A recent patient case has reminded me of the power of the Rotation in Flexion procedure when treating with back injuries that have a lateral component. The indication that a lateral component is present could be unilateral symptoms into the lower extremity, Abbarent lateral motion with flexion/extension ROM testing, lateral shift when assessing spinal position, etc. When you have exhausted the extension principle force progression with lateral components, remember to add in rotation in flexion.
Rotation in flexion is performed in theory to create a bow-stringing effect on the nucleus pulposus to create a force to bring it centrally. In order to complete the procedure, begin with the patient in supine, flex the knee to 90 degrees or to the point where there symptoms respond positively, then rotate to the painful side. This position could be maintained for up to two minutes but is ultimately based on patient response. If force progression is necessary, the therapist can stand in a staggered stance next to the painful side and have the patients lower legs rotate over to the clinician's anterior thigh. The anterior thigh can be used to support the lower body while a rotation mobilization can be performed by stabilizing the patients shoulder and using the patient's knees to further the rotation force.
This has recently been very effective in my practice with unilateral radicular symptoms that other lateral procedures and weight bearing motions have exacerbated symptoms. The rotation in flexion can essentially be considered a force progression of the extension principle with lateral components.
