This is rotation of the entire leg:
But the femurs do not comprise the entire leg. They’re only the thigh. If someone is standing like so,
A common mistake is thinking because the feet are turned out => the leg is externally rotated. But the feet are not the femurs! Just because the foot is turned out does not mean the knee is also turned out.
Looking more closely at this person’s left leg, the knee is pointing straight, while the foot is turned out,
The femur, relative to the lower leg, is internally rotated.
While on the right side,
The knee and foot are more lined up. The femur isn’t internally rotated relative to the lower leg. The right leg is externally rotated.
Wrong!
Let’s look at things from the back.
The hamstring insertions provide a guideline for femoral rotation.
Things should look pretty darn symmetrical.
Notice how much more of the medial thigh is showing compared to the lateral,
While even in neutral alignment you’ll always see more of the medial thigh, you should still be able to see a decent chunk of the lateral, or the insertion should at least be pronounced.
From the front, we originally said,
- Left femur is neutral but lower leg is turned out => Femur is internally rotated relative to lower leg
- Right femur and leg are externally rotated
The left leg matches up with what we said earlier- it’s in neutral. You may have even thought the left femur, from the front, was internally rotated.
But we can see there is a decent chunk of the lateral thigh showing.
Meanwhile the right, the leg we said was externally rotated, looks internally rotated! The lateral hamstrings are nearly out of the picture. It’s not a ton, sometimes the lateral insertion is out of the picture, but it’s certainly not externally rotated. The lateral chunk of thigh would be very prominent in that case.
In fact, when we take into account the right femur is internally rotated, but the foot is turned out,
then we can say the femur is even more internally rotated, relative to the lower leg. Same thing with the left. Even though the left femur is in neutral alignment, the lower leg is turned out. Therefore, the left femur is, relative to the lower leg, also internally rotated.
What happened?
The patella has some mobility to it. It can glide up and down, and side to side.
We need to be careful assessing femoral internal rotation from the front, because we’re relying on the patella as a landmark, but that landmark can move. It’s rare to see a patella excessively gliding medially, but it’s common to see it excessively glide laterally. (Something a stiff IT band can be responsible for.)
The hamstring insertions aren’t mobile like the patellae though. If they aren’t fairly symmetrical from the back view, then a bone, the femur, must have moved them.
- You never want to only use the anterior view of someone -only the patellae landmarks- to let you know if their femurs are internally rotated while standing. We can use the front view, but it’s part of the picture.
- You never want to only use the feet to tell you what’s going on at the femurs. We need to also use the femurs!
Summarizing this person,
- Left femur is in neutral, but lower leg is turned out = Femur internally rotated relative to lower leg.
- Or, lower leg externally rotated relative to femur.
- Right femur is internally rotated and lower leg is externally rotated.
- Right femur looks laterally rotated from front though = likely lateral glide of patella going on at that side (and probably a stiff IT band).
This is important because one might look at this person and say, “Their right leg is externally rotated due to where their foot is,” and subsequently start doing a bunch of internal rotation work, on a femur already in some internal rotation!
You might also see the left leg and go, “Their femur is internally rotated,” and do a bunch of external rotation work. But if you ignore the lower leg, the thing that’s really out of neutral, you might not get anywhere. The femur is in neutral but the lower leg is not. Should you be focusing on femoral external rotation, or tibial internal rotation? (We’ll assume no tibial torsion is going on for this!)
As is always important to mention with posture assessment though, this is merely a starting point for assessing movement. Posture is a window into movement, but you can only see so far through a window without walking through the door. We likely wouldn’t want to take much more from this assessment than whenever this person moves, having a little extra attention to when / if their knees turn in and or their feet turn out.
Sammy guzman
December 4, 2015
So what do you do about it? I’m assuming the lateral muscles would be weak and the medial hamstring/adductors would be way too tight.
reddyb
December 7, 2015
If you mean how do you not have the femurs internally rotated, then you don’t let them be rotated :).
When standing you’d externally rotate the femurs some, but keep the feet straight. When doing anything else, you would do the same thing.
In this case, because we’re talking about changing something while standing, it doesn’t typically require much strength. This is more about changing a habit than it is getting something stronger or loosening something up.
Connie
January 7, 2016
I have been working on changing my gait to one that is posteriorly-pushed off as I am slowly developing more lateral hip strength (I think in the past I used my quads to pull my opposite leg forward). Lately, though I have developed medial knee pain and I suspect I have internally rotated femurs. I have been trying to follow much of Katy Bowman’s work (she calls it Restorative Exercise), which seems to mesh well with your work. She has posture points about stance regarding keeping your feet straight ahead, your hips back, your ribs down, and keep your knee pits neutral (those two lines of your hamstrings facing parallel as they point back). When I try to externally rotate my thighs to the point where my knee pits FINALLY point straight back, trying to activate my lateral hips, if I maintain that position and bend my knees, my knees are definitely pointing outwards at appromimately 45 degrees (when I look down and my feet are at 12 o clock pointing straight ahead, my right knee points to 2 o clock and my left knee to 10 o clock).
Is this right? Or are your knees supposed to point straight ahead when you bend them as you are externally rotating your femurs using your lateral hips??
Also, what does it mean if when I look at my left knee pits, that there is no lateral line? Are my hamstrings just too weak/underdeveloped? It makes it impossible for me to assess what is neutral.
I started all this because of extremely tight calves and tibialis posterior/peroneal problems.
reddyb
January 10, 2016
Hey Connie,
If you externally rotate the femurs so they are in neutral, then when bending the knees the femurs, if they don’t move, would stay in neutral.
It’s always hard to say how *you* are supposed to move. Not everyone’s structure is the same. The hips and knees will do many different things when bending for many different reasons. Example here: http://b-reddy.org/2013/05/09/talking-about-hip-retroversion/
When it comes to assessing the hamstrings, it’s possible a lack of development is there. But really, trying to self-assess this is incredibly hard. Especially if you’re trying to do this with a mirror. It’s too easy to fool oneself in this scenario.
Here are some links on posture assessment which may be helpful. You can also see how I help people with this remotely, if interested:
http://b-reddy.org/2013/02/06/example-of-a-postural-assessment-2/
http://b-reddy.org/2013/02/20/another-example-of-a-postural-evaluation/
Crop
February 22, 2016
I get that hamstring insertions indicate rotation of femur, because patella can be glided and is mobile.
And feet indicate rotation of tibia, right? But the thing is, feet are even more mobile than patella, so how can we assess tibial rotation by looking at how feet are rotated?
And also, are hamstring insertions always same on both sides? I mean if we are born with same “package” on both sides.
Thanks
reddyb
February 23, 2016
Hey Crop,
I believe you’re asking how to assess tibial torsion. The feet are often a good indication e.g. if the knee is straight and level (can be tough to know clinically), if the tibial tuberosity is straight, but the feet are turned out (or in), the tibial torsion radar gets turned up.
But the feet can certainly play tricks here too. For instance, if the arches are collapsed the feet tend to turn out. Another thing is an abducted foot. So you could get a false positive. Being in a supine or seated position can help here, but it’s easy to miss these things.
Some like to use the malleoli as an axis reference in comparison to the condyles’ axis (plenty of videos out there on this). This has merit too.
Personally, I don’t bother with getting goniometers out and getting that worried about it. If the knee is straight, the tibia is straight, but the feet are turned out yet look fairly normal, that’s enough for me to say something structural is likely going on from mid shin down. Something we likely don’t want to be forcing into a different position.
I’m unaware of differences between hamstring insertions, though it wouldn’t surprise me if there were. I go over differences in patellar tendon insertions here: http://b-reddy.org/2016/02/14/the-genesis-of-patellar-tracking-and-instability-issues-and-what-to-do-about-them/
It’s not only whether we’re born similarly on both sides, but activities can change structure, particularly those started early in life. For example, baseball players tend to acquire a retroverted throwing arm during development. I wouldn’t be surprised if tendon insertions get changed based on activity growing up as well.
Good questions.
Andrea
May 12, 2016
For people who has internal rotation femurs.. what kind of shoes should we use? Is there something to do with over pronators? Thank yoU!
reddyb
May 13, 2016
I like to start by correcting the hips / knees first. While an over pronated foot can cause the knee to turn in, it tends to be more a result of what’s going on at the hips.
For over pronated feet, I try to correct the movement pattern first before going to orthotics or special shoes.
If the shoes are worn out, that can cause issues though. I discuss this in the footwear manual: https://b-reddy.org/2014/10/30/a-guide-to-footwear-table-of-contents/
Riley
May 29, 2019
Been trying to figure out what is going on with my hips, pelvis and legs. So far, 3 PT and 2 chiros cant really figure it out.
I seem side bent to my right with some sort of pelvic rotation (belly button and chest look more to my right vs looking straight head), neck side bent to left – right shoulder low.
Right sided hip, butt, groin, pubic bone, medial knee, medial ankle, neck, shoulder, low back/si pain. Inner thigh muscles seem tight.
Left side is relatively pain free UNLESS I try to straighten my posture and face forward, or rotate left femur out. Doing that causes left shoulder pain, left hip pain (maybe TFL? Its more front side of hip compared to right)
Very tight QL, side abdominal muscles on right.
Cant easily cross right leg over left to push down on outer leg (i think that is similar to FABER) – limited. Opposite is the case on left. When doing the opposte motion, its easy on right and hard on left.
Painful on outer hip to lay on right side.
Left femur appears to rotate inward along with knee with foot straight ahead or left foot toes outward in order for knee to face straight ahead.
I tend to walk this way all the time. Its most obvious if my knee is not bent at all – at the end of extension you can see what appears to be the femur rotating in with foot pointing more straight ahead. I can rotate the femur out, but then my medial part of left knee starts hurting and my left foot wants to walk on its outer edge and/or turm way out. Up until 2 months ago, I could barely walk at all for almost a year. Had to keep my right ankle wrapped at all times. The ankle, groin, knee pain was unbearable – ended up walking when I could without much hip extension. PT and chiro has gotten me to where I can walk. Though its still painful, but not as bad.
Any ideas? suggestions? Spending a ton of $ each week on medical providers and not sure Im heading down the right path. When I asked all why my left femur does what appears to be rotating inward, I got mostly puzzled looks with a general “I think we just have to get you stronger” yet I was told I was weak on my right side 8 weeks ago and then told my side to side seemed roughly equal but my brain forgot how to move my right side correctly (ie couldnt do sit to stands at all on my right side – would fall backwards, BUT after 3 PT visits I could do them equally on both sides).
b-reddy
May 31, 2019
Hey Riley,
This is pretty in-depth for the comment section. Really fits in more with an assessment- https://b-reddy.org/the-remote-client-process/
As a general starting point though, whenever that kind of confusion around the hips is going on, something structural should be at the forefront of the mind. May want to read this: https://b-reddy.org/talking-about-hip-retroversion/