Lying Knee-To-Knee Stretch
Written on April 29, 2009 at 7:09 am, by Eric Cressey
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Q: I have a question about your 22 More Random Thoughts article from October of 2008 on T-Nation. In the stretch for the hips found above #10, I can’t tell is that athlete bridging or are the hips on the ground. Also, can you please explain exactly what is stretched and how a little bit about how it corrects out-toeing of the feet?
A: Sure, no problem. Here’s the lying knee-to-knee stretch, for those readers who missed the original article:
First off, it’s a stretch for the hip external rotators, and the athlete is not bridging up. However, it’s also useful to do the stretch in a more hips-extended position, as a small percentage of athletes will feel it more in that position. To perform this stretch, we’ll do the exact same position, but have the athlete set up atop a stability ball (which keeps the femurs in a more extended position).
Poor hip internal rotation range-of-motion is something you’ll see quite frequently in soccer players, hockey players, and powerlifters, as all spend a considerable amount of time in hip external rotation. Likewise, I monitor this closely with all my baseball pitchers, as front leg hip internal rotation deficit is a huge problem for pitchers. When the front hip opens up too soon because of these muscular restrictions, the arm lags behind the body (out of the scapular plane). As such, it isn’t uncommon for pitchers with elbow and/or shoulder pain to present with a significant hip internal rotation deficit.
There is also a considerable amount of research to suggest that hip rotation deficits – and particularly, hip internal rotation deficits – are highly correlated with low back pain. There was a great guest blog post at Mike Reinold’s blog recently that highlights all this research; you can check it out HERE. My personal experience with hundreds of people who have come my way with back pain overwhelmingly supports this “theory” (if you can even call it that). It’s my firm belief that this is one of the primary reasons Mike Robertson and I have gotten so much great feedback on our Magnificent Mobility DVD from folks who have seen a reduction (or altogether elmination) in back pain. Teach folks to move at the hips (particularly in rotation) instead of the lumbar spine, and whatever’s going on in their low backs calms down.
Our goal is a minimum of 40 degrees of hip internal rotation. This is measured in the seated position (hips flexed to 90 degrees).
In addition to the classes of athletes I mentioned earlier, we also need to watch out for hip internal rotation deficit (HIRD) in the general population because of what happens further down the kinetic chain. We all know that overpronation at the subtalar join is a big problem for a lot of folks. This can occur because of a collection of factors, from poor footwear (too much heel lift), to muscular weakness (more on this in a second), to mobility deficits (particularly at the ankle), to congenital factors (flat feet). To understand how pronation affects the hip external rotators, you’ll need to listen to a brief synopsis of subtalar joint function…
During the gait cycle, the subtalar joint pronates, to aid in deceleration. Basically, the foot flattens out to give us a bigger base of support from which to cushion impact, and from there, we switch back over to supination to get a rigid foot from which to propel. The picture below shows what our foot looks like when we have too much pronation.
Here’s where our hip gets involved. Physical therapist John Pallof once called the subtalar joint a “torque converter,” and it really stuck with me. What that means is that while the subtalar joint allows motion in three planes for pronation/supination, it converts this motion into transverse plan motion where it interacts with the tibia. And, as you can imagine based on the picture above, when you pronate, you increase tibial internal rotation. This, in turn, increased femoral internal rotation. Taken all together, we realize that increasing pronation means that there is more tibial and femoral internal rotation to decelerate with each step, stride, or jump landing.
The hip external rotators are strong muscles with a big cross sectional area, so they can take on this burden. However, over time, they can get balled up from overuse. As a result, the hip will sit in a more externally rotated position all the time – and the feet simply come along for the ride. That said, as I wrote HERE, it isn’t the only cause of this foot position, so be sure to assess thoroughly and individualize your recommendations.
Also, a quick side note, be careful using this stretch with individuals who have previously experienced medial knee injuries, as the valgus stress can be a bit too much for some folks.
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Have a great week!