Today’s post comes from Dan Lorenz, MS, PT, ATC/L, CSCS. Dan is a graduate of the sports physical therapy fellowship at Duke University and is currently a sports medicine specialist at Providence Medical Center. He has great experience with a wide variety of orthopedic and sports medicine patients, including stints with the US Olympic Training Center, Chicago White Sox, and most recently the Kansas City Chiefs.
RESEARCH UPDATE: The Effect of Hip Rotation Deficits on Low Back and SI joint Pain
Low back pain (LBP) is arguably one of the most common diagnoses treated by rehabilitation specialists. LBP constitutes a perplexing problem that can exact enormous human and societal costs, and whose successful evaluation and treatment continue to elude the efforts of those who care for these patients.1 A myriad of potential causes of low back pain exists, but evidence is mounting to support the possibility that low back pain may be a result of hip rotation deficits. Several investigators have reported that LBP may be related to hip pain secondary to limited range of motion in the hip.2-6
Ellison et al2 sought to determine the prevalence of passive hip rotation deficits in healthy subjects (n=100) and those with low back pain (n=50). Researchers suggested that there was an association between those with hip rotation ROM imbalance and the presence of LBP. 48% of subjects with LBP had increased lateral rotation than medial rotation of the hip.
Vad and others7 investigated hip rotation deficits in a group of professional golfers to determine if these deficits correlated to LBP. LBP is the most common musculoskeletal complaint experiences by both amateur and professional players.8 Forty-two male, professional golfers were categorized as having no history of back pain or those with a history of low back pain greater than two weeks affecting play within the past year. 33% of golfers had previously experienced LBP. Researchers found that a statistically significant correlation was observed between a history of LBP and decreased lead hip internal rotation and FABER’s position distance, and lumbar extension loss.
Cibulka and coworkers9 investigated rotation deficits of the hip with those experiencing signs/symptoms suggestive of sacroiliac joint (SIJ) dysfunction. In one-hundred male and female patients with low back pain, unilateral hip rotation deficits were found to correlate with SIJ dysfunction. In those with LBP but without evidence of SIJ dysfunction, significantly greater hip external rotation than internal rotation bilaterally, whereas those with LBP and signs suggesting SIJ dysfunction had significantly more external rotation than internal rotation unilaterally. Specifically, the deficit was observed on the side of the posterior innominate.
In a case study, Cibulka10 describes the treatment of a patient who had signs/symptoms of a sacroiliac component of LBP. The patient described right low back pain and evaluation of this patient found excessive right hip lateral rotation and limited right hip internal rotation. Of note, the patient frequently crossed his right leg over his left leg. After restoring hip rotation and SIJ dysfunction via manual therapy techniques, the patient no longer complained of LBP. The case suggests that hip rotation asymmetry may contribute to the SI component of LBP.
Finally, Warren11 also described a patient case with SIJ dysfunction and concomitant asymmetrical hip rotation deficits. After six physical therapy visits focusing on stretching, manual therapy, and postural education, hip rotation ROM was restored and the patient resumed full-time work and golf without back pain.
Based on this summary of relevant research, it appears that evidence supports the relation of deficits in hip rotation to both LBP and SIJ pain. Specifically, it appears that a loss of internal rotation is implicated in these cases. Biomechanically, this finding in the physical examination is plausible. Using gait as an example, a decrease in hip internal rotation will not allow the pelvis to rotate over the stance limb, thereby limiting the coupling mechanics (a whole other discussion!!) of the sacrum and lumbar spine. Additionally, muscles in the low back, like the multifidus, will not achieve their normal length-tension relationships. Potentially, that could also be a source of low back pain. The lack of motion in the sacrum and low back may lead to degenerative changes and excessive compression of the facets on one side. The clinical significance then is that the therapist must screen every patient for hip rotation deficits in cases of SIJ or LBP.
EDITOR NOTE: Very interesting research Dan, thanks for sharing with us. As many of your know, I am a big advocate of the biomechanical factors associated with pathology. That is why I like the works of Porterfield & DeRosa and McGill so much. We talk so much about the “core’s” influence on the distal extremities, but there would be an obvious inverse relationship as well. These studies certainly make me want to examine the lower extremities in more detail in my low back pain patients. I would challenge us all to critically exam our patients to see what lower extremities alignments (pes planus/cavus, leg length discrepancies, tibial/femoral rotation, genu valgum/varus/recurvatum, etc.) have an immediate impact on hip rotation and subsequently low back pain. The days of heat packs, ultrasound, massage, and ESTIM for low back pain are over!
- Porterfield JA, DeRosa C. Mechanical low back pain: Perspectives in functional anatomy. 2nd ed. Philadelphia: WB Saunders, 1998.
- Ellison JB, Rose SJ, Sahrmann SA. Patterns of hip rotation range of motion: a comparison between healthy subjects and patients with low back pain. Phys Ther. 1990; 70(9): 537-541.
- Chesworth BM, Padfield BJ, Helewa A, et al. A comparison of hip mobility in patients with low back pain and matched healthy subjects. Physiotherapy Canada. 1994; 46: 267-74.
- Friberg O. Clinical symptoms and biomechanics of lumbar spine and hip joint in leg length inequality. Spine. 1983; 8: 643-51.
- Mellin G. Correlation of hip mobility with degree of back pain and lumbar spinal mobility in chronic low back pain patients. Spine. 1988; 13: 668-670.
- Offierski CM, MacNab I. Hip-spine syndrome. Spine. 1983; 8: 316-321.
- Vad VB, Bhat AL, Basrai D, et al. Low back pain in professional golfers: the role of associated hip and low back range of motion deficits. Am J Sports Med. 2004; 32(2): 494-497.
- Batt ME. Golfig injuries: an overview. Sports Med. 1993; 16: 64-71.
- Cibulka MT, Sinacore DR, Cromer GS, Delitto A. Unilateral hip rotation range of motion asymmetry in patients with sacroiliac joint regional pain. Spine. 1998; 23: 1009-1015.
- Cibulka MT. The treatment of the sacroiliac component to low back pain: a case report. Phys Ther. 1992; 72: 917-922.
- Warren PH. Management of a patient with sacroiliac joint dysfunction: a correlation of hip range of motion asymmetry with sitting and standing postural habits. J Man Manip Ther. 2003; 11: 153-159.
Ellison JB, Rose SJ, Sahrmann SA (1990). Patterns of hip rotation range of motion: a comparison between healthy subjects and patients with low back pain Phys Ther DOI: 2144050