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External Rotation of the Femur

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Others publications and sources

Others publications and sources

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I would like to share with you some thoughts about “external rotation of the femur”.

Jan Sultan clarified an important point for me in his description of “internal and external types”. His external type had a tension in the piriformis muscle of the external rotator group. The effect of a short piriformis is an internal (!!!) rotation of the knees, i.e. “knock knees” in the standing position. The external types often have a barrel chest with tightness in the rhomboids and pectoral muscles. In terms of other functions, people with this body type are often the victims of onset diabetes. They have a slow metabolism, and their liver has difficulty metabolizing fats.

An asymmetrical tightness in the piriformis on one side can irritate the is chius nerve. If the piriformis is tight on both sides, it pulls the apex of the sacrum forward and down, the base of the sacrum tipping posterior resulting in the straightening of the lumbar spine. This can lead to “collapse” of the intervertebral disc.

Part of my confusion over the years was that I thought that a tightness in the external rotators produces external rotation of the femur. Sounds logical. And it is so in a four-legged animal. However, when we stand on our back legs (full extension), the angle of the piriformis from the sacrum to the femur produces internal rotation of the knees, because the piriformis attaches on the anterior surface of the upper border of the greater trochanter. (See Gray’s Anatomy) The other rotator muscles attach on the medial surface.

The other part of my confusion was that Kendall, Kendall and Wadsworth in their book Muscles: Testing and Function while they are correct in my experience with every other muscle, they give an incorrect test position for the piriformis muscle. The action of the piriformis in terms of external vs. internal rotation of the knees changes as the angle of lateral rotation and flexion/extension of the femur changes. A good test of the strength of the piriformis is with the knee bent forty-five degrees (the sole of the foot resting on the medial surface of the knee) and femur laterally rotated ninety degrees, hold the hip in place and push the knee posterior. To go from the theoretical discussion to reality, put one hand in the piriformis and see in which of the two positions you actually use the piriformis when muscle-testing.

People whom I call the “third type”, have thin, straight legs and externally rotated knees. ‘They often have a thin, narrow, long chest with “angel-winged ” shoulder blades and square, high shoulders. Their external rotation of the femur is due primarily to a shortness in the obdurator internus.

However, sometimes in the “third type”, working on the obdurator internus is not enough to eliminate the external rotation of the knees. The external rotation can be “held” in the shoulders by a shortness of the triceps muscle. Here, I suggest working on the infraglenoid tubercle to lengthen the triceps by working on the golgi nucleii in the ligament. I suggest having the client lie on their back, with their arm extended above their head to bring the shoulder blade more lateral to give you easier access to the infraglenoid tubercle. You can use their elbow as a lever, bending the arm to lengthen and stretch the triceps while you hold onto the scapula.

I also find it helpful to free the head of the humerus. With the person still lying on their back, with the palm facing away from the table, and the hand at shoulder height, resting on the table about ten inches lateral to shoulder. (If you are familiar with “geography” of acupuncture, follow the line of the lung meridian.)

The next step is to bring down the shoulders in the back by working the levator scapula.

Then you want to look at the junction of the occiput and C1. You might need to free the condyles of the occiput from C-1 by getting some length posterior. If you have the cranialsacral therapy tools, you could do a still point followed by diaphragm releases, paying special attention to the cranial base.

The result is that the angel-wings are eased more into resting on the posterior surface of the thorax; the hyper extended elbows soften; and the elbows rotate more outward from the body. The forward-rounding of the shoulder girdle diminishes; and the shoulders widen and now have room to glide down and rest on the chest.

You can now lift the first three ribs by working the clavicle at the lateral edge of the attachment of the sternocleidomastoid muscle. Also, lengthen the pectoral minors.

You also want to lengthen the posterior serratus inferior. This has been holding the ribs medially and inhibiting the action of the respiratory diaphragm.

Follow your manipulation with a little movement training, because, now your client should be able to inhale without lifting the shoulders, rather by effortlessly using the respiratory diaphragm and the anterior serratus.

They should feel more grounded. They are no longer holding their head “up” with their triceps and shoulder blades, but are giving in to the experience of gravity and getting lift from “the line”.

Dr. Rolf gave us the connection. In eighth or ninth session shoulder girdle work, we can expect to see the changes in the pelvic girdle. So, if you have prepared your “third type” externally-rotated-knees type client in the sixth session, but have still not gotten the desired changes, you can probably get what you want from these specific procedures on the shoulder girdle.

Stanley Rosenberg is a Certified Roller in Silkeborg, Denmark.External Rotation of the Femur

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