out by gait and human movement. Because, it is very complicated. And if one is not looking close enough, paying enough attention with enough fundamental knowledge, things are going to get overlooked and missed when solving for "X" in a client's pain/problems/movement. Compensation will ensue, all too easily. Build strength on said compensations and we are off to the races in driving neuronal pasticity into potential asymmetries. If one is strength training a client without examining them and making specific corrections along the way, well, we reap what we sew. Ok, enough soap-boxing. -Dr. Allen
Here, don't take our word for it, . . . . .

"Correlation between Hip Rotation Range-of-Motion Impairment and Low Back Pain. A Literature Review."
Ortop Traumatol Rehabil. 2015 Oct;17(5):455-62. doi: 10.5604/15093492.1186813.
Sadeghisani M1, Manshadi FD1, Kalantari KK1, Rahimi A1, Namnik N2, Karimi MT3, Oskouei AE4.

"There is a hypothesis which suggests that a limited range of hip rotation results in compensatory lumbar spine rotation. Hence, LBP may develop as the result. This article reviews studies assessing hip rotation ROM impairment in the LBP population.

"Asymmetrical (right versus left, lead versus non-lead) and limited hip internal rotation ROM were common findings in patients with LBP. Reduced and asymmetrical total hip rotation was also observed in patients with LBP. However, none of the studies explicitly reported limited hip external rotation ROM."

CONCLUSION: "The precise assessment of hip rotation ROM, especially hip internal rotation ROM, must be included in the examination of patients with LBP symptoms."

Photo credit: courtesy of Pixabay

The next time they have gait asymmetry, try changing out the insole...

or putting a textured one in there...or maybe putting a some sand or dirt in their shoe...

image credit: https://torange.biz

Textured insoles change (we like to think for the better) proprioceptive input and can improve balance and gait performance, both statically and dynamically. We have seen this in folks with parkinsons (1) as well as stroke (2), though it can be used in the elderly (3), in diabetes and neuropathy (4), as well as healthy individuals (5,6). Changes from postural stability, to changes in anterior/posterior sway, to medial/lateral sway, to step length and height, the research is there.

These results support the hypothesis that enhanced somatosensory feedback to the sensory system, both through the spinocerebellar and dorsal column pathways, as well as the vestibular system, results in an improved motor output (and most likely coordination) of gait.

1. Qiu F, Cole MH, Davids KW, et al. Effects of textured insoles on balance in people with Parkinson's disease. PLoS One. 2013;8(12):e83309. Published 2013 Dec 12. doi:10.1371/journal.pone.00833

2. Ma CC1, Rao N2, Muthukrishnan S3, Aruin AS4. A textured insole improves gait symmetry in individuals with stroke. Disabil Rehabil. 2017 Aug 7:1-5. doi: 10.1080/09638288.2017.1362477. [Epub ahead of print]

3. Annino G1,2,3, Palazzo F2, Alwardat MS4, Manzi V5, Lebone P2, Tancredi V1,2,3, Sinibaldi Salimei P2,6,7, Caronti A2, Panzarino M2,3, Padua E2,3. Effects of long-term stimulation of textured insoles on postural control in health elderly. J Sports Med Phys Fitness. 2018 Apr;58(4):377-384. doi: 10.23736/S0022-4707.16.06705-0. Epub 2016 Sep 15.

4. Paton J, Glasser S, Collings R, Marsden J. Getting the right balance: insole design alters the static balance of people with diabetes and neuropathy. J Foot Ankle Res. 2016;9:40. Published 2016 Oct 5. doi:10.1186/s13047-016-0172-3

5. Steinberg N1, Tirosh O, Adams R, Karin J, Waddington G. Influence of Textured Insoles on Dynamic Postural Balance of Young Dancers. Med Probl Perform Art. 2017 Jun;32(2):63-70. doi: 10.21091/mppa.2017.2012.

6. Collings R1, Paton J2, Chockalingam N3, Gorst T2, Marsden J2. Effects of the site and extent of plantar cutaneous stimulation on dynamic balance and muscle activity while walking. Foot (Edinb). 2015 Sep;25(3):159-63. doi: 10.1016/j.foot.2015.05.003. Epub 2015 May 11.

Toe extension matters.

The season to pathologize our feet is upon us. Toe extension matters.

I blew out my flip flop,
Stepped on a pop top;
Cut my heel, had to cruise on back home.
But there's booze in the blender,
And soon it will render
That frozen concoction that helps me hang on. - Jimmy Buffett

I continue to see more and more people with inadequate toe extension. It is complicated. I see those who do not even have the awareness of toe extension, loss of strength of toe extension, loss of endurance of toe extension, loss of global range of toe extension (dorsiflexion at the MTP joint), more failure of long toe extensor (EHL) strength and more prominence of increased short toe extensor strength (EDB) and more frightening, a lack of disassociation of toe extension (MTP dorsiflexion) and ankle dorsiflexion. Many clients when asked to life their toes, will drive into ankle mortise dorsiflexion; ask them to just purely toe dorsiflex and the mental games begin, a wrinkled brow, intense concentration. If you cannot extended the toes sitting, how are you going to find them in swing phase of gait when balance, and other things, are more important?
Stand and lift your toes. The arch should go up, you have engaged the Windlass Mechanism, that winds up the plantar fascia and raised the arch. If you do not have competent, unconsciously competent, toe extension, your arch is not all that it can, and should, be. If you cannot raise your toes, thus raise the arch, thus plantarflex the first metatarsal, then in gait, when the foot is on the ground, you cannot properly position the sesamoids, properly get safe terminal ranges of hallux dorsiflexion at toe off, properly position the foot for loading and unloading, adequately achieve ankle dorsiflexion, adequately offer the hip a chance for ample hip extension, offer the glutes optimal chance to work in all phases to help control spin of the limb during loading and unloading, and the list goes on and on. I am sure I left much out there, this was written in a few minutes and unedited, just a short rant for the weekend. But if you have not championed toe extension, both in an unloaded and loaded foot (on the ground), achieved control of both long and short extensor muscles to the toes (and paired them well with the long and short toe flexors), disassociated toe extension from ankle dorsiflexion, and then figured out how to properly, timely, engage all these processes into your gait unconsciously, you are working on less of an optimal system than you should be. So, if your feet hurt, hips hurt, or a plethora of other problems that you are trying to fix with orthotics or other toys, maybe start with, "can you lift your toes?". It is a piece of the puzzle, trust me.
Or, you can just stay in your flip flops and perpetuate your toe flexion and wait for bad things to take root After all, tis the season soon !
Yes, toe extension in flip flops (we must flex our toes to keep them on) is as rare as a good multi-tasking man.

Shawn Allen, one of the gait guys.

" "Stand and lift your toes. The arch should go up, you have engaged the Windlass Mechanism, which winds up the plantar fascia and raises the arch. If you do not have competent, unconsciously competent for that matter, toe extension, your arch is not all that it can, and should, be. If you cannot raise your toes, thus raise the arch, thus plantarflex the first metatarsal, then in gait, when the foot is on the ground, you cannot properly position the sesamoids, properly get safe terminal ranges of hallux dorsiflexion at toe off, properly position the foot for loading and unloading, adequately achieve ankle dorsiflexion, adequately offer the hip a chance for ample hip extension, offer the glutes optimal chance to work in all phases to help control spin of the limb during loading and unloading, and the list goes on and on."

More asymmetrical thoughts

Again, in this study, like the last we discussed here, we are looking at experienced (and in this case, young) runners; sprinters specifically. Again, they ran relatively short distances (20 meters). More than 1/2 the runners had “large” asymmetries, and they all had asymmetries of some type. Some athletes had injuries and some did not.

There wasn’t a difference in sprint performance over this short distance. This is not surprising in light of the previous paper we discussed; asymmetries seem to worsen over time (Hanley 2018). The level of compensation present (since these are experienced runners) may also be better; the folks that were uninjured having compensation patterns that were more in line with their anatomy, than the injured ones.

• The asymmetries did not change. Thinking about anatomy, especially with hard deformities like torsions or versions, why would they? You can’t change the stripes on a tiger.

• Injured and non injured athletes did not differ in asymmetry before or after the study. Again, why would they? We are talking about gait changes (or perhaps compensations). What is significant for one individual (tibial torsion, femoral retroversion, leg length discrepacy) may not be as significant as it for another, depending on the compensation present.

The study concludes “... kinematic asymmetries in the stride cycle were not associated with neither maximal sprint running performance nor the prevalence of injury among high-level athletic sprinters.” Note that they are talking about prevalence of injury, not incidence of injury.

We still think that asymmetry matters...

Haugen T, Danielsen J, McGhie D, Sandbakk Ø, Ettema G. Kinematic stride cycle asymmetry is not associated with sprint performance and injury prevalence in athletic sprinters. Scand J Med Sci Sports. 2018 Mar;28(3):1001-1008. doi: 10.1111/sms.12953. Epub 2017 Aug 15.

Thought experiment on symmetry: Does symmetry always matter?

the short answer is probably not. the long answer is maybe...

This study looked at gait variability asymmetry in small cohort of experienced distance runnners. They measured different variables at 1500, 3000, 5000, 7500 and 9500 m of a 10000 meter run (about 6.2 miles) on a treadmill. Generally speaking, variability was low and athletes were symmetrical for 5 of seven variables measured and assymetry, when present, was in flight time and impact forces Most aththletes were asymetrical for at least one variable as well.

Their conclusion basically said that being asymmetrical in a few variables is not abnormal and not indicative of asymmetrical gait and since many practitioners analyze symmetry (and variability) caution should be exercised when determining the need for intervention.

So what do we think this means?

most likely:

• these folks were symmetrical with low variability. In other words, when asymmetry was present, it was small

• some asymmetry, in some parameters, is probably normal...but,it is usually small if it doesn’t matter. Keep in mind these were expreienced, uninjured folks. th results could have been different with a bigger cohort and less experienced runners and thus...

• The study does not talk about inexperienced runners. Symmetry and/or asymmetry may not be normal for inexperienced runners

• Results may have been vastly different if the run had been longer. The study did show that variability increased the further along on the run the athlete was.

• The study was performed on a treadmill, which may not exemplify or highlight asymmetry, as it creates artificial constraints which we have discussed in by us here, here, and here:

• We think asymmetry matters, particularly when it comes to hard deformities like torsions and versions, which change the biomechanics of that individual extremity and can be a diagnostic tool for future problems

• perhaps asymmetry is significant in his population of runners on a subclinical basis

Hanley B, Tucker CB. Gait variability and symmetry remain consistent during high-intensity 10,000 m treadmill running. J Biomech. 2018 Oct 5;79:129-134. doi: 10.1016/j.jbiomech.2018.08.008. Epub 2018 Aug 16.