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June 6, 2023

The Relationship Between Hip Rotation Range of Movement and Low Back Pain Prevalence in Amateur Golfers: An Observational Study

This observational study examines the link between hip rotation range of movement and low back pain in amateur golfers. Learn how to reduce your risk of injury on the course.

Brent Brookbush

Brent Brookbush

DPT, PT, MS, CPT, HMS, IMT

Research Review: The Relationship Between Hip Rotation Range of Movement and Low Back Pain Prevalence in Amateur Golfers: An Observational Study

By Amy Martinez DPT, PT

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

Original Citation: Murray, E., Birley, E., Twycross-Lewis, R., & Morrissey, D. (2009). The relationship between hip rotation range of movement and low back pain prevalence in amateur golfers: an observational study. Physical Therapy in Sport, 10(4), 131-135. - ABSTRACT

Introduction: A growing body of research has established a correlation between low back pain (LBP) and reduced hip internal rotation range of motion (ROM) (1-6). Professional golfers with LBP have demonstrated limited internal rotation ROM of the lead hip (5). This 2009 study by British researchers on amateur golfers with LBP demonstrates the same limited ROM of of the lead hip, both passively and activity. These findings suggest that human movement professionals should assess and address hip internal rotation in those individuals with LBP, and special attention may be given to the lead hip of golfers.

Goniometry of hip internal rotation in a prone position. (Image: Courtesy of www.BrentBrookbush.com)

Study Summary

Study Design Observational Case-Control Study
Level of Evidence Level III: Evidence from non-experimental descriptive studies, such as comparative studies, correlation studies and case-control studies
Participant Characteristics Demographics - Overall
  • Number of participants: 64
  • Age: 18 - 70
  • Gender: 43 male and 21 female
  • Amateur golfers

Demographics - LBP Study Group

  • Number of participants: 28
  • Age: 56.4 +/- 8.4
  • Gender: 26:2 (male: female)
  • Height: 179.1 +/- 8.7 cm
  • Weight: 85.2 +/- 14.5 kg
  • Hand Dominance: 25:3 (right: left)
  • Rounds played per week: 2.0 +/- 0.9
  • Years of play: 27.3 +/- 11.3

Demographics - Control Group

  • Number of participants: 36
  • Age: 54.3 +/- 14.4
  • Gender: 32:4 (male: female)
  • Height: 176.8 +/- 7.8 cm
  • Weight: 78.2 +/- 10.2 kg
  • Hand Dominance: 33:3 (right: left)
  • Rounds played per week: 2.1 +/- 1.1
  • Years of play: 22.9 +/- 15.6

Inclusion Criteria

LBP Study Group:

  • Current or history of low back pain (LBP) within 12 months prior to the study
  • Injury duration greater than 2 weeks

Control Group:

  • No history of LBP

Exclusion Criteria

LBP Study Group:

  • LBP due to a clear traumatic event
  • History of spinal surgery

Control Group:

  • N/A
Methodology
  • Participants were placed in the study and control groups after completing a screening questionnaire, which included:
    • Anthropometric and golf participation data
    • Self-reported LBP in the past 12 months
    • Description and location of injury on a body chart

  • Two examiners collected data while blinded to participants' group assignments
  • Participants performed a standardized 5-minute warm-up on a stationary bicycle
  • Following the warm-up, hip medial and lateral rotation range of motion was measured in the prone position
  • Active and passive measurements were obtained for the right and left sides
  • The mean of 3 trials was taken for each measurement
Data Collection and Analysis
  • Mean data for passive and active hip medial and lateral rotation range of motion for the lead and non-lead hips were analyzed using the Kolmogorov-Smirnov rest, and were shown to be normally distributed
  • Inter-group measurements were analyzed by independent samples t-tests
  • Intra-group measurements were analyzed by paired sample t-tests
  • Inter- and intra-rater reliability was analyzed by intra-class correlation coefficients for all measures
Outcome Measures
  • History of LBP
  • Lead and non-lead hip medial and lateral rotation (passive and active)
  • Inter- and intra-rater reliability
Results Medial Rotation
  • Participants in the LBP group had a 10-degree deficit in mean passive hip medial rotation of the lead hip compared to those in the control (t= -4.352, 95% CI -14.621 - -5.205)
  • Participants in the LBP group had a 7-degree deficit in mean active hip medial rotation of the lead hip compared to those in the control (t= -3.014, 95% CI -11.147 - -2.036)
  • There was no difference in mean passive or active hip medial rotation of the non-lead hip (t=-0.888, 95% CI -6.578-2.530; t=-0.142, 95% CI -4.985-4.350 respectively)

Lateral Rotation

  • There was no statistically significant difference in mean passive or active hip lateral rotation of the lead hip (t=0.446, 95% CI -2.928-4.571; t=1.931, 95% CI -0.155-8.901 respectively)
  • There was no difference in mean passive or active hip lateral rotation of the non-lead hip (t=0.220, 95% CI -4.361-5.417; t=1.482, 95% CI -1.182-8.031 respectively)

Within Group Comparisons

The LBP group exhibited:

  • A 7-degree deficit in mean passive hip medial rotation between the lead and non-lead hip (t=-6.659, 95% CI -11.446--6.054)
  • A 9-degree deficit in mean active hip medial rotation between the lead and non-lead hip (t=-4.196, 95% CI -11.700--4.196)
  • No difference in mean passive or active hip lateral rotation between the lead and non-lead hip (t=1.002, 95% CI -1.907-5.550; t=-0.198, 95% CI -3.669-4.455 respectively)

The control group exhibited:

  • No difference in mean passive hip medial or lateral rotation between the lead and non-lead hip (t=0.541, 95% CI -4.090-2.368; t=-0.863, 95% CI -2.066-5.122 respectively)
  • No difference in mean active hip medial or lateral rotation between the lead and non-lead hip (t=-1.121, 95% CI -4.450-1.284; t=-0.319, 95% CI -4.093-2.982 respectively)

Reliability

  • Intra-class correlation coefficients (ICCs) for active medial and lateral rotation measurements ranged from 0.91 to 0.99, respectively
  • ICCs for passive medial and lateral rotation measurements ranged from 0.83 to 0.99, respectively
  • ICCs demonstrated significance of p<0.001 for all measures
Our Conclusions Our conclusions match those of the researchers, as described below. These findings support the altered movement patterns described in the Brookbush Institute's predictive model of lumbo pelvic hip complex dysfunction (LPHCD) and Lumbosacral Dysfunction (LSD).
Researchers' Conclusions

This study demonstrates that amateur golfers with LBP have significantly reduced lead hip medial rotation compared to the non-lead hip and the control group. Measures for non-lead hip medial rotation, as well as lead and non-lead hip lateral rotation, were not significant and were not found to be associated with incidence of LBP. These findings suggest that decreased lead hip medial rotation may be a component of LBP and may be relevant for screening or treatment selection.

Hip medial rotation during golf swing. (Image: Zach Dischner - Swing Away!, cc-by-2.0, https://commons.wikimedia.org/wiki/File:Swing_Away!_(4683150851).jpg)

How does this study contribute to the body of research:

Low back pain (LBP) is the most commonly reported injury among golfers (7). Research has demonstrated that professional golfers with LBP exhibit limited lead hip internal rotation ROM, and excessive lumbar spine flexion and rotation during swing (5, 8). This study investigated active and passive hip rotation range of motion (ROM) in amateur golfers with and without LBP. This study adds to the body of evidence by demonstrating that the limitations in hip ROM occur both passively and actively, and include amateur golfers (3-6).

How the Findings Apply to Practice:

The findings of this study suggest that a reduction in lead hip internal rotation is associated with low back pain (LBP), especially in golfers of all levels. For those individuals exhibiting signs of LBP, human movement professionals should consider hip rotation goniometry and interventions for addressing ROM limitations.

The study had many methodological strengths, including:

  • Researchers were blinded to participants' group assignments, enhancing the validity of data collection and minimizing tester bias.
  • Inter- and intra-rater reliability was calculated through intra-class correlation coefficients (ICCs), demonstrating significance and reliability for the data collected.
  • The sample size of each group was determined based on previous research, powering the study to adequately detect significant differences.
  • Both passive and active mobility was assessed, providing additional information about the nature of range of motion deficits.

Weaknesses that should be noted prior to clinical integration of the findings include:

  • Inclusion criteria for each group was based on subjective reporting of LBP. Formal diagnosis, objective and/or functional data would better ensure that individuals are assigned into the appropriate group.
  • Participants in each group were not matched for factors such as height and weight, as the LBP group was noted to be heavier than the control group. Matching participants in the study and control groups would help reduce extraneous variables in the data and results.

How does it relate to Brookbush Institute Content?

The Brookbush Institute has developed predictive models of postural dysfunction that aggregate evidence of common tissue changes (muscle, joint, fascia and nerve) to aid human movement professionals in selecting optimal assessments, manual interventions and exercise. The Lumbo Pelvic Hip Complex Dysfunction (LPHCD) model notes changes in lumbar mobility and hip mobility that are consistent with the findings of this study, including a decrease in hip internal rotation, and potentially asymmetry between right and left hip ROM.

The following videos illustrate common assessment techniques for the LPHCD , as well as interventions commonly used to improve hip internal rotation ROM.

Overhead Squat Assessment: Sign Clusters - Lumbo Pelvic Hip Complex Dysfunction

Goniometry: Hip internal rotation in prone

Goniometry: Hip Internal Rotation in Supine (90/90 Hip IR)

Tensor Fasciae Latae Self-Administered Static Release

Tensor Fasciae Latae Manual Static Release (Soft Tissue Mobilization)

Hip Joint Lateral Manual Mobilization

Bibliography:

  1. Barbee Ellison, J., Rose, S. J., & Sahrmann, S. A. (1990). Patterns of hip rotation range of motion: a comparison between healthy subjects and patients with low back pain. Physical Therapy, 70(9), 537-541.
  2. Cibulka, M. T., Sinacore, D. R., Cromer, G. S., & Delitto, A. (1998). Unilateral hip rotation range of motion asymmetry in patients with sacroiliac joint regional pain. Spine, 23(9), 1009-1015.
  3. Vad, V. B., Gebeh, A., Dines, D., Altchek, D., & Norris, B. (2003). Hip and shoulder internal rotation range of motion deficits in professional tennis players. Journal of Science and Medicine in Sport, 6(1), 71-75.
  4. Grimshaw, P. N., & Burden, A. M. (2000). Case report: reduction of low back pain in a professional golfer. Medicine and Science in Sports and Exercise, 32(10), 1667-1673.
  5. Vad, V. B., Bhat, A. L., Basrai, D., Gebeh, A., Aspergren, D. D., & Andrews, J. R. (2004). Low back pain in professional golfers: the role of associated hip and low back range-of-motion deficits. The American journal of sports medicine, 32(2), 494-497.
  6. Mellin, G. (1988). Correlations of hip mobility with degree of back pain and lumbar spinal mobility in chronic low-back pain patients. Spine, 13(6), 668-670.
  7. McHardy, A., Pollard, H., & Luo, K. (2006). Golf injuries: a review of the literature. Sports Medicine, 36(2), 171-187.
  8. Lindsay, D., & Horton, J. (2002). Comparison of spine motion in elite golfers with and without low back pain. Journal of Sports Sciences, 20(8), 599-605.

© 2018 Brent Brookbush

Questions, comments, and criticisms are welcomed and encouraged.

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