Can miserable malalignment be fixed quickly?

If you've never heard of the medical diagnosis "miserable malalignment" it's because it hasn't been discussed much until recently. The first time I heard about it was from a client. She was a physical therapist who had been diagnosed with the condition.

femoral internal rotationThe right leg (left in the picture) has relatively internally rotated femur and externally rotated tibia.

Why is it en vogue now? Because a growing number of surgeons are starting to talk about the surgery as a surefire cure for knee, leg, and hip pain. 

But as we've seen with spine, hip, knee, and shoulder surgeries, the medical industry has a long history of overselling the benefits of new orthopedic surgeries.

So in this article, we're going to take a closer non-medical look at miserable malalignment.




What is miserable malalignment?

Put simply, it's a misalignment of the bones of your leg. Your thigh bone rotates internally (so the knee points inward), your lower leg bones rotate out, and your arch (sometimes) collapses.

In anatomical terms, it's when your femur and your tibia are not aligned. 

This situation is believed to be the cause for knee pain, hip pain, ankle pain, and foot pain. 


How can miserable malalignment be fixed?

In the medical world, you have a choice of a few surgical procedures. According to some websites, the solution could be as simple as a bolt that looks like this:

bolt to fix miserable malalignment

What in the world would you do with that bolt? The manufacturer proposes that you bolt it into your ankle bone. This is supposed to provide support to the lower leg and improve the alignment of the bones.

Another option is a procedure that involves breaking your tibia and screwing in external fixators. The fixators are used to torque the tibia and femur into a better relationship over time. This is an involved, invasive, and lengthy process. 

One of our clients was told this is the procedure he needed in order to fix the pain in his right foot, ankle, knee and hip. This is AFTER he had already had a hip surgery that failed to provide any pain relief. 

He retells his story in the video below.


Why is surgery for miserable malalignment growing?

This is where things get interesting and where a little historical perspective goes a long way.


How orthopedic surgeons create joint pain theories

To start, you need to understand that in the medical world, different issues are the responsibility of different specialists. Pediatricians concern themselves with children and their issues. Oncologists deal with cancer. Obstetricians deal with pregnancy and childbirth. 

Everyone has been given a realm of expertise and specialists don't cross over into other specialties generally.

surgeons look for ways to do surgeryWhat should we cut?

A pediatrician will refer you to an obstetrician if that's appropriate. Your primary care physician will refer you to an oncologist if you have cancer. The expertise of the specialist is generally not questioned.

So what about musculoskeletal pain?

Pain in and around the joints historically has been the responsibility of orthopedic surgeons. Certainly, there are some other specialties that do deal with joint pain (like rheumatology or physiatrists), but the most authoritative voices in "joint pain" are orthopedic surgeons.

Orthopedic surgery as a field has an obvious bias to perform surgery. It's a practice that has evolved from battlefield surgery tents in World War I and II - where swift and invasive surgeries save lives. 

Orthopedic surgeons look for structural deformities to correct. That makes sense in a battlefield tent. Shrapnel, a bullet, or a bone fracture could be threatening the life of a patient.  

In the world of chronic joint pain, orthopedic surgeons apply this same mentality. They look for a discrete structure that can be fixed through surgical means. 

If your hip hurts, it's because your hip is damaged. If your back hurts, it's because your spine is arthritic. If you shoulder hurts, it's because your bones are deformed. If your knee hurts, it's because the padding is torn and needs to be removed.


Orthopedic surgery as a field has an obvious bias to perform surgery. It's a practice that has evolved from battlefield surgery tents in World War I and II - where swift and invasive surgeries save lives...


Sound familiar?

Did you realize that those are all examples of ideas that have been proven to be false over time? The medical community is trying to get away from those treatments because they are expensive, risky, and can make patients worse off. 

Recent research has consistently shown that pain often has nothing to do with the structures surgeons keep cutting. 


Is this happening again with miserable malalignment? 

It certainly looks like surgeons are looking to make surgery for miserable malalignment more common. As with previous surgeries in history, there are incentives that make this almost unavoidable.

coin toss for miserable malalignment surgery

First, there is the procedural fee incentive.

Surgeons earn considerable amounts of money per procedure. Imagine that you earn tens of thousands of dollars for one procedure. You believe this procedure helps people. So you publish papers on how useful it is. This boosts your reputation in the field which also means your fees go up...

Will you be easily convinced that the procedure may not be the best way to help people? Are you incentivized to critically compare your procedure to a noninvasive procedure? 

Second, there are hidden financial incentives.

Take a look at this study on surgery miserable malalignment for an example. It's a VERY small study claiming a perfect 100% success rate for surgery.

Scroll to the Conflicts of Interest section,  and you'll see something seemingly innocuous. The surgeons in this study used specific devices to "fix" miserable malalignment. Notice that the senior author of this study is a paid consultant and speaker for the manufacturer of the devices.


We can't say that the authors are definitively biased. But we can say the risk of bias is incredibly high.


Put yourself in the shoes of this surgeon. You believe in your heart that this surgery helps people. You earn money from performing this relatively new procedure. You are also paid by the device manufacturer for consulting and speaking to other doctors about the procedure. 

Will you be likely to report anything negative about the surgeries you've personally performed that used the devices someone is paying you to promote? 

We can't say that the authors are definitively biased. But we can say the risk of bias is incredibly high. We can also note that many other orthopedic surgeries have started out in this exact same way before being debunked decades later (see meniscus surgery). 

The likelihood that this is happening again with miserable malalignment seems quite high.


The problem with medical specialization and joint pain

Now we come to a big problem that has occurred throughout the history of musculoskeletal pain. 

Remember that orthopedic surgeons define the problems with chronic joint pain. If they say something like, "knee pain is from damage in the meniscus, and we can fix it by removing the meniscus," it goes unchallenged for years. 

In those intervening years, primary care doctors, physical therapists, and everyone else in the medical world echo what the orthopedic surgeons have said. Because the surgeons are the experts publishing papers on the problem.

Physical therapy focuses on approaching knee pain the way surgeons have defined it. Therapists will tell you to unload the knee, stay away from loading the "compromised" knee, and will be ready to help you AFTER surgery.

By the time the research catches up, billions of people already believe that the only cure for knee pain is removing a damaged piece of the knee. This delays or completely stops any development of different perspectives or nonsurgical approaches to the problem. 

That's why it took decades for the medical world to finally say, "wait, spinal surgery should be a last resort...Exercise should be one of the first."


So are there nonsurgical approaches to miserable malalignment?

Just as with other "orthopedic conditions," there's a common prevailing belief that the only solution is surgery. 

Will the surgery work sometimes? As with all treatments, it will definitely work - sometimes. Even leech bloodletting cured some patients. 

We aren't surgeons so we can't say any of our clients had an official "medical condition." However, we have trained many clients over the years with very clear rotations of the tibia relative to the femur. 

Here is a brief outline of what we've done with clients to help them retrain the hip and leg muscles for better alignment and, consequently, less pain: 

  • Increase strength of lateral hamstrings at a lengthened position (stretch first, then build strength at that length). This allows the tibia to internally rotate.
  • Increase the strength of the internal rotators of the tibia in all positions, especially in a shortened position. This is create active internal rotation torque on the lower leg. Muscles includes the medial hamstrings, gracilis, and gastrocnemius.
  • Increase strength of the hip abductors and external rotators. Muscles include glute medius, maximus, the deep hip rotators, and the hamstrings. This rotates the femur laterally.


Exercise ideas for miserable malalignment



The "tibial twister" stretch to realign the tibia and femur. 


Active internal rotation to strengthen your tibial internal rotators. 

The exercises above can help you get things realigned in the leg. They don't address the weaknesses that are often up in the hip too. You definitely want to be thinking about the hip muscles as well to get great results. 

Why does any of this work? For one simple reason: bone position is a result of muscle activity. Put another way, bones DO NOT move themselves. So if we teach the muscles to move the bones in the direction we want, we can improve positions. 

That's how you improve posture. That's how you improve your ability to do a pushup or a squat. You teach muscles to move bones the way you want. 


If the tibia is externally rotated relative to the femur, then you reduce the pull of the external rotators (first item in the list) and you get the medial rotators more active (second item in the list).

If the femur is rotated internally, then you get the external rotators more active (third item in the list). 

It's important also to work on these things in multiple hip angles so that you have confident control in all positions throughout the day. 


The bottom line on miserable malalignment

There are big incentives for surgery to become more popular and more strongly recommended for miserable malalignment. 

There are systemic issues that promote overreaction to this "condition" and prevent serious consideration of nonsurgical treatment of miserable malalignment for the next several years. 

But if you are trying to solve your own issues, we believe it is safer, cheaper, and more rational to train the hips and leg muscles consistently and gradually as outlined above.

If you're a physical therapist or a trainer who helps people learn to move better, then please let us know how the ideas above help you with your people. 

Finally, it's a process to reactivate all these muscles. Some clients have reported relief within weeks. Some within months. Almost all required detailed movement coaching to understand the WHYs and HOWs and the ways in which daily habits affect muscle activity. 

In the end, it takes time, attention, and the willingness to learn and adapt.

Train your body to be more flexible, strong, and resilient! 

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