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Tuesday, June 6, 2023

Hip Range of Motion and Low Back Pain

Brent Brookbush

Brent Brookbush


Research Review: Comparing Hip Range of Motion and Low Back Pain

By Erik Korzen, DC, NASM CES

Edited by Brent Brookbush DPT, PT, MS, PES, CES, CSCS, ACSM H/FS

Original Citation: Ellison, JB., Rose, S., Sahrmann, S. (1990). Patterns of Hip Rotation Range of Motion: A Comparison Between Healthy Subjects and Patients with Low Back Pain. Phys Ther 1990. 70: 537-541. FULL TEXT

Why is this relevant? For human movement professionals, it is essential to understand asymmetry and how it applies to people that are currently in pain or to recognize they may experience pain in the future. Hip range of motion (ROM) is a relatively common assessment used for low back and lower extremity pain. Currently, the American Academy of Orthopedic Surgeons considers medial (internal) and lateral (external) rotation of the hip to be essentially symmetrical (1). Discrepancies, however, are quite common in range of motion assessments bilaterally. The authors of this research compare bilateral hip medial and lateral rotation.


Study Summary

Study DesignQuantitative Analysis
Level of Evidence Level IIA: Evidence from at least 1 controlled study without randomization
Subject Demographics
    • 100 Healthy subjects
      • 25 male
      • 75 female
      • 20-41 years old

    • 50 Patient subjects

      • 21 male
      • 29 female
      • 23-61 years old
      • reported Low Back Pain and undergoing treatment at time of study, pain varied from 1 week to 20 years

Outcome Measures
  • Goniometer and Inclinometer measurements of hip internal and external rotation in prone and sitting
    • No significant differences found between prone and sitting

  • All subjects placed into a specific category or sub-category based on findings
    • Total Medial ROM: Left and Right Medial rotation
    • Total Lateral ROM: Left and Right Lateral rotation
    • ROM considered equal if differences were 10 degrees or less

  • Subject Categories
    • Pattern I: Total Medial ROM = Total Lateral ROM
    • Pattern IA: Left Medial, Left Lateral, Right Medial, Right Lateral ROM ALL within 10 degrees of each-other
    • Pattern IB: Total Medial ROM = Total Lateral ROM, but 1 or more of the Left Medial, Left Lateral, Right Medial, Right Lateral differed by 10 degrees or more
    • Pattern II: Total Medial ROM > Total Lateral ROM by 10 degrees or more
    • Pattern III: Total Lateral ROM > Total Medial ROM by 10 degrees or more

  • Pattern IA: Healthy n = 27, Patient n = 7
  • Pattern IB: Healthy n = 5, Patient n = 4
  • Pattern II: Healthy n = 41, Patient n = 15
  • Pattern III: Healthy n = 27, Patient n = 24
  • Pattern IA demonstrated in 27% of healthy group
  • Pattern II demonstrated in 41% of healthy group and 30% of patient group
  • Pattern III demonstrated in 27% of healthy group and 48% of patient group
    • Total Medial Rotation was LESS than Total Lateral Rotation

Conclusions of the Researchers
  • Mean Values of Medial and Lateral ROM for BOTH Healthy group and Patient group were less than 45 degrees
  • Pattern II most prevalent in healthy group
  • Pattern III most prevalent in patient group
  • Pattern IB was least demonstrated pattern
  • Patient group was older overall, compared to healthy group
  • Pattern III had higher prevalence in patient group
  • Low back pain may be related to imbalance in hip ROM
    • specifically Total Lateral ROM > Total Medial ROM by 10 degrees or more

Review & Commentary:

This study provides a unique perspective for human movement professionals by comparing symmetry and medial (internal) and lateral (external) rotation in low back patients. The set of patterns that the researchers set forth help to categorize large sub-groups of ROM discrepancies.

A significant limitation of the study is the discrepancy in age of those who presented with Pattern III (Total Lateral > Total Medial ROM). The patient group, which presented with this pattern was generally older. The researchers state that they do not believe this finding is related simply to age, but further research should support the assertion.

Another potential limitation is the numerous clinical diagnoses related to low back pain/dysfunction, including acute and chronic conditions. Failing to identify if hip ROM asymmetry was related to the chronicity of a person's condition fails to identify whether these changes could be the cause of low back pain, result from initial onset, or be the result of chronic adaptation to low back pain. Further research is needed to determine if chronicity of low back pain has an effect on hip ROM.

The researchers use of categories does help to identify the most common, and potentially deleterious relationships between symmetry, hip range of motion and low back pain. Identifying Pattern III (Total Lateral > Total Medial ROM) may be useful indicator of potential or contributing factors to low back pain in a clinical or exercise setting.

Another strength of this study is the inclusion of not only right and left hip range of motion, but comparison of medial and lateral rotation. This is an important distinction as many professionals consider bilateral asymmetry to be a potential issue, but less frequently consider comparing internal and external rotation to one another. Interestingly in this study, right to left asymmetry was not as prevalent as Pattern III (Total Lateral > Total Medial ROM), or significantly different between groups.

Why is this study important?

Comparing a subject's ROM bilaterally, as well as opposing rotational movements of a joint can provide great insight into potential dysfunction and the ability to move optimally. The hip itself is a structure intimately related to the pelvis and lumbar spine, and should be considered when functional activities, dynamic movement assessment, and/or gait result in lumbar spine pain and dysfunction. Specifically, a loss of hip medial rotation and an increase hip lateral rotation may be a contributing factor to low back pain, or may be a predictor of future back pain.

How does it affect practice?

This study gives the human movement professional impetus to include hip internal and external rotation as an integral part of an assessment protocol designed to identify lumbo pelvic hip complex dysfunction and/or low back pain. Goniometry is not complex and can be mastered by human movement professionals in all settings.

Further, understanding the limiting structures to hip internal rotation and over-active structures that may be contributing to hip external rotation hyper-mobility may enhance interventions. Continued effort should be made by all human movement professionals to deepen their understanding of functional anatomy in the pursuit of optimal intervention selection. For example, the piriformis deep rotators of the hip , biceps femoris and adductor magnus have a propensity to become over-active and may restrict hip internal rotation. This may indicate that release and lengthening techniques for these muscles would be appropriate. For a more complete list of potential restricting structures it is recommended that the following lesson is reviewed: Lower Body Goniometry .

Goniometric Assessment
Caption: Goniometric Assessment

How does it relate to Brookbush Institute Content?

The Brookbush Institute discusses dysfunction of the hip joint and the potential for low back pain in the predictive models of Lower Leg Dysfunction (LLD) and Lumbo Pelvic Hip Complex Dysfunction (LPHCD), as well as the variation of LPHCD, Lumbosacral Dysfunction . In all three models asymmetry between medial and lateral rotation is noted and the affect on muscle activity and length is discussed. These models are congruent with the findings of this study; however, consider additional research and a more complex look at arthrokinematic and fascial adaptations in the pursuit of optimal intervention. Below are videos on techniques that may improve hip internal rotation range of motion:

Self-administered Hip Mobilization

Gluteus Minimus Release:

TFL Release:

Piriformis and Deep Rotator Release:

Kneeing Hip Flexor Stretch:

Piriformis Stretch:

1. Joint Motion: Method of Measuring and Recording. Chicago, Ill: American Academy of Orthopaedic Surgeons

© 2015 Brent Brookbush

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