What's The Deal With Hip Internal & External Rotation?

As I near my 2 year mark in clinical practice, you start to realize trends. Sometimes these trends solidify what we already know, align greatly with what we are already practicing, and allow us to continue down the beaten path.  However, there are things we begin to see as key indicators on how an injury occurred, things that are so simple, they often get overlooked in a treatment plan.  Today I want to briefly discuss an item that falls under both of these categories.  

Hip range of motion (ROM) is often taken for granted, until that time comes where one side is severely restricted and we are unable get up off the floor without the use of our hand, or the assistance from another.   As I have progressed clinically, hip ROM started as just something to jot down in a patients notes, but has quickly become one of the first areas I look to and address for nearly all of the low back pain** and lower extremity complaint (acute and overuse) patients that come into our clinic.  

The problem we see is that the restriction is never symmetrical, causing compensatory patterns that quickly lead to injuries and confused patients. While getting you out of pain is our job, our goal is education and prevention.  Below are some great stretches and mobility movements that are not only easy to perform, but effective is restoring symmetrical movement.  Enjoy.  

Learn, Practice, Perform!  

Level 1 Hip Internal & External Rotation

Internal Rotation Hang

Setup: Lie flat on back with knees bent and feet about 6 inches wider than shoulder/hip width.

Step 1: Allow knees to ‘hang’ inward, letting gravity to do the work.  We want to sit here for 1-2 minutes.  

Step 2: If you get bored, slowly and gently, swing the legs/pelvis back and forth to induce some extra motion into internal rotation.   

External Rotation/Mobilization Stretch

Setup: Lie flat on back with the leg being treated in a flexed hip position and the non-treated leg lying flat on the floor.  

Step 1:  Pull the foot of the flexed hip leg toward the mid-line and up toward the torso, you should begin to feel this over the posterior hip in the external rotators and glutes.  

Step 2: Pull the knee toward the OPPOSITE shoulder and hold for a 3-5 count, release and repeat 10 times on each side.  

 

Level 2 Hip Internal and External Rotation

Internal Rotation with band assistance.

Setup:  Our setup is the same as the ER exercise in level one.  This time with a band wrapped around the mid-foot and tracing the outside of the leg.  

Step 1:  The band provides a mechanical advantage and when pulled over the knee and across the body, provides assisted over-pressure into hip internal rotation.  

External Rotation: Pigeon Pose

Setup:  In a modified lunge position, externally rotate the treated leg and and sit back with the non-treated leg extended behind you.  

Step 1:  Begin with the foot of the treated leg near mid-line (easier) and begin to bring your torso closer to the ground while maintaining a straight spine.  

Step 2:  As this movement becomes easier, our goal is to get the treated lower leg perpendicular to your torso and away from the pelvis. Again, push the torso down toward the ground with a straight spine.  

 

Level 3 Internal/External Rotation - 90/90 Get-up to 1/2 kneeling  

Setup:  Sitting up tall with a straight spine, the forward leg positioned in external hip rotation and the leg 'coming through' in internal hip rotation. The lead leg foot should be close to midline and near the other leg making this a closed position.  

Step 1:  Push into the ground with the outer knee of the forward leg and bring the rear leg around to the front, landing in a lunge/half kneeling position.

Step 2:  In a slow and controlled manner, return to the starting position...enjoying the eccentric phase.  

** A 2015 study out of the Shahid Beheshti University of Medical Sciences found that Asymmetrical and limited hip internal rotation ROM were a common finding in patients with LBP.  Another study from The Sahmyook University Department of Physical Therapy found that hip mobilization brings positive effects on pain, function and psychological factors for patients with chronic low back pain, causing them to strongly recommend hip mobilization as an effective treatment method in treating chronic low back pain. 

Break Up the Endurance Training With Some Strength!

Endurance athletes, especially runners, tend to shy away from strength training due to what I would consider a misunderstanding of what it can provide. After working with hundreds, probably thousands by now, of runners and triathletes over the last few years, I find very few have a regular strength plan. Some are afraid of getting hurt, some do not know how to effectively strength train, and some still have the ridiculous notion that if they lift weights they will get so bulky, the can no longer run!

Let’s address these, shall we?

STRENGTH TRAINING SAFETY

As with every sport, there is a calculated risk of injury when strength training.  What will surprise some is that it is often much lower than the risk associated with training for an endurance sport.  This can depend on whether you are single sport athlete (running only!) or have taken to the range that triathlon offers.  

More can be read about sports specialization HERE from Dr. Greg Schiable. While this article is focused on sports specialization in children, the same can be shown for adult athletes who only participate, practice, and focus on one sport….an explanation why overuse injury rates are lower in triathletes compared to strict runners.  

This morning, I read a great post from Chris Beardsley (CLICK FOR FULL ARTICLE)  discussing the relative safety of strength training, especially when compared to endurance sports.  This article launched me into, again, thinking about strength training for endurance athletes, and puts another feather in the cap of it being a great cross option to break up the often monotonous droning on that running provides.

We can show that single sport athletes are more prone to overuse injuries and burnout, as well as demonstrate the benefits strength training gives to endurance, injury prevention and movement efficiency.

An interesting point made...Beardsley writes,

In comparison to the overall rate of injury in strength sports of between 0.24 – 5.5 injuries per 1,000 hours of training, the rate of injury during long-distance running is around 2.5 – 12.1 injuries per 1,000 hours and the rate during triathlon is around 1.4 – 5.4 injuries per 1,000 hours training.

He goes on to state that many studies put running injuries on the higher side of the stated rate.  

 

GETTING SWOLE

Let’s talk about getting bulky, to the point where you start to lose speed and endurance because you are just too massive to run efficiently.  It used to be that this conversation was primarily had with female athletes, but more and more we find male runners of the same belief.  In short, this is non-sense! Why is that you ask?

GENETICS: 

As a younger male, I spend countless hours, day after day, month after month, for a number of years, trying to pack on muscle and reach the elusive 200 lb mark.  It was a stage in my life….enjoyable and very educational… I have since returned to my love of endurance training, but strength training remains a big part of what keeps me fit, injury free, and happy.  

ENERGY & FOCUS:

I never made it to that 200 lbs mark.  Mainly because I could not eat, sleep, and breath lifting weights and energy intake.  To go from a slim and trim 155 to 200 is a feat which requires a lifestyle shift and not much time for anything else.  As runners, we simply can not consume enough, or slow down enough to really pack on muscle.  To make that shift, one would have to take all the time invested in putting in the miles...almost completely stop...and replace it with lifting weights...Not going to happen!  Stop worrying about getting bulky and think of what a 10-20% increase in strength could do for you during those last miles of a long run or how you can conserve energy by moving more efficiently.

 

BUT GYMS ARE SCARY

Many endurance athletes just don’t know what to do when they end up in a gym.  Fortunately, popular running sites and magazines have jumped aboard the strength train (locomotive type), and there are countless exercises and routines available if one simply does a Google search.  

My personal advice is to first master your body weight, which allows you to more comfortably perform exercise at home or on a track after a run.  Begin with push-ups, pull-ups, squats, lunge variations and jumps.  Once you reach a point where sets of 10, 20 or even 50 feel ‘easy’, it may be time to add in some weighted movements like kettlebell swings (my #2), deadlifts (my #1), and overhead press and pull variations.  

 

If you feel like you have been in a rut this summer or have had more than your share of injuries lately, maybe it is time to try something new?  Change up the routine a little...it is likely that you will enjoy the change and be surprised by the outcome.  

What Do My Hands Do When Running?

Every runner has been through this, and most of us have tried more styles than Tiger Woods has swings, but seriously…what the heck do I do with my hands when I am running?

Lets get something straight from the start, when we are on our long run or are racing, wasted energy is just pure evil. With that, being relaxed up top while running is the name of the game. There should be no clinched fists, shoulders floating up around your ears, violent rotation from side to side or veins popping out of your face and neck like you are trying to pass a block of cheese. Everything above your waist should be relaxed and fluid…like a breeze blowing through a meadow (I don’t know…it sounds relaxing, just go with it).

If you find you are always having side stitches, cramps in you upper back, headaches, numbness in your hands and fingers or are just uncomfortable when you run, here are a few easy tips for your next run. Try them out, you really have nothing to lose.

Step 1: Shoulders down and back, head up with ears over shoulders looking ahead. Until you get this, your arm swing is lost and so is a ton of energy.

Step 2: Keep your elbows bent somewhere between 45–90 degrees. As you run, work on lightly driving your elbows back, letting gravity bring them back forward.

Step 3: Keep those hands loose. Pretend you are holding something delicate in your hands (a flower, really small animal, whatever) and the last thing you want to do is squeeze it too tight.

Step 4: About every 100–200 steps, shake your arms and hands out. Allow your shoulders to relax if they went back up to visit your ears, pick your eyes up from the ground, reset and push forward.

Finding what works for you, as I have outlined what works for me, can allow you to run more comfortable….allowing you to run further and faster!


Dr. Reheisse is a Board Certified Chiropractic Sports Physician practicing in Cottonwood Heights Utah. Revive Sport & Spine provides evidence-supported chiropractic care and conservative sports injury management.

A Quick Take on Running Form

As our last article, stretching, went well, lets keep on the controversial topics and take a brief look at another that gets runners all up in a huff, because my technique/form is better than yours! SPOILER — it IS the best…for you!

When you talk about running form, there are many different camps: Newton Running, Chi, Good Form, Pose, etc., all preaching less injury, better efficiency and faster times. Who is right? What do we know about form anyway? Is the barefoot movement the right way to go or is maximal best?

Well….Yes.

Yes? What do you mean? What I mean is that yes, with all those things you could experience less injury, better efficiency, and faster running, but why?

If you choose any one of the above listed running camps and stick to the plan, have patience and work through the changes, you would come out a better runner most of the time. I am not saying you are not going to hit some injury set backs, but all of these plans focus on two things: (1) Drills that make you stronger and develop better neuromuscular control (2) Running, and lots of it! Both of those things will make you a better runner. All come with their pros and cons, but here is what we know (below) as well as an interesting look at the foot strike of the fastest distance runners on the planet.

Forefoot/Mid-foot Strike vs. Heel Strike Runners

Here are the simple facts to this debate. While one might find comfort, balance and efficiency with one and another person the other…it basically comes down to what works for you. If you spend months (and it takes MONTHS to make any kind of change to your form) and are met with pain and discomfort while running, is that drop of 5 seconds per mile worth it? I would personally rather enjoy my run! Now,                                                                                       the injuries associated with each as NEITHER                                                                                   are injury free.

FOREFOOT RUNNERS

  • Decreased ground reactive forces = less ankle/knee/hip joint pain.
  • Increased risk of foot stress fractures as the metatarsals experience more force. Beware of march fractures or even a neuroma as your feet adjust.
  • Increased tension taken on by the Achilles = Higher risk of Achilles tendon injuries or soleus/gastroc strain. Though that Achilles is designed to absorb that shock and provide some recoil, if you have never run this way, it must be slowly introduced to the drastic change in work load. (BEMS, 2013).

HEEL STRIKERS

  • The American College of Sports Medicine showed that Heel Strikers experience more ankle/knee/hip related injuries as well as a higher rate of stress fractures of the tibia and femur.
  • With the advent of shoes, especially the newly formed maximal movement, increased padding can decrease forces in heel strikers allowing a more comfortable run.

Both forms of running injuries can be prevented with adequate strength and mobility as well as allowing your body to rest, recover, and adapt to the stress that running provides. I have personally worked through a few running form programs and have not adopted one style, but parts from each through drills and exercises that ALLOW ME TO RUN MORE COMFORTABLE. That is what is most important because if you do not enjoy your run, it will feel like work….and who likes being at work? Below are some basic tips to help you run more comfortable. If that equals better efficiency and faster times, well good for you, I’m about enjoying my run and taking in the vast adventures around us. Happy Running!

Easy Tips to Run More Comfortably

  • Cadence: Higher cadence (steps per minute) has been shown to decrease ground reactive forces, shoot for 170–180 per minute.
  • Posture: Neutral spine with a slight lean forward (5-ish degrees) coming from the ankles, not the hips. Keep the hips tucked under you, remember ‘Without Limits’?…like that. Also, don’t let your head get ahead of you, chin tucked back with ears over shoulders and arms relaxed.
  • Foot Landing: Posture will help with this one as well. Simple goal here, your foot strike should land as centered under your body as possible
  • Rest & Recovery: You will not get stronger, adapt to the stresses of training or get faster if you do not take rest days and allow your body to recover. You recover when you sleep….ahh the dream life, just running and sleeping…if only.
  • Trails: Run on trails as much as possible. Not only does the challenging terrain develop strength and stability but the ground does not fight back like the road does. Trails will absorb a lot of the force you put into it with little kick back, making for a much more comfortable day after. More on trail running to come later but just thought I would throw this in last minute.

Dr. Reheisse is a Board Certified Chiropractic Sports Physician practicing in Cottonwood Heights Utah. Revive Sport & Spine provides evidence-supported chiropractic care and conservative sports injury management.

S T R E T C H I N G

Do you stretch? When? How? More importantly WHY? This will be brief, and there are many sides to this table, but where do you sit on this topic? When the discussion about stretching arises, it is sort of like the old saying on religion and politics; no matter what you have to say or how compelling your argument, you will never change the views of the other person and will usually walk away further apart on the subject than when you began.

Lets start the conversation…shall we?

When you stretch, what are you trying to accomplish? Are you trying to lengthen a muscle, increase range of motion or are you just reaching and praying that one day you can wrap your fingers around those toes down there? Truth is, you can elongate a muscle, kind of, and only temporarily. What you are actually stretching is the sarcomere, the contractile unit of the muscle, causing it to elongate but also decreasing its ability to contract. The sarcomere at rest, has quite a bit of overlap between the actin and myosin filaments. As you stretch, it creates less overlap and leaves the muscle with not much to grab on to when it is called on to work, decreasing its power and increasing risk for injury.

When a sarcomere is stretched, there is less myosin and actin overlap causing less power and increasing risk for strain.

In January 2014, The Journal of Strength and Conditioning Research studies the effects of static and dynamic stretching, revealing that static stretching had a negative impact on performance for up to 24 hours while dynamic stretching improved measures in power movements such as jumping. (Haddad et al.)

I do not despise stretching, just stretching of the static type before activity. I cringe when I see someone hop on to the field, or out of their car at a race and reach for their toes, pull their heel to their butt and off they go. I refer to this as the ‘stretching the cold rubber band trick’, it may work once or twice but eventually it is going to pop.

Some Non-Stretching (Static) Ideas

  • Before exercise: Activate and be Dynamic! Activate the muscles you are going to use, increase blood flow and ease into your exercise. Before running, activate the glutes, hips and core followed by some dynamic movement such as skips, leg swings and sport specific drills.
  • Foam Rolling provides a much better option to stretching as it allows trigger point work, reduced tension at the myotendinous junction and helps with circulation of fresh, oxygenated blood to flush out H+ buildup from lactate* breakdown, decreasing DOMS.
  • Mobility: Some may confuse mobility and stretching but the key difference here is that it not only works with muscle flexibility but joint mobility as well. Exercise or not, mobility should be addressed daily with focus on your trouble areas, which, depending on your sport and job, probably includes hips and thoracic spine.

This is the side of the table I sit on when it comes to stretching. This position comes from recent literature but mostly from personal & professional experience. Take it for what it is but if you are suffering from injury and you just can’t get it to loosen up, maybe stretching is the problem, not the answer.


Dr. Reheisse is a Board Certified Chiropractic Sports Physician practicing in Cottonwood Heights Utah. Revive Sport & Spine provides evidence-supported chiropractic care and conservative sports injury management.