I’ve found any discussion regarding structural abnormalities of the hip to be really confusing. I’m going to try to simplify this and, hopefully, not lose any technical aspects in the process.
Common structural hip issues
When talking about structural issues at the hip the first area causing confusion (at least for me) is the lack of discernment between acetabular abnormality and femoral abnormality.
The structural abnormalities I’m going to cover are the “versions.” AnteVERSION and retroVERSION.
Ante = forward.
Retro = backward.
Either the acetabulum or femur is in a ”version;” either the acetabulum or femur is rotated forward or backwards.
The acetabulum is rotated backwards (left) or forwards (right):
Now an example of the femur:
In a retroverted femur, the femoral head gets pushed backwards:
Retroverted femur on left, normal femur on right:
When the head is retroverted, you can see how the available internal range of motion is lessened (red line on left versus right):
While the lateral range of motion is increased (green line on left versus right):
What’s important to realize is regardless which bone is “verted,” the consequence appears to be the same.
In terms of rotation:
Anteversion: The hip joint has a greater than normal ability to internally rotate and lesser than normal ability to laterally rotate.
Retroversion: The hip joint has a greater than normal ability to laterally rotate and lesser than normal ability to internally rotate.
In terms of side to side movement:
Anteversion: The hip joint has a propensity to adduct.
Retroversion: The hip joint has a propensity to abduct.
Anteversion: The hip joint turns inward more easily than normal.
Retroversion: The hip joint turns outward more easily than normal.
Hopefully that makes sense.
Anteversion has been talked about quite a bit; I want to focus on retroversion.
Assessing clinically (without x-ray / MRI / imaging)
A good portion of my clientele has a history of a chronic, yet not completely debilitating issue. They want to work on this issue and workout at the same time. Because of this, I don’t assess structural issues at the hip immediately with every single person I get. Often, I’ll make my way there. (It always depends though.)
Here’s roughly how I may go down that path. In essence, these are movement signs which could lead you to directly test someone for a structural hip issue:
A quick way to get an indicator of hip retroversion is to look at the person in stance. If they naturally stand with their feet and knees both facing straight ahead, or their knees facing inward, they probably don’t have retroverted hips. (Not a guarantee.)
However, if they stand with their knee(s) and feet both pointing out, and maybe even spread apart (abducted), we may be on to something.
It’s important to mention again, knees AND feet. Discerning a “toed” out posture is not enough. The toes may be pointed out while the knees face straight ahead, meaning the feet are turned out relative to the femur. It’s the femur we’re more concerned with as it connects to the hip, while the foot / shin does not.
I want to reiterate, a person can have an internally rotated femur in stance and a retroverted hip. Standing posture is an indication, that’s all.
Hip flexion with significant external rotation / abduction
Look at the differences between sides here:
Right leg (left in picture):
Versus left leg:
See the greater external rotation and abduction when the left hip flexes?
If a person has a propensity to externally rotate / abduct (turn their knee out) during hip flexion, we may have another sign. Because a retroverted hip is structurally positioned into external rotation, a person with this abnormality is going to have a copious amount of hip external rotation, a limited amount of hip internal rotation, and this contrast will be readily apparent during hip flexion.
Prone hip rotation
This is really the money test.
Have the person lay on their stomach, bend one knee, then rotate the leg side to side (making sure the lower back does not move).
We’re looking for a big difference between lateral rotation and medial rotation. Specifically, limited ability to rotate the leg out (medial / internal rotation), but excessive ability to rotate the leg in (external / lateral rotation).
Tangent, what’s normal hip motion?
For the purposes of this post we’re going to use these norms:
Hip internal rotation ROM: ~45 degrees
Hip external rotation ROM: ~45 degrees
In the context of this post, a significant contrast between directions, say 15 degrees or more, is what we’re looking at here. E.g. a hip which can laterally rotate 60 degrees but only medially rotate 10 degrees should cause one’s ears to perk up.
Back to the prone hip rotations
Example of retroversion:
See the differences?
Let’s look closely at the left leg in particular. Medial rotation:
That is a big, big difference.
Teal is the midline, red is the rotation:
The reason prone hip rotation is the best (clinical) indicator of retroversion is when in prone, the hips are not really limited into medial rotation by muscular forces. No muscle is fully being stretched when the hip internally rotates. As mentioned, a retroverted hip is structurally limited into medial rotation. So, the prone hip internal rotation assesses the ability of the hip to medially rotate, structurally. Therefore, it’s a good test for retroversion.
In contrast, when the hip externally rotates something like the TFL can really limit motion.
In prone, if the hip is limited into external rotation you can’t deduce it’s because of a structural issue at the hip; it’s probably muscular, like a stiff TFL.
Which brings us to this: If, in prone, the hip is limited into medial rotation (e.g. less than 25 degrees) and lateral rotation, you have to also put the person in a seated position, and test again. Because now you don’t have the asymmetry in rotation, rather, you have limited rotation both directions. And we don’t know what’s limiting the lateral rotation. Is it muscular, or structural? By putting the person in a seated position we take out the TFL factor, as it’s no longer fully on stretch when the hip is significantly flexed.
Teal is our midline again:
If the person suddenly has a bunch of lateral rotation, they probably have a retroverted hip and a stiff TFL. If they’re still limited into lateral rotation then you have an overall hypomobile hip.
(In the video and pictures above you can see Chris is pretty much the same in prone and in seated.)
Now, this isn’t perfect. The opinions on this vary. Some think while in prone the lateral rotators are taut enough to play a role, some think capsular issues are at play, all in conjunction with possible bone changes (e,g. retroversion). Without an X-Ray, it seems like you can’t be quite positive. However, if you see somebody with a drastic asymmetry in rotation, and it doesn’t improve pretty quickly, I have no qualms saying the hip is structurally atypical, and research supports this.
Quick note on Craig’s test
I pretty much never bother with Craig’s test. Mainly because the average person I have is overweight. Try palpating a greater trochanter when there is a bunch of fat around it.
The most important takeaway from this condition is it’s structural. The issue is bone. Bone doesn’t manipulate like muscle or soft tissue. We can’t fight a structural issue, we have to give into it.
The main thing we give into is the fact the leg has a proclivity for external rotation and abduction. It wants to turn out.
Let’s say a person has a right retroverted hip. Some examples:
Instead of this,
We can give in to this,
Instead of this,
We accept this,
Avoid medial rotation / adduction positions
Such as sleeping:
Training / exercise considerations
In a squat, or sit to stand motion, you’d allow the person to open their foot and knee, opposed to keeping it straight:
Right foot turned out a bit,
In something like a lunge, you’d do the same thing. Remember, the person does not, structurally, have the ability to fully flex their hip with their knee straight in front of the hip. The leg needs to be laterally rotated and abducted. (How much depends on the degree of retroversion.)
We want to avoid instances where the hips medially rotate, and, again, we do not want to forcefully try to improve medial rotation. Avoid a stretch such as:
I will allow people to perform medial rotation in the prone position as it’s low intensity, and the person can get a good gauge for when they go too far (avoid any pinching). After a certain point though, you and the client need to accept the person has all the internal range of motion they’re going to have.
A common example where this medial rotation would pose a problem for retroverted hips is a golf swing. Watch a slow swing in action. Still shots to follow.
Notice the internal rotation of the femurs at various points during the swing:
For someone like Chris who lacks internal rotation of the femurs (Chris is the same guy in the examples above), his golf swing is not friendly to his hip structure. He even has a tendency to internally rotate the right femur just in his set-up:
One way to try and get around this is to have the person open their feet and knees more. This will give the person extra room to internally rotate the femur.
We saw Chris’ lack of internal rotation earlier. In his set-up is already approaching what is probably his maximum amount (distance between teal and red):
However, if the leg is opened up a bit, we give some more room for internal rotation.
Say the green is our new starting point for the knee and foot. Instead of internally rotated, the femur starts off externally rotated:
Now Chris has some more room to internally rotate his hip before he reaches his maximum amount:
This isn’t great though. You’re still putting a hip which hates medial rotation into an activity requiring a violent degree of it.
What population is this most common in?
Hip retroversion is more common in men than women, and active people (or those with a history of being active). Specifically, it appears quite common in athletes where a good deal of cutting / planting is required. Think soccer or football.
If memory serves me right, this is fairly common in the plant leg of baseball pitchers as well.
This makes sense considering all these activities require a great deal of external rotation and abduction of the femur. Think about the defensive position a basketball player is constantly in:
Two good resources for continued learning
This is a good discussion: Retroversion of the acetabulum.