Externally rotated leg/lack of hip joint space: Squatting.

[M10001]

Hi guys,

just a couple of things before I get onto the actual question. I filled out the medical questionaire, but I wish to clarify that I have been diagnosed with osteoporosis once in the past but a while after was told my bone density was in the normal range.

Basically, I have Chronic Recurrent Multifocal Osteomylitis in my left hip, with an active arthritis and have also been told I have reduced hip joint space in my left hip. (slightly unsure on this)

My condition, thankfully, is stable at the moment.

I enjoy exercising, and recently have tried squatting (using my own bodyweight). My back did not feel too great afterwards. I tried squatting in front of a mirror with the front of my hips visible and noticed my hips went down, but then my left hip stayed at the same point and my right hip continued to go down. I cannot imagine that is good for my back.

If I stand up, and lift my right knee up so that my thigh is parallel to the floor, it comes up fine. However, if I lift my left knee up, it externally rotates, with my left thigh turning outwards, leaving my lower leg at an angle like this \.

So, 1) Is it likely this is caused by the lack of hip joint space in the left hip, or could it be something like a lack of flexibility or strength?

Earlier I tried slowly squatting to a very shallow depth with my fingers on my hip bones, I could make them go down at the same level then felt more muscle strain in the left hip and thigh. I don't think I could maintain this for anything deeper than that though, perhaps it is partially muscle strength, and joint space?

I will add here, that if im bending at the knees and allowing my heels to come off the floor, I don't have this problem. It's when I squat with heels flat and 'sitting back'.

I will add even just sitting in a chair, my left leg turns outwards at the hip.

Yesterday, I thought I would try to actually record the strength difference in my hips. I strapped about 5kg of ankle weights and did adduction and abduction exercises (and the one lifting the leg up from lying). Have to say, what I found was quite odd.

On the left leg, there wasn't that much fatigue in the hip, but instead more pain in the lower leg including shooting pain. On the right hip however, fatigue was almost immediate in the hip area but felt a lot more healthy without the pain. My left thigh is smaller than my right and I usually expect it is weaker (and same goes with the hips).

I will add when walking my right leg (just to complicate things), externally rotates. Not sure if this is relevant.

So what could be causing this problem? It could very well be that I won't ever be able to do squats for leg strength, and if so, what is a safe, effective way to make my legs stronger? (Lunges have generally felt ok, but perhaps I should check in front of a mirror).


I look forward to your replies, please ask if more information is required.

Many thanks!

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[alophysio]

hi - great post and great detail !!

Please remember that it is hard to be definitive when i haven't examined you (all the usual disclaimers )

It would seem that your left hip indeed is not working properly. It may be from the osteoarthritis or the osteomyelitis. It may be from a tight hip capsule or muscles. There are many different possible causes of the problem.

However, one of the observations is decreased hip joint space. That sounds consistent with your descriptions of what is happening functionally (during squats, sitting etc).

You are right, the left hip stopping during your squat is not ideal for your back - it places an uneven load on the whole body.

The real question is whether you can control the hip better. This is hard to test - even physios have trouble knowing whether the hip is centred during motion... The most common movement during motion is an anterior glide - this is where the hip should sit centred in the socket but it slides forward. When this happens, it pinches against the cartilage (labrum) and can cause the joint to painfully or not painfully stop moving.

The external rotation you have in your hip during sitting could be because it has run out of space to flex and so has to roll outwards to find room for the hip to accommodate your sitting.

As for the weights, that type of exercise is not necessarily indicative of your true hip strength in standing etc because you did the tests lying down. In fact, those tests claim to be muscle strength tests but they also test your coordination, joints and beliefs! For example, if i did the test and you had perfect muscles but a broken leg, you would test "positive" for weak muscles. In the same way, if your coordination is off, you can test positive. There have been different types of studies which show the effect of encouragement, beliefs etc on performance...all of this i guess is to tell you that you aren't necessarily weak in your hips...maybe your right hip is tired of catering for the left hip!

Anyway, you need to find someone who knows how to assess your hips and whether your coordination and joints are ok...that will not be so easy Once you have found that person, you will be able to get a better idea on how to strength your legs safely.

Hope that was helpful for you

Cheers!

[Dr Damien]

Dear M10001

How are you? I dont have very much to add but I am just going to add a little to what Alophysio has said. I am going to agree fully with alophysio on this advice, however like he said, without a good assessment physically we can only make speculations.

You pointed out that squatting with your heels down makes the hip uncomforable but not when the heel is up. It sounds like you have a few muscle length relationship issues, If I imagine what your posterior limb muscles are doing when you squat ( I mean your hamstrings and calf muscles) I would say your calf muscles are partcularly tight. These muscles (calfs and hamstrings are two joint muscles) , by two joint we mean the cross two joints and can influence movement in those joints, a short calf muscle would mean its superior attachments can pull on the femur when short, this can cause a superior glide as alophysio has described, especially if you have short hip flexors as well (particularly the quads)...think of a synergy of muscles working to try to give effecient movement...

As alophysio described, a joint (or bone ends making a joint ) will only move within the path of least resistance...if you are having a hip that naturally falls into external rotation when you bend then probably the external rotators are tight as well...

Just a brief description, the quads move the pelvis anteriorly, the hamstrings posteriorly...when bending you should have a posterior tilt of the pelvis to give room for the hips to move properly... this may not be happening in your case...

Arthritic changes owing to whatever pathology (osteomyelitis etc ) may have caused some degeneration in a few tendons, plus pain protection as you have walked over the years may have contributed to some shortening as well in a some tendons....

so your hamstrings are probably long, your calves are probably short, your quads are probably short, and your hip external rotators are probably short...this can make your gluteus muscles generally weak

In a addition, because you described a hip that doesnt go down when you squat compared to the other i would think that the posterior structures of the hip may be stiff, as you need the head of the femur to sink down to complete the motion of flexion. If this is not happening, then your spine will compensate by moving too much causing some discomfort.

This brief analysis may explain why you are getting stress in your thigh, hip and back when you squat. Shooting in your leg may also indicate tight rotators of the hip or generally overworked hamstring (my guess is the rotator) as these can compress your sciatic nerve...

I would suggest a good assessment of the length tension relationship of the muscles that control your pelvis as they relate to your hip and knee, and muscles that control the knee and foot, compare them to the other limb...

What you may need are some specific stretching exercises...

cheers

[M10001]

Many thanks for the replies guys!

I appreciate that it is hard without giving an assesment.

Alophysio, thanks for the info some interesting stuff there especially regarding the lying hip tests

Dr. Damien, I am well thankyou. Have just been on a very basic day course learning about bricklaying. Hard work being crouched down and bent over etc! (Not something I'm planning to do was just to learn a bit more). Thankyou for the information regarding the muscles. I would definately say I have tight hamstrings. I cant touch my toes (am quite far off, say mid shin) even with curving my back (I generally try to avoid stretching with curving the back). If I stand with my back straight and start to bend forward, I can feel tightness after just a very slight angle. As for my calf muscles, I guess I cant really judge but if I stand on a step with the front of my foot and let my weight go in the usual stretch, I wouldn't say they're particularly tight.


I suppose at this point it could be either the muscles or the joint, and obviously one is a lot more treatable than the other!

Many thanks again guys.
I do stretch but only after going to the gym. I should stretch more to loosen them up, but then that would involve some form of warm up? I don't know how warm they need to be before stretching?

Perhaps I should get an assesment. I could go NHS, Suppose private but depends how many sessions really... Have to say, without sounding horrible, that I think there can be great differences between how good different physios are, for instance regarding how much they know and how up to date they keep themselves ( I have had physios in the past ).

[alophysio]

Hi,

If you can feel the stretch nearly straight away but can get your hands down to the mid shin area, it is possible that your muscles and/or nerves are restricting your range but it is more likely that your muscles are overactive...you see, given that you can still move quite a fair distance after the stretching has started would say to me that the physical length of your muscles and nerves are not limiting your movement...

You say it is either a muscle or a joint but don't forget that it could be a nerve problem, a back problem or even simply a coordination (motor control) problem...so don't limit the possibilities of what it could be

As for finding someone who knows, i would suggest you email [email protected] to find out who to contact in the UK about who has done the Discover Physio Series or any of their other courses...they will probably think in a similar way to what i have portrayed here. Otherwise, you could contact people from Manual Concepts and ask them the same thing - they are australian educators who do the UK as well. Then if that fails, you could try other educators - sorry, i only know of those 2 personally.

All the best

[M10001]

Thanks Alophysio! I will bear those points in mind, as well as the email adress you gave me!

The stretch in my hamstrings appears almost instantly only if I keep my back straight with no flexion. In order to get down any distance I would have to allow my back more flexion.

Thanks again.

[alophysio]

hi,

Thanks for that. I agree, at the moment, the only way for you to bend lower is to bend your back.

What i am suggesting is to bend from your hips (i know you don't get far) and to use that as your exercise/stretch to increase how far you can bend from the hips. Ideally 80degrees from vertical would be nice (nearly horizontal) but i would be happy with 60deg

And again, i don't think it is your hamstrings that are tight, more like they are overactive (switched on too much) or that the sciatic nerve is physically shortened for some reason.

thanks!