Working with Bowed Legs: Making a Bow into an Arrow

by Dominika Borovansky Gaines

Recently a Facebook group of movement teachers of which I am a member had a query about working with people with bow-legs, which exercises were successful and which were less so.  As I drafted a response, I realized that the work I'd been doing with one of my clients was worth sharing.

My client, a mature woman, has been working with me for over 15 years.  She travels internationally for work and pleasure and remains very active with hiking, biking, fly-fishing, sailing and many other wonderful adventures. She is a dedicated student and is diligent about doing homework and taking care of her body when she is not in the studio.

Historically we focused on Pilates and GYROTONIC® exercise with some Ideokinesis here and there, but as the years have passed my client has had more recurring pain in her knees, a hip replacement, and a severe shoulder injury following surgery.  Since my own education has broadened in the past five years to include Restorative Exercise and Z-Health® Performance skills, I've implemented a more blended approach in our work together.

A big part of Nutritious Movement™'s Restorative Exercise program is the implementation of a biomechanical model for neutral stance that emphasizes three key points different from other models: weight stacked over the lateral malleoli/heel, externally rotated femurs with knee pits facing back, and anterior lower ribs over ASIS.  These three areas were not vertically aligned in my client's habitual posture.  Her bowed legs sent her knees behind her heels and her knee pits faced diagonally away from each other, so she was constantly living in femoral internal rotation.  To counter-balance the locked-back knees, she habitually thrust her lower ribs forward, which often led to lower back pain and variable core stability.

We first began working with finding external rotation of the femurs using an exercise charmingly known in RE-circles as "The Human Pez Dispenser."  A block is placed between the inner thighs and the participant actively rotates the femurs to move the block forward (external femoral rotation) and back (internal femoral rotation).  When first learning this exercise, we allowed the entire leg to externally rotate and the weight to roll to the outside edges of the feet.  As external femoral rotation became more natural, we looked at her weight distribution on her feet and aligned the critical points to a more neutral stance, with weight at the base of the big toe and lateral heel.  Finally, we included awareness of when the knee pits were facing back.

Because of the shape of her legs, we also needed to attend to the tibial torsion of the lower leg.  We worked on at bringing the calf muscle more medially along with the femoral rotation. This creates a strong feeling of spiral all the way from the foot to the hip.  Because she hikes frequently, we worked on bending and straightening the knees while maintaining that rotation.  We practiced this with her standing, lying on the GYROTONIC® equipment and doing various hamstring series exercises, sometimes stepping up onto a platform and practicing sit-to-stand keeping this spiral active. We also discussed mindfulness when walking: visualizing the knee pits facing back so the knee flexes sagittally in gait, and lower ribs staying over the hips and not in front of them.

Part of correcting the bow of the legs has been to bring more balanced activation of the muscles around the entire hip joint. A cue that I have found extremely valuable for activating all of the muscles of the hip and pelvis simultaneously is to "imagine pulling on a pair of tights." In order to get the crotch of the tights up to the pelvis, you gently pull up on all sides.  You can't force any one direction or the tights will get a hole. And there's nothing more annoying than a crotch slipping down!

With an integrated spiral in the legs becoming more natural to her, we began attending to the idea of concentric and eccentric muscle contractions.  I observed many times that my client was able to activate her hamstrings and adductors when her legs were externally rotated but as soon as she moved into internal rotation, any contraction gave way to no activity (this was her comfortable, normal).  At first we worked with simple sagittal movements (GYROTONIC® leg pumps and Dolphins) with me verbally cueing "concentric" and "eccentric".  Then I added the challenge of movements which involved coordinated internal and external femoral rotation (GYROTONIC® hip and knee mobilization).  Many times we had to limit the range of her internal rotation to prevent her from "letting go.”

Next we started working on ankle and knee mobility and muscular coordination with some specific Z-Health skills.  (What I like about these movements is that they are simple, take very little time to perform and can be done anywhere/anytime without any props.) With bowed legs, the relationship between the lower leg bones and the feet are askew.  We began working on gliding the ankle both sagittally and in the frontal plane.  Forward and backward rocking, side-to-side rocking, gliding heel circles with pressure against the floor and unweighted ankle circles have all assisted her in getting a better sensory map of her ankles and feet.  Then I added hip mobility skills, working first on small lunge knee circles, and emphasizing a continual low-grade muscular activation, so that the adductors and medial hamstrings continued to fire as she straightened her leg. As this became more consistent, I also added disassociation while standing: making a movement with the femur without moving the pelvis.

My client's legs have quite literally changed shape, as this video illustrates:

Now we're taking all of this up to the pelvis.  For many years we've worked on the Pelvic Clock, noting where there are skipped portions in the circle. Initially this was a very challenging exercise for my client, particularly following her hip replacement surgery.  We've found that working on lateral glides of the pelvis relative to the femur, the femur relative to the pelvis, and rotating the pelvis relative to the femur have all been fantastic for re-mapping this area.

Because many people lock their knees before fully extending their hips when coming to standing, we complete each session practicing sit-to-stand.  Layering, we have: engage the hamstrings, spiral the femurs, press the heels down, pull your tights up (I say, "Your knees will be straight when you've lifted your hips high enough.") On the way down: move the pelvis back, hamstrings engaged, keep the spiral, lower the pelvis.  As she said recently, "If you lift the pelvis and not the ribs, it's better and doesn't hurt my knees."

So, there you have it.  Two years of work.  And bows that have become arrows.