[This post is directed toward those readers in the exercise and physical therapy and orthopedic communities. Lay readers are welcome to partake.]
[Herein, I use rotation to refer only to hip internal and/or external rotation. Note that hip extension and flexion and ADduction and ABduction are also rotations.]
A friend—who I deeply respect—recently asserted the following:
“Only dancers, particularly ballet, need [their] hips to [internally and externally] rotate. Regular people, especially ones with hip issues, never need [internal and external] rotation.”
Momentarily, I ignored this statement as I was very focused on other issues about hip rehabilitation. Last night, I began to ruminate on it. It caused me to lose sleep. It forced me to consider some new notions. This is always a good sign that my mind has seized a proverbial bone not to be relinquished.
For the past couple of weeks, I have been talking with Sean McNicholas and Drew Baye about performing hip internal and external rotation exercise as I explain in my book, Hip. Therein, I show how to strap the subject into a Leg Extension machine to accomplish this with the application of Timed Static Contraction (TSC) exercise. Before the advent of my book, this approach has not been applied either preventively or rehabilitatively.
As a result of our talks, Drew has expertly replicated some of the pictures from Hip on his Facebook page. In addition, we plan a YouTube video this week to show how to employ these techniques. The video will not suffice for the detail made in Hip, but there are other related details that a video is best for demonstrating. One of these is how best for the patient to enter and exit the Leg Extension machine.
It then occurred to me that—unless the subject sits side saddle in a MedX® Leg Extension machine and then spins on his buttocks to slide his lower legs behind the movement arm—the subject will often first place his legs in front of the movement arm and then swing them around behind the movement arm. This swinging is performed with both internal and external rotation. Yikes! I must demonstrate how to avoid this for early-stage rehab.
Also note that other equipment—Hammer Strength® for example—requires internal hip rotation to insert the lower legs into the movement arm.
And when I mention early-stage, I am NOT referring to the “early-stage” used routinely by the physical therapists. They routinely mean 5-6 weeks post operatively to begin rehab. TSC allows this to be shortened to about two weeks. Again, the detailed considerations for this advantage are found in Hip.
[Earlier rehab is a hedge against nerve and muscle death or atrophy.]
Granted, “regular people,” compared to dancers, do not often need AS MUCH in the degree (range of motion—ROM) of hip rotation, but hip rotation is an important aspect of normal locomotion.
I assert that there is no other way to safely work these delicate rotators than what I have described in Hip. For example, try this as ONLY a thought experiment:
Sit the subject in a recliner with one leg straight (knee extended) as you hold his corresponding foot. With the foot in standard anatomical position, rotate the entire foot outward to produce external hip rotation and rotate the foot inward to produce internal hip rotation.
This is dangerous for several reasons:
This is dynamic. Only the statics of TSC offer the required control
The force and motion are produced across many joints. The foot, alone, is highly flexible, and rotations will occur at the ankle and at the tibial plateau (knee) before the force is transmitted proximally to the hip
We have no way of safely delimiting ROM
Additional Observations:
Internal and external hip rotation is involved in leisurely crossing one’s legs (not as much in crossing one’s ankles).
It is common for stroke patients to drag their affected leg as its hip is externally rotated. Part of the solution is to strengthen the hip’s internal rotators.
Brenda’s hip fracture (actually the neck of the femur, not the hip joint) was achieved when she turned in the kitchen as her foot caught on the grout. Her femoral head was literally twisted off the top of its femur. At the time, she was very strong. Might specific strengthening for these rotators have led to a more robust femoral neck?
Note that my illustrious friend followed the quote above with:
“Hip ABduction and ADduction TSC is very adequate. I think…?”
The assertion is indeed questionable as my friend is not on proverbial terra firma. Nor have I been for many years regarding the need for these extremely isolatory exercises.
Note that—as told in Hip—I did not devise the hip internal and external TSC exercises until ten years AFTER Brenda’s focused hip replacement rehabilitation. And although I had a virtual explosion of useful ideas for her program, these exercises were not included. I, too, believed that TSC hip ADduction and hip ABduction (along with hip extension and flexion) to be adequate.
For Brenda, the POSSIBILITY of these exercises was not even on my proverbial radar… not a consideration. And if they had been within my repertoire, would I have employed them with my then bias that ADduction and ABduction were adequate? [I also employed TSC hip extension and flexion to great benefit for her.]
Perhaps the ADduction, Abduction, and Extension are/were adequate. Perhaps the rotations would have been too painful or threatening to perform, at least for the earliest weeks. And if nothing else, the rotations would have provided me with more tools in the rehab toolbox.
These exercises offer a new vista for hip rehab and prevention… and these do not only apply to hip replacement. They are largely unknown to the orthopedic and physical therapy communities. They deserve consideration and will require time to assess.
The first instructor to employ all of the TSC hip exercises—including the internal and external rotation exercises—was Josh Trentine. He was encountering a very challenging hip rehab case just as I was completing Hip.
[If I remember correctly, I was explaining the techniques to Josh over the phone as I was in final edit of Hip and as he was waiting for the patient to momentarily arrive in his facility. Perhaps he will share his story. I understand that the program for this patient was highly successful. I believe (needs Josh’s confirmation) that the patient had a rotation deficit before her first session and had gained it almost entirely back after once performing these static exercises that involved no movement, i.e., NO STRETCHING ! ]
And while it is true that the muscular functions of the intrinsic musculatures of the hip are involved in ADduction, ABduction, and/or hip extension—as I have maintained for decades, is there an innervation component that deserves the specific attention by way of these new exercises? I’m starting to suspect there is, especially in the context of subjects with greatly marginalized hips.
My friend’s first assertion, while being blatantly incorrect, is not an indication that the second statement—TSC ADduction and ABduction is adequate—is also incorrect. TSC ADduction and ABduction, along with TSC hip extension and flexion may truly cover all the proverbial bases and there remain serious impediments to performing additional exercises: The patient’s tolerance to pain and mind share to focus and remain guarded. Volume must be delimited.
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