Excessive internal hip rotation

[Alix James]

We have a client in the gym who presents with excessive internal rotation in the hips. The can sit on there bum with feet turned out to the sides comfortably.

Initially it wasnt causing too much problem but we are struggling to move them up through a strength program as they are uncomfortable with squatting over 70kg and deadlifting over 90kg. We started very light and are struggling to get past this point, the client can press over 50kg and bench 90kg but we can push the DL and squat any more for fear of losing form and injuring the client.

The client naturally performs an air squat better with feet closer together and toes pointing forward, we have worked with some 12'' bands to get a stronger knees out toes out squat, which is ok until loaded above 50kg. Also implemented some band lateral walks etc to try and build some stability in the region.

Whilst DLing lumbar curve is perfect with hips really low at light weight, a higher hip position then causes rounding of the lower back.

Just wondering if we are heading in the right way or if there is a better approach.

Thanks for any help given!

[Brent Sallee]

To be perfectly honest, most people don't just have excessive internal rotation. Your client likely has femoral retrotorsion, which is an excessive spiraling of the femur. The femoral head is in neutral, but it looks like the individual is in internal rotation. It'll also look like he/she has very little external rotation, if that's the case. Honestly, this is a point where you have to question if heavy weightlifting is right for this individual. To properly deadlift and squat, slight external rotation is preferred. However, even at neutral, they are already in external rotation, reducing the contact surface between the femoral head and the acetabulum (concave socket of the hip). That increases their risk of serious injury and even osteoarthritis in the long haul. Honestly, it may behoove them to focus on other movements. Heavy squatting and deadlifting aren't going to be a good fit for them.

[Alix James]

Hi Brent, thanks for the reply, I had begun to think similar which is why I hadn't continued to load those movements.

I have checked internal/external rotation and external rotation is still equal or greater than a normal range of motion.

Whats your thoughts on fixing the client at a set weight, say 40kg, and performing more sets/reps for back squat/deadlift days. Just hoping to find a stimulus that keeps the client progressing and won't be causing any problems to them.

[Brent Sallee]

Originally Posted by Alix James

Hi Brent, thanks for the reply, I had begun to think similar which is why I hadn't continued to load those movements.

I have checked internal/external rotation and external rotation is still equal or greater than a normal range of motion.

Whats your thoughts on fixing the client at a set weight, say 40kg, and performing more sets/reps for back squat/deadlift days. Just hoping to find a stimulus that keeps the client progressing and won't be causing any problems to them.

Interesting - can you give me any idea of how much internal and external rotation (in degrees)? If he's/she's hyperflexible both ways, then it could just be indicative of the collagen content within the connective tissue.

Does the client tend to fall into a genu valgum position (knee falls inward toward midline) when under significant weight? If this is the case, you'll really have to focus on strengthening the external rotators of the hip, mainly isometrically and eccentrically. Also, why isn't the client comfortable with heavier weights? Does it cause pain or physical discomfort? Is it a mental thing?

And in the meantime, doing what you're suggesting is the best way to continue progressing. Higher reps, same weight, will still increase the work capacity of the individual.

[Alix James]

I'd say internally, the right leg is a comfortable 65degrees and can be pressed through more. The left slightly less.

External probably 50-55degrees both sides.

Below 40kg the client can be queued to drive the knees out, getting past 50 yes the right knee especially falls inward. Bringing the heels in an inch fixes this a little but its not a solution I think is gonna help in the long run.

The client has been reporting discomfort pain in their lower back, specifically not the hips they say after squatting or lifting. Bodyweight stuff they are fine. It isnt a mental thing as the client wants to lift more and would try if we allowed them to. They are fine at handling weight in presses and upperbody movements.

Thanks for your help so far Brent, I will continue to try and find a solution - currently setting up an seperate program for him for those days.

[Brent Sallee]

Originally Posted by Alix James

I'd say internally, the right leg is a comfortable 65degrees and can be pressed through more. The left slightly less.

External probably 50-55degrees both sides.

Below 40kg the client can be queued to drive the knees out, getting past 50 yes the right knee especially falls inward. Bringing the heels in an inch fixes this a little but its not a solution I think is gonna help in the long run.

The client has been reporting discomfort pain in their lower back, specifically not the hips they say after squatting or lifting. Bodyweight stuff they are fine. It isnt a mental thing as the client wants to lift more and would try if we allowed them to. They are fine at handling weight in presses and upperbody movements.

Thanks for your help so far Brent, I will continue to try and find a solution - currently setting up an seperate program for him for those days.

Do you notice a butt wink of any sort as the client gets deep into the squat? Can you measure his hip flexion stopping when the pelvis starts to compensate? Sounds like they may be prematurely flexing at the spine, which would be caused by lack of hip flexion. If the person truly did have lax connective tissue, I don't think this would occur... Hm.

[Alix James]

When loaded, there is a slight butt wink but this would only occur after the the right need has moved in. An air squat can be preformed without problem although its clear the client feels much more comfortable with heels in and feet parallel.

I asked if xrays had been carried out in the past to look at any twisting or abnormalities with the head of the femur but none have ever been taken, will keep a close eye on it and hopefully we can keep him progressing

[Brent Sallee]

Originally Posted by Alix James

When loaded, there is a slight butt wink but this would only occur after the the right need has moved in. An air squat can be preformed without problem although its clear the client feels much more comfortable with heels in and feet parallel.

I asked if xrays had been carried out in the past to look at any twisting or abnormalities with the head of the femur but none have ever been taken, will keep a close eye on it and hopefully we can keep him progressing

If there's a butt wink and drop of the knee, that suggests to me he's compensating for something at a certain level. Depending on how his hip flexion is, you may want to stretch for that. That's the number one cause of the buttwink.

Most of the time, general doctors don't consider femoral ante and retrotorsion. I've seen it most commonly measured by PTs by locating the greater trochanter, positioning it where the hip should be in neutral and looking at where the knee/leg are. On top of that, I think even orthopedists complete the same diagnostic test - it's not typically x-rayed in my experience.