Ida Rolf created a system of values to determine the relative spatial order of the human body. These values give us a framework to make assessments about the body-in-gravity (by means of a projection of a conceptual grid of vertical and horizontal lines), and the interrelationships of the major segments or components of the body in that gravitational grid. Dr. Rolf did not discuss varus/valgus leg patterns in her teaching or writing.

In my own process of learning the work after my initial training, I began to suspect that Dr. Rolf had seen legs as generally disorganized and had a broad template to “organize” them in the gravity template, but did not differentiate that into a typology of pattern. In the early eighties, it occurred to me that there were two general, or polar types of posture and contour. These I called the Internal and External types, as each demonstrated a preference for organization around the vertical midline that was either internally or externally rotated. Without going into the whole concept here, it is sufficient to say that the externals would generally tend to valgus legs, and the internals varus.

If you approach the leg pattern in the context of the relation to the whole structure, then you have a good chance of easing the extreme expression of the pattern, and lining the legs up under the body, so the knees can “track” more or less straight ahead in walking and running.

Tactically, the two types of legs will respond to a general approach through the Recipe, but in fact each of the two polar types needs a different approach to access the “lines of transmission” of weight and the corresponding musculofascial development. The valgus pattern, and its correspondent, varus, are primarily genetic, and not adaptive. You can see these patterns come down family lines. The leg pattern, being part of a system-wide morphological preference, cannot be taken as a local event in the legs. That is not to say that it cannot be changed with our work. It is to say that it is not an isolated pattern, out of context to the general postural preferences of the body.

Valgus patterns in the leg can have several variations. As a baseline, consider that a relatively normal leg will have, as seen in Figure 1, the neck of the femur and an axis through the femoral condyles relatively parallel. In neutral, and in motion, the knees track (more or less) straight ahead.

<img src=’https://novo.pedroprado.com.br/imgs/2010/1086-1.jpg’>
Figure 1: Normal Legs

In the valgus pattern, that axis will have shifted so that the femur (the bone itself) has a twist down its length that puts the femoral condyles in external rotation in relation to the neck of the femur. This produces the classic “X” or knock-kneed pattern. This twist can be mild to severe. This pattern is not dominant in females, but seems to be distributed equally in the genders. The relative width of the female pelvis may dispose females to show more stress in the more extreme expressions of the pattern. Valgus is often associated with obesity, which indicates that the shape of the legs may be the outward sign of system-wide preferences metabolically. Valgus people are slower oxidizers as well! Valgus (see Figure 2) then is X-legged or “A deviation from the longitudinal alignment of the body in which the deformity turns away from the midline.” (Chambers Dictionary).

<img src=’https://novo.pedroprado.com.br/imgs/2010/1086-2.jpg’>
Figure 2: Valgus Legs

Varus legs will have the relationship between the neck of the femur and the condyles in a twist that brings the condyles into medial rotation in relation to the neck of the femur. That forces the leg to assume the classic ?O? or bowlegged shape. Generally these people are faster oxidizers.

Varus (see Figure 3) is a “bow-legged” condition or “A deviation from the longitudinal alignment in which the part turns towards the midline.” (Chambers Dictionary).

<img src=’https://novo.pedroprado.com.br/imgs/2010/1086-3.jpg’>
Figure 3: Varus Legs

When the varus or valgus pattern is more postural than structural, we will often see a leg in which the femur is relatively straight (not twisted) but the whole leg is in external rotation (valgus) or internal rotation (varus). This being more of a postural pattern than structural, it is much more accessible to higher organization through education and manipulation to bring the leg toward normal. In a genetically based pattern, it requires system-wide intervention over time, plus an internal awareness in the individual, to bring lasting change. This asks for long-term intervention through manipulation, education, and consistent yoga-like movement work.

Jan Sultan

Advanced Rolfing Instructor

Working effectively with a client who exhibits the valgus leg pattern begins with determining whether the pattern is actually problematic, as opposed to being a congruent and functional manifestation of the general way in which the particular person adapts to gravity.

One benefit of our Advanced Training is how it leads the practitioner to make finer and finer distinctions. For example, while the pattern is often a result of genetic structure and bony alignment, it becomes problematic only when continuity of motion is lost. When continuity of motion is not present in the foreground, this discontinuity is the result of the myofascial imbalance and faulty movement patterns that we must address.

When Ida Rolf said “Gravity is the therapist,” she gave us an opportunity to reflect on just how law-abiding structural integration must be. According to Newton’s Universal Law of Gravitation, each massive particle in the universe attracts every other massive particle with a force directly proportional to the product of their masses and inversely proportional to the square of the distance between them. Although today’s physicists might describe gravity somewhat differently, Newton’s law still works.

In distinguishing patterns from problems, we should remember Wolff’s Law: form follows function. Although we recognize the wide applicability of this abbreviated version, German anatomist and surgeon Julius Wolff (1836-1902) was talking about bone: Every change in the form and function of a bone leads to changes in its internal architecture and in its external form.

The way I typically begin my own sessions honors Wolff’s Law: I try to feel beyond the soft tissue to the bony lay of the land. The width of the hips (be they male or female) is far less relevant to the valgus pattern than the relationship of the hips to each other; to the sacrum and spine above; and to the femurs, legs, and feet below. My sense of the shape, contour, volume, and dimension of the osseous infrastructure informs my strategy for intervention in the soft tissue.

Whatever strategy is chosen, its implementation will implicitly depend on Davis’ Law, which describes how soft tissue forms in response to demands: ligaments and other soft tissues, when placed under unremitting tension, elongate by the addition of new material. When remaining uninterrupted in a lax state, they gradually shorten by the absorption of material.

Given the law of gravity, the laws concerning how the osseous and soft-tissue components of living systems respond to the gravitational and other stresses imposed upon them, and the intent of the Rolfer toward balance and integration, let’s see how we might address the valgus leg pattern.

If palpation reveals what Jan Sultan(1) has described as the congruent genu valgum pattern(2), consistent throughout the structure, we find the following:

• ilia tilted posterior on the axis through acetabula
• primary and secondary curves of the spine diminished
• ischial tuberosities narrow and iliac crest wide
• femurs externally rotated relative to the sagittal plane

In working with a congruent valgus leg pattern, Sultan(3) suggests that work in the following regions tends to bring the overall structure to a higher level of order:

• the high fixed arch (use intra-articular stretching)
• medial tibia (upper 1/3 to 2/5 of the medial gastrocnemius and the deep posterior compartment)
• lateral hamstrings and the adductor/quadricep line of differentiation
• gluteals
• rotators
• psoas major and minor
• sacrotuberous ligaments (to open narrow ischial tuberosities)
• obturator internus (to open the core)

When palpation reveals a lack of congruence with respect to the genu valgum pattern, the laws of Wolff and Davis still govern, particularly when we “hunt for the feel of the tissue”(4) and allow the palpation to inform our strategy. For example, as in the case of a recent client whose right femur was more externally rotated than his left, the planes through the greater and lesser trochanters were diagonal to a true coronal plane. This affected the extensor/flexor, front/back balance in the soft tissue throughout his structure. The structural asymmetry in the pelvis and valgus leg pattern was reflected functionally as a discontinuity of motion in his gait. Having honored Wolff’s Law in order to feel the pattern in the bones of the pelvis, the operation of Davis’ Law helped me to sense and release the soft-tissue restrictions influencing the pattern. The result was a dramatic increase in range of motion of the femur in the acetabulum, along with the advent of anterior translation of the right ilium in walking. In other words, by addressing the incongruence of the more externally rotated right femur to bring it more toward neutral (i.e., symmetry with the other femur) and into congruence with the pattern of his structure overall, structural integration yielded greater functional continuity.

Endnotes

1. Based on Jan Sultan’s internal/external taxonomy.
2. In my twenty-three years of clinical practice, I have observed no gender-based correlation with respect to the genu valgus pattern.
3. Sultan, Jan, “Practical Exercises”; “X and O Tactics”; “How to Work a Congruent X Leg Pattern.” Class handouts from Sultan’s Advanced Training, November 2005.
4. Sutherland, William G., Contributions of Thought: The Collected Writings of William Garner Sutherland, D.O., 2d ed. Portland, OR: Rudra Press, 1998.

Sally Klemm

Advanced Rolfing Instructor

For me, the most useful model for understanding valgus leg patterns is Jan Sultan’s article on structural types. Sultan distinguishes two polar structural types based on pelvic inclination and femoral angle: the internal type, with varus legs etc.; and the external type, with valgus legs. While any typology has limited application to reality, Sultan’s work helps us think about femoral angle and whole body structural preferences. Excluding developmental anomalies, femoral angle is always influenced by the gravitational preferences evidenced by the structure as a whole. For example, diminished amplitude of the spinal anterior/posterior curves usually accompanies valgus leg patterns. Improving the bias toward valgus patterns in the legs will also involve improving anterior/posterior balance in the spine, particularly in the neck. Additionally, and more specifically, Sultan lays out the “lines of transmission” in the legs that express the soft-tissue strain patterns that hold the valgus or varus pattern in place. For a valgus pattern, shortness in the lateral hamstrings is usually present.

What is important here is to realize that we are all living in patterns of balance that have inherent biases. An external structure will always have a tendency toward valgus patterns in the legs, until the entire structure evolves more toward neutral. This is only possible after the structure has achieved a significant degree of internal coherence or continuity “within its biased pattern.” Most of the structural problems dealt with early on in Rolfing Structural Integration have to do with conflicts within the inherent structural pattern of the client, i.e. high-amplitude spinal curves and an anteriorly shifted pelvis with valgus legs would represent a conflict between the structural pattern in the spine and the legs. Clearing up the conflicts is the first step in integration and the foundation for any movement toward a more neutral structure.

Hans Flury, in his article on pelvic inclination, and the recent work of Hubert Godard, both emphasize that the inclination of the pelvis has a strong and perhaps determining effect on femoral angle. For example, an anteriorly shifted pelvis that is slightly posteriorly rotated will necessitate external rotation of the femora, resulting in a valgus pattern in the legs. Correcting the valgus pattern will always involve migrating the pelvis toward a more neutral position which, of course, involves spinal curve preferences. In fact, if the upper body’s center of gravity (g’ in Godard’s system) moves posterior, the pelvis is impelled to shift anteriorly and the femora to externally rotate. So, as Dr. Rolf said, it’s a whole-body pattern.

Having said that, disruptions in normal positioning of the ilia will influence femoral angle. If one ilium is posteriorly and inferiorly displaced with a slight out-flare (these configurations often go together), the ipsilateral femur will externally rotate.

I always say the knee is the victim of what happens above and below. Hence, there can be distinct influences from the ankle that pull the knee into external rotation and put the femur into a valgus bias. Stabilization of any femoral pattern will always involve balance in the ankle and foot. The problems in the foot usually involve slight displacements of the talus, which then disrupts the normal distribution of weight anterior/posterior and medial/lateral in the foot.

Michael Salveson

Advanced Rolfing Instructor

I thought I would provide my outlook on genu valgum patterns (with apologies to Jan Sultan if I have misinterpreted any of his internal/external typology).

Being an adherent of Sultan’s internal/external typology, and having used this way of assessing the body’s structure for almost twenty years now, it is my belief that any deeply held structural pattern has a genetic component – you are born either an internal or external and will carry that blueprint throughout your life. I also feel that you are not doomed to be trapped in that pattern. I can present myself as a prime example. I was born an external with almost all of its requisite characteristics – flat lumbars, out-flared hips (“apple butt”), X-leg pattern, flat occiput, and high, vaulted arches. I also had a slumped-shoulder posture with head jutting forward that was not congruent with Sultan’s typical external type of shoulders held back in a “military posture.”  It turns out, though, that this slumping of the upper pole was not due to my shoulders being pulled forward and down by my pectorales minor (seen in a typical internal), but rather by shortened scalene muscles – a “core” shortening that is in agreement with the external type.

Over the years I have had numerous Rolfing sessions as well as other types of bodywork (including a fair amount of excellent Feldenkrais work years ago), along with a lifetime of yoga and t’ai chi practice. I no longer have the exaggerated look of the external body type that I showed in my youth. I am still, and will always be, a core-bound external, but I no longer feel constrained by this pattern. My knees do not exhibit the infamous X-leg pattern, I have a slight lumbar lordosis, my scalenes no longer pull my head forward (a special thanks to Stacy Mills for that), and I actually have a butt now. My overall structure has moved toward a more neutral-looking type. I firmly believe that had I not embarked on this particular path, I would now, at fifty-six, exhibit a much more exaggerated external body type. With effort, attention, and intention, I have been able to free myself of my innate structural patterns and inhabit a body I feel comfortable in and that serves me well.

John Schewe

Fascial Anatomy Instructor

Valgus legs or knees is more common in women and, as you mention, is thought to be related to females’ wider hips (see http://www.asicsamerica.com/asicstech/structural_differences.htm). This suggests that at least some of the contributing factors are structural or genetic (“nature”); of course it is our Rolfing credo that movement patterns and activities (and other “nurture” factors, like Rolfing) can mitigate (or exaggerate) this kind of structural tendency.

Is genu valgum due to osseous, myofascial, or functional issues? I’m not sure these things can be teased apart in a causal sense since, like nature and nurture, they’re reciprocally reinforcing. Chicken or egg? In terms of practice-room strategy, these factors may not even need to be separated out, as we see good results from both structural and functional work, and probably even better results when they’re combined.

It could be that you’re wondering about how much change to expect, and how best to proceed? Considerations: there are several sophisticated models for understanding and working with leg alignment. A simple bowstring analogy would predict tighter longitudinal tissues on the lateral leg that cross the knee: iliotibial band, vastus lateralis, biceps femoris, lateral head of gastrocnemius, and their fascial extensions. Sultan’s internal/external model would suggest working his external “lines of transmission”: the septa of the medial quadriceps, lateral hamstrings, and postero-medial tibia. Classic Ten-Series work addresses a genu valgum pattern in each of the even-numbered sessions. Flury, Goddard, Gaggini, Myers, and others have their own well-reasoned models too.

I’ve had good luck working to first free the obvious (visible or palpable) joint or soft-tissue restrictions. Then, in standing, we build the client’s awareness of aligned function via explorations in weight-bearing and transmission through the hips, knees, and feet. For example, I present a knee-bending/weight-bearing koan: how can I bend my (valgus-tending) knees and maintain even weight-bearing through both my medial and lateral arches, without pulling the knees apart or letting them fall together? If that seems impossible to the client, often there’s more soft-tissue work to be done, or my instructions need to be even simpler. Clients eventually get it, and this serves as the beginning of a sense of support and connection all the way up.

Til Luchau

Foundations of Rolfing SI InstructorWorking with a Valgus Leg Pattern[:]