Triangle Pose & Femoral Version: Why It Matters
Let’s talk hip health in yoga postures. Specifically, let’s discuss femoral version. Femoral version is a term that has been around for decades, but the utility of it really wasn’t relevant, or so we thought, until the advent of better diagnostic technology that allowed the scientific community to develop measures to prevent premature degeneration of the hip, and as a result, hip replacement surgery.
It is thought that hip replacement surgery might have been preventable in a large number of cases had hip arthroscopy been available, as well as the rehabilitation to go with it, in previous decades. Thankfully, we know have advanced ways of not only viewing the hip, but addressing the problems that can plague it, which is making life livable again for the scores of folks afflicted with hip labral and impingement injuries.
But what does femoral version have to do with hip health? Femoral version describes the angular measurement of the femoral neck as compared against the distal femoral condyles.
What does that mean in English?
Have a look at this illustration below (Figure 4.25) from my text yoga in rehabilitation. In the figure, you can see a person lying on their stomach (prone-lying) with their knee bent (flexed) to approximately 90 degrees. A measurement is taken by palpating (touching) the greater trochanter (the part of the hip you can feel from the side of your pelvis) and centering it up in the middle of the upper thigh by internally and externally rotating the femur until the “centered” position is achieved. The angle you see, as is demonstrated in the photograph, is called the femoral version angle and can be taken with a digital or manual goniometer from the vertical axis of the tibia or a horizontal level line drawn between the two distal femoral condyles. A “normal” range for femoral anteversion, which is what the normal femur should possess, is between 8-15 degrees from the vertical, where the femur is slightly internally rotated. Anything above that measurement (greater than 15 degrees), is considered excessive femoral anteversion, and anything less than roughly 8-15 degrees (I typically use 15 degrees as a cutoff) is considered femoral retroversion. Seem complicated?
Watch my Femoral Version Instructional below, also known as the Craig Test.
In it I demonstrate two variations on how to pull an accurate measurement.
Now, what does that mean in plain English?
It means that, through CT scan studies, femoral version can be correlated with a loss of normal physiological osteokinematic range of motion. That is to say, if a person is found to have excessive femoral anteversion, he or she will likely have limited external rotation. If a person has femoral retroversion (any amount is considered excessive) then she or he will have limited internal rotation. This has profound implications for the practice and prescription of yoga, whether when used by a yoga teacher, yoga therapist, or healthcare provider in clinical or wellness practice.
Protection, Preservation, & Performance
Let’s apply the implications of femoral version practically, with an assessment of Triangle Pose, one of the biggest offenders of the hip and certainly one of the most commonly mistaught or malpracticed yoga postures.
First, no yoga posture practice should occur without an initial screen of the hip joints.*
Second, there are a few universal cues that should immediately be forever banned from triangle posture instruction vernacular.
“NEVER-USE CUES” for teaching Triangle Pose:
- “Square your pelvis.”
- “Put your body between 2 panes of glass.”
- “Square your pelvis as if it is between 2 planes of glass.”
- “Reach as far as you can down the front leg with your hand to support the pose.”
- “Go deeper in the pose, as you are able.”
- “The full expression of the pose looks like….”
These cues tempt injury, and some are just flat-out anatomically impossible, a kind of cruel biomechanical joke. The offense of the FIRST THREE “NEVER-USE CUES” is that they are the equivalent of biomechanical torture. In other words, the position suggested by these cues may be possible for some hyper mobile or incredibly retroverted (femoral) hips, but it is not safe and not sustainable. It invites injury on multiple levels, especially to the bony, capsular, ligamentous, and labral components of the pelvis and hip. The LAST THREE “NEVER-USE CUES” could be applied to many postures and not just triangle, because they needlessly needle a student to push, strive, and reach for a sort of perverse “physical perfection” in a pose. But guess what, “perfect poses” don’t exist. Especially in triangle pose, where safety and prevention of hip impingement or labral injury is paramount, alongside health of the sacroiliac joint, iliolumbar ligaments, pelvic floor, and soft tissue of the hamstrings and adductors, just to name a few.
The Good, The Bad, and the Ugly: Avoiding the Trifecta of Injury
Next, look at the juxtaposition of Triangle pose aligned in a healthy way (Figures 3.20 and 3.21) and one that encourages what I call a “TRIFECTA OF INJURY” (Figure 6.38) for the general population. The “Trifecta” is what I call the combined movements of spinal flexion, rotation, and side bending over a long level arm (moment arm of the head balance on the end of the spine) introduced in a vulnerable standing position that (unnecessarily) seeks extreme hip range of motion. The locks described in Figure 3.20 are explained in detail in my textbook, however, for this post just know that use of the Locks System is a critical key to creating the stability needed for safe performance of triangle pose. The locks provide internal support for triangle pose, and many others, however a discussion of locks deserves its own post, and occupies a large section of Medical Therapeutic Yoga as a foundational precept for use of yoga in safe programming. I’ll be posting in the future on the Yogic Locks System.
Figure 3.20 demonstrates a triplanar action of triangle pose, the foundation of safe performance. This means that the trunk is kept in a relative spinal neutral position, along with the sacroiliac joint, because the pelvis is in a transverse plane (NOT forced to be square or “between 2 panes of glass.”) There are modifications that would need to occur, chiefly flexion at both knees, in order to adapt the pose to someone with excessive femoral anteversion or femoracetabular impingement (false or actual). The person with femoral retroversion (an angle less than 8-15 degrees femoral anteversion) may still need to adapt this pose by avoiding end range of motion at the hip (since they tend to have excessive hip external rotation and very limited hip internal rotation). The back knee may need to be flexed 5-10 degrees in order to mediate the pelvic obliquity required in this transverse position, which would create a hip internal rotation and adduction moment, not a happy position for those with measured femoral retroversion.
The TATD breath would also be necessary, especially during transitions, in order to transfer load safely from the trunk to lower extremity. It would also be quite helpful due to its biomechanical involvement in those who have pre-existing iliotibial band syndrome, back pain, sacroiliac joint pain, or general knee pain, due to the fascial and diaphragmatic components which tether the trunk and lower extremity in structure and function.**
In FIGURE 3.21, those with an absence of TATD breath mastery could still perform the pose, but with external support (a chair, a ball, etc.). Those with less responsive posterior tissue in the back of the legs (it’s not just about the hamstrings folks, you’ve got fascial, neural, and vascular tissue that need as much attention as a needy Labrador Retriever) or a lack of hip awareness or mobility will also need to follow Figure 3.21 and not place the hand as far down the leg. Medical Therapeutic Yoga outlines and provides more illustrations on evidence-based modifications.** Learn the TATD Breath
Figure 6.38 demonstrates the “TRIFECTA OF INJURY,” one of the ways that triangle pose is often performed and taught. The pose should not be taught to those without first mastering the postures outlined in MTY, and at the very least mastering Abdominodiaphragmatic Breath (AD) and TATD Breath. If you have difficult learning the breath types and tend to chest breathe or find tension in the head, neck, and/or face, try practicing on THE YOGA COUCH.
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Next, in those with a history of low back pain, hip pain, pelvic pain, or sacroiliac joint issues, or in those with muscular weakness or lack of awareness, in addition to the inability to demonstrate mastery of A-D Breath and TATD Breath, avoiding this particular “TRIFECTA” alignment becomes paramount. This is because there is a lack of internal support to perform the pose, and the long moment arm and load of the trunk is a disadvantageous lifting angle. Think safe lifting “101” where we are all taught to lift with our legs not our backs. The same old proverb holds true here, especially for those with the aforementioned issues. Performing the pose as in Figure 3.20 or 3.21, or using any of the many adaptations given in my textbook, maximizes potential for optimizing pressure between THE THREE DIAPHRAGMS (vocal/thoracic, respiratory, and pelvic). Discussion of the three diaphragms is also outside the scope of this post but is something I will be covering in future posts.
The “Trifecta” is just one of a few ways that triangle can go awry. Some of the others are in using dangerous cues listed above, such as the “panes of glass” cue or the “reach further” type of cues.
Finally, with respect to femoral version angles in this particular pose, remember that hip external rotation will be limited in those with diagnosed excessive femoral anteversion, which means triangle will look different. Likewise, in those with diagnosed femoral retroversion, internal rotation will be markedly limited. As above, the knees may be flexed if there is an active tear, recent repair, flare-up, external or internal impingement, or hip range of motion needs to be limited. Read my post on Hip Impingement to learn more. Alternately, less degrees of freedom may be taken in the pose in order to minimize load transfer requirements, which means the hand will rest farther up the leg, closer to the hip, or even use other external supports like the wall or a chair. The key to safe performance of triangle, as always and especially in absence of a thorough physical examination of the hip, is to listen to your body and err on the side of caution. Some final tips for safe performance if you suspect you or a student or patient may have pathologic femoral version include:
- Avoid end range of motion in all poses, not just standing postures.
- Flex the knees in postures like Warrior I, II, Triangle, Extended Side Angle, and Revolved Triangle.
- Use a triplanar alignment for Triangle pose, as well as Extended Side Angle pose. Warrior I, II, and Revolved Triangle use a different alignment, which will be addressed in future posts.
- Practice with me on YouTube! These videos also accompany the Medical Therapeutic Yoga text, which give precaution, indications, and contraindications for standard yoga postures.
- Pick up a copy of Medical Therapeutic Yoga to guide your own personal or professional practice.
*Note that assessment and evaluation of the hip joint should be done by a licensed healthcare provider, preferably a physical therapist or orthopaedist. It may be possible for a yoga teacher to screen healthy range of motion in the hips, but assessment and evaluation would be beyond her/his legal capability.
**Please refer to Medical Therapeutic Yoga for citations, and more information, including instruction, and scientific evidence-base and rationale. Please lease feel free to leave your comments below the blog.
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