Hipsters Part II – The Lateral Rotators

I must confess, I may have bitten off more than I can chew with this hip article. But now that I’ve started, I have to finish. Today, I’m going to talk about the rotators — the muscles that turn your leg inwards or outwards (i.e., medial or lateral rotation).

Here’s a family portrait of the lateral rotators :

And I don’t know why they’ve put the gluteus minimus in this photo because it is NOT a lateral rotator, it is a medial rotator. Grr!

For future reference, here’s a picture of your pelvis, because below there’s going to be a lot of mumbo-jumbo talk about attachment points, so it might be helpful to know what an ilium is.

And I’ll warn you right up front — there’s going to be a lot of mumbo jumbo in this, but if you skip to the end, we get to exercises. So decide if you want the in-depth version, or just the highlights and read accordingly.

Also, some terminology refreshers right up front. Anterior means front. Posterior means back. Lateral means side (as in the outside edge of your body or of a body part). Medial means closest to the middle or inside edge of your body or body party. Superior means above; inferior means below. Foramen, foramina, etc. are like a ligament or tendon. A line or fossa or tuberosity or a ramis is just a point on a bone where a muscle attaches. Origin is where a muscle starts. Insertion is where a muscle ends. The origin pulls the insertion towards itself, which determines the action a muscle has on a joint.

Okay — to the muscles. Most of these guys toil in anonymity, but of all these lateral rotators, you might have heard of one: the piriformis. Especially if you’re someone who has sciatica. The sciatic nerve passes underneath the piriformis. So if the piriformis is too tight (runners often have very tight piriformi), it can press or rub on the sciatic nerve, bringing about the tell-tale pain, tingling or numbness in your tuckus. This condition is also called “piriformis syndrome.”

The piriformis is a flat muscle, pyramidal in shape, lying almost parallel with the back edge of the gluteus medius.

It originates on the front of the sacrum attached to the portions of bone between the first, second, third and fourth anterior sacral foramina (which you can’t see in the picture below because they’re covered up by all those ligaments), the margin of the greater sciatic foramen (located in the middle left of the photo below) and from the front surface of something called the sacrotuberous ligament (it’s in the lower right hand corner of this picture).

The piriformis passes out of the pelvis through the greater sciatic foramen and is inserted by a rounded tendon into the upper border of the greater trochanter. And since it starts on the ilium, then wraps around the back of the thigh bone to insert on the front of the thigh bone, you can see how if the origin were to pull the insertion point towards itself, it would turn the hip outwards, yes?

Besides external/lateral/outward (whatever word you want to use for it) rotation, the piriformis is also responsible for adbuction (moving out to the side) of a flexed thigh — very important when walking.

The other players in lateral rotation are the gemellus superior and inferior. Superior is higher up; inferior is lower down. BUT — the superior muscle is smaller than the inferior muscle. Go figure. Both these guys are teeny tiny and are considered accessories to the Obturator internus. Is accessory another word for flunky? Basically, they work as a team.

The gemellus superior originates on the outer surfaces of the ischium, blends with the tendon of the obturator internus and then inserts on the medial surface of the greater trochanter.

The gemellis inferior is such a copy cat. It also arises from the ischium, blends with the obturator internus (only instead of being above the obturator, it’s below it), and inserts on the medial surface of the greater trochanter.

Look closely. It’s hard to tell them apart. They’re practically twins. Well, guess what? Gemellus means “twins,” so another mystery solved.

Besides lateral rotation, the gemellus muscles (like the piriformis) also are responsible for stabilization of the hip.

Next up (for no reason other than that there are also two of them) are the obturator internus and obturator externus. Guess what their names mean? One’s inside, one’s outside.

The obturator internus originates on the medial surface of something called the obturator membrane, the ischium near the membrane and on the rim of the pubis. (NOTE: if you look at the picture above of the pelvis with all the ligaments and foramen’s, you’ll find the obturator membrane located in the lower left hand corner of the picture. Actually, you can also see it in the lower right hand side, too, it just isn’t labeled there. It’s behind the sacrotuberous ligament.

The obturator internus fibers all converge at the lesser sciatic foramen, unite into a single flattened band, hook up with the gemelli brothers and likewise attach on the medial aspect of the greater trochanter. I believe, but am not certain, that it is called “internus” because it is sandwiched in between those gemellis guys.

Here’s a picture that separates them out for you. The obturator internus is shown on the left side of the hip. On the right side of the hip, from top to bottom, are the piriformis, the gemellus superior, then the gemellus inferior. See the space between the superior and inferior gemellis? That’s where the obturator internus goes.

The obturator internus, in addition to lateral/external/outward rotation also assists in abduction of a flexed thigh and in stabilization femoral head in the hip socket. So for a little guy, it’s pretty important.

The obturator externus is called externus I guess because it’s not sandwiched between the gemellis. It originates on the obturator membrane, the superior (top) pubic ramis and the inferior (lower) pubic ramis. It inserts on the greater trochanter. Below is a picture.

Lastly, of the primary lateral rotators is the quadratus femoris (not to be confused with quadriceps or rectus femoris). It originates on the ischial tuberosity of the ischium and inserts on the back of the head of the femur. It is a strong lateral rotator and also an ADDUCTOR (meaning it draws the leg back towards the body if the leg is extended to the side). See picture below.

Phew!

But wait — you’re not done. Those are just the primary lateral hip rotators. We haven’t even touched on the secondary lateral hip rotators.

The secondary group is comprised of the Sartorius (which we met in the hip flexor group), the Gracilis (don’t think we’ve covered it yet), and the Gluteus Medius.

And now you’re probably thinking: “Why are there so many dang muscles on the hip socket?”

Because the hip has to perform so many functions. Think about it. Your elbow just has to bend and straighten And yea, it rotates slightly when you turn your palms up or down.

But the hip?! It has to bend, extend (to powerfully push you forward when you’re walking, running or climbing stairs), the legs have to go out to the side (whether it’s because you’re doing a side-step or just shifting your weight minimally mid-stride as you walk), and then there’s the whole rotation thing. Why does it do that? Did our bodies know evolutionarily that some day there’d be such a thing as a Ninja and we’d need to be able to do those sweeping, looping side kicks?

The legs/hips operate in so many planes of movement, and throughout it all, they have to support our weight. The hip socket, like the shoulder socket, has to be extremely versatile, and yet extremely strong. You wouldn’t want your leg popping out of socket while you’re doing any of the movements you have to do. So the body has this amazing network of tendons and ligaments and muscles to keep everything in place. Strong, yet supple. It really is an amazing, amazing joint.

And beyond the primary and secondary lateral rotators, we’ve still got internal rotators, and abductors, adductors and extensors, oh my!

Maybe I don’t go into all that. Maybe you’re getting bored. But I thought it was worth it to touch on all these so that you can see that just walking or just running is not going to target all the muscles that impact on your hips.

And if you want to have strong hip bones possible (and let’s face it, who doesn’t?), then you need to think outside the gym and/or treadmill box.

This is why yoga (yes, I’m talking about yoga again) is such a terrific exercise for combating osteoporosis. Because in any number of yoga poses, balance is required of you. Take single leg standing poses like Warrior III, or Half Moon, or even one of the “simpler” ones like Tree (and before you freak out about these poses, scroll down the page and click on the “modifications and props” tab. Shows you how to “walk” before you “run”). When you are standing on one leg and balancing, the muscles on all sides of the joint of the supporting leg are all firing at once, working together symbiotically to keep you upright. If you’re someone with excellent balance, you may not even notice this happening. It’s la di da, la di da.

But the gravitationally challenged will definitely feel it as their body sways too far to one side and then to the other. All those minute (and not so minute) corrections are the muscles struggling to divvy up the job between themselves to find a place of stasis.

But beyond one-legged poses, in just about any yoga posture that involves legs, one leg is being pitted against the strength of another. The hamstrings are working against the quadriceps, there is a powerful rotation –it’s –

I’ll just say I have never gotten the kind of leg workout at a gym that I have gotten in a yoga class. Period. And best of all, when I leave a yoga class, instead of feeling strong and stiff and sore, I feel strong and lithe and weightless. And younger. Because I can move without groaning.

But I know yoga scares many people with osteoporosis.

So here — If you’re someone who goes to a gym and traditionally uses the abduction/adduction machine, you are really missing out on a great opportunity to work all these other muscles.

If you would try switching to the cables instead — let me tell you — you’d feel all those puppies working. Plus, you’d get the added benefit of an abdominal workout as well, because there’s no such thing as slack abs and balance. You have to contract the abdominal muscles if you want to remain upright.

CAUTION:  I just read a notice on a physical therapist’s site that said cable abduction and adduction could potentially cause a hip fracture if you are osteoporotic.  I would think this would depend on (a) your hip density and (b) the weight load.  I’ve been doing this with no problems.  But as with everything, check with your doctor first!

The biggest mistake most people make when using cables is they overload the weight. They use too much and cannot move their leg unless they grab onto a bar and then OOOOOOF put their entire body weight behind the movement. Don’t do that. Besides doing it “wrong,” you could also hurt your back.

The second biggest mistake they make is by using the cables while standing with both legs on the floor. This will cause you to have to “hike” up one hip. Again, you could hurt your back.

Get a small platform or stair stepper over and stand on the platform with the cabled ankle hanging off to the side. The weight stack should be closest to your standing leg, not the leg with the weight on it).

Actually, I would start with absolutely no weights at all. Just try standing on one leg with the other leg hanging off to the side so that your hips are level (you can tell by placing your hands on your hip bones. Your hands should be at exactly the same height). Then slowly, slowly abduct your leg (i.e., move it out to the side) and then return to your starting position.

If you’re worried about balance, stand close enough to the cable machine (they usually have grab bars) so that you can grab on if you need to. Or better yet, place your hands lightly on the bar, but see if you can do the move without hanging on for dear life.

If you can do that, then attach a cuff to your ankle and hook up a cable. Start with very light weight. I think five pounds is as low as it goes, and try taking your leg out to the side (abduction).

Now the fun thing about cables is (unlike the chair machine) you can turn your thigh out (so that the top of your thigh and your toes point towards the ceiling), and you can turn your thigh in (so that your toes and top of your thigh point towards the floor). Or you can work with a neutral leg (toes and thigh pointing straight ahead). In this way, you can work all those muscles of the hip socket — the external rotators, the internal rotators and the abductors.

Then you can try lifting your leg to the front (i.e., hip flexion). You’ll have to change your physical orientation to the cables for this — the weight stack should be behind you). It’ll be easier on your back if you work with a bent knee on this one. But, if you were to keep your leg straight, you could once again work with your leg rotated inwards, outwards, or with the toes pointing straight up.

Then face the weight stack and do leg extension (moving your leg behind you, keep your knee straight).

Finally, stepping further away from the weights with the weight stack and cable closest to the leg your working and start with your leg away from your body (abducted) and try to bring the leg back to center (adduction).

You can see video of hip abduction with a cable here. Note: she is not standing on a platform, so you’ll see how she has to hike her hip up at the beginning and end of the movement. BAD. Don’t do that. Also, remember to try to do this without hanging on for dear life.

You can see video of cable hip adduction here. Again — bad form. No platform. Grr.

Video of cable hip extension here. NOTE: I don’t like that he’s bending his knee, and also it looks as if he’s slinging the weight behind him. You want to be working at a weight level so that it’s your leg, not your back, doing the work.

Video of cable hip flexion here. Now here’s a gal after my own heart. She’s not hanging on. She moves easily and naturally. The only thing I wish is that she was standing on a platform. Because when she swings her leg back to the back (or to the front), she has to hike her hip or bend her knee in order to pass through that standing position. But other than that, she’s pretty flawless.

If you aren’t afraid to try yoga, or if you want to dip a toe in, Yoga Journal has an excellent website. They break down poses by the body part worked. When it gets to the hips, there are many poses that would be contraindicated (because there’s spinal flexion involved — like Big Toe Pose or Cat Pose). But Cow Pose, on the other hand, is terrific. I also like that some of the poses have videos that go with them, in addition to a breakdown of how to do the pose. If you click on a pose, then scroll to the bottom of the page, it tells you the anatomical areas worked.

If you want to work on balance, try Extended Hand to Big Toe Pose. You can do this against a wall or with one hand on a chair if you’re worried about balance. And you can use a belt from a bathrobe and wrap that around your foot if you are unable to reach your toe. You can also do this pose lying flat on your back on the floor.

Or Happy Baby Pose. This is one that I just love.

And not to give Pilates short shrift, the side lying leg exercises for Pilates are fantastic. Many folks shy away from Pilates because of the whole spinal flexion thing involved in the roll-ups and the like. And they should. But the Pilates series was conceived as rehabilitative movement for injured dancers. The side-lying leg series is fantastic for increasing your range of movement. I don’t know about building up strength, per se. Maybe if you did the exercises with ankle weights? Here’s a video of the leg circles exercise, bicycle, and leg lift. I would recommend starting out laying fully on your side, rather than hoisted up on one elbow, just so that you’re not putting any strain on your neck.

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