Low Back Pain and Hip Motion Correlation

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

DSC02377 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!

REFERENCES:

  1. Porterfield JA, DeRosa C. Mechanical low back pain: Perspectives in functional anatomy. 2nd ed. Philadelphia: WB Saunders, 1998.
  2. 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.
  3. 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.
  4. Friberg O. Clinical symptoms and biomechanics of lumbar spine and hip joint in leg length inequality. Spine. 1983; 8: 643-51.
  5. 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.
  6. Offierski CM, MacNab I. Hip-spine syndrome. Spine. 1983; 8: 316-321.
  7. 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.
  8. Batt ME. Golfig injuries: an overview. Sports Med. 1993; 16: 64-71.
  9. 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.
  10. Cibulka MT. The treatment of the sacroiliac component to low back pain: a case report. Phys Ther. 1992; 72: 917-922.
  11. 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

23 replies
  1. ปวดเอว
    ปวดเอว says:

    The condition can cause a variety of symptoms, the severity of which typically
    depends on the extent to which the spine has abnormally curved.
    Definition of Back pain-Backache OR What is back pain-Backache.
    Everybody has experienced the back pain that you get when you sleep incorrectly, at least once.

    my web page; ปวดเอว

  2. Alex nielen
    Alex nielen says:

    Great post, thanks. Would you know whether the study you reference – Ellison et al, which pertains to those with more external rotation are more susceptible to back pain. Was anteversion and retroversion taken into account when measuring ER/IR as I could not find out from the study’s abstract.

    I find this important as this would implicate either a structural or muscular component.

    I hope this made sense.

    Kind regards,
    Alex

  3. Kyung Ifft
    Kyung Ifft says:

    • “I had to refresh the page times to view this page for some reason, however, the information here was worth the wait.”

  4. Paul Richards
    Paul Richards says:

    Hi Guys

    I know this is an old thread but hope someone is still around to answer…

    I have really good results increasing hip ROM but want to know the underlying cause of why the ROM decreases in the first place. If we know this then we can prevent it from returning. I read on a Grey Cook article that he thinks its lack of general rotary stability.

    Anyone got suggestions?

  5. Chiropractor Grand Junction
    Chiropractor Grand Junction says:

    i have once undergone x-ray because of my lower back pain, but the doctor couldn't see anything wrong. thank you for sharing this article. it helped me a lot.

  6. Corey Ham
    Corey Ham says:

    Back pain in patients with low back pain is common and persistent that is considered an urgent solution for these patients, findrxonline.com indicate that appropriate medications for this pain should lower their cost.

  7. Mike
    Mike says:

    Hi Harrison,
    Is there any tests you use to isolate the SIJ as the culprit versus lumbar?
    Thanks,
    Mike.

  8. Anonymous
    Anonymous says:

    I just finished treating a retired PRO FOOTBALL player in his mid 40’s. His main complaint was tingling in the left anterior tibialis during golf activities. He presented with a left rotation passive intervertebral motion restriction of the lower lumbar segments, but negative SLR. After his lumbar mobility was restored, he still had tingling with IR of the left hip during his golf swing and only at the end of his swing, which could be reproduced with a simulated golf swing in the clinic. I then began further examination of the SIJ……….. he lacked IR of the left ilium. After one manipulation to improve IR of the ilium, he no longer reported any radicular sx.

    I have been trying to locate any research to assist me in further investigation of this dysfunction and primarily why the tingling went beyond the knee. Can anyone asssit??

    Thank you,
    G. Parsonis, PT, MPT, MTC

  9. Jan
    Jan says:

    I kept up the reading on the hip and I have a lot of patients with vague complaints of low back pain, especially during running. They do not periphilise pain when provoked nor do they complain about pain when they perform a loaded lumbar extension.

    I find a single leg stance very revealing with 90 degrees hipflexion. A give-away is an slight externaly rotated standsleg. There is also an assymetric lift pattern. A failed repeat after I told them to keep the toes pointed straight forward, tells me something is wrong in (rotation) stability.

    I use a thomastest and usually proceed with hipmobilisation exercises combined with training of reactive patterns. Years of complaints usually resolve within weeks.

  10. amy castillo
    amy castillo says:

    Harrison,
    I am curious what special test you use to isolate the SIJ as the culprit versus lumbar?
    Thanks
    Amy

  11. Harrison Vaughan, PT, DPT
    Harrison Vaughan, PT, DPT says:

    I do find that not only hip ROM is limited with LBP, but can be painful into IR most of the time if SIJ is involved through combination of special tests. I usually find too that hip ROM actively and passively is improved and less painful upon re-testing after performing manual therapy to the SIJ. This tells me, and more importantly the pt, that we are making mechanical improvements. Clinically, this agrees with what Dan said that SIJ/hip ROM and LBP are related through the above studies. I feel addressing the SIJ will improve the hip without necessarily stretching the hip as what Dave D was asking in a prior post.

  12. Ruth
    Ruth says:

    I recently came across your blog and have been reading along. I thought I would leave my first comment. I don’t know what to say except that I have enjoyed reading. Nice blog. I will keep visiting this blog very often.

    Ruth

    http://fendisite.com

  13. Brian O'Neil, PT
    Brian O'Neil, PT says:

    I have always felt that hip IR is completely underestimated. In my practice, poor hip IR (as well as poor hip extension) is probably one of the things I find myself treating the most. It can manifest as LBP, achilles tendinitis, shoulder impingement (the golfer is a perfect example), as well as a host of other soft tissue compensatory responses. Not only does it shorten the stance phase of gait as Dan describes above, but a lack of hip IR will also inhibit the most powerful muscles of the body, glut max. All three glutes, as well as piriformis, the gemellis, the obturators, and illiopsoas act to decelerate femoral IR during functional activities. If the hip can’t fully internally rotate, the muscle spindles won’t fire, the GTO’s will not be fully activated, and these muscles will not be able to generate contractions strong enough to stabillize the knee, hip, and pelvic joints.

  14. Anonymous
    Anonymous says:

    I also think this is a very interesting post. Along with the references cited, its also interesting to consider that two clinical prediction rules for LBP have hip ROM measurements as variables (Hip IR for manipulation and SLR for stabilization).

    Regarding Dave’s concerns about comparing limited ROM to WNL, the studies did not compare the subjects to a predetermined normal range. They either compared to matched controls, the asymptomatic side, or ratios of IR/ER within the individuals.

    I share Dave’s second concern about making treatment decisions off of this info. We do have research that indicates manual therapy can improve hip IR ROM deficits, but does this improve the patient’s back pain? I tend to use a test retest approach with the limited ROM and a functional test that reproduces the patient’s pain and have found some patients do respond well to hip treatment. I think this is an interesting topic for future research.
    Cody

  15. Dave D
    Dave D says:

    Interesting post.

    One thing that concerns me when people start talking about Hip Rotation ROM is how are they assessing what is normal and what is limited?

    I was hoping to be able to quote the exact study, unfortunately I couldn’t locate it. I know there have been studies that have shown huge variation in what is normal Hip Rotation ROM (e.g. something like 40-45 degrees +/- 20-25 degrees).

    Another issue is, is the difference in ROM due to structural (which we are not going to be able to change) e.g. retroversion, anteversion or soft tissue limitation?

    I think it is definitely something that needs to be assessed.

    I’m not sure it is as easy as someone who has LBP, decreased hip internal rotation and therefore needs stretching into internal rotation.

    Any thoughts?

  16. C.L. SPT
    C.L. SPT says:

    Interesting post…tried to access the reference articles but school didn’t have access to them. I’m curious as to the strength of the original research articles though because correlation isn’t indicative of cause, regardless of statsitical significance. Wouldn’t assessing the mobility of the sacrum for backward or forward sacral torsions be a more reliable approach?

Trackbacks & Pingbacks

  1. […] and SI joint dysfunction… Hmm. Internal rotation is actually important. Read more about that HERE on Mike Reinhold’s site. Seriously. It’s a good read with some interesting case studies […]

  2. […] Source: Low Back Pain and Hip Motion Correlation ~ MikeReinold.com […]

  3. Samson's Training Blog - 2012 says:

    […] you guys go. I reckon I'm barely getting 25deg! Should be 40. Some interesting research reported here too linking a Hip Internal Rotation Deficit (HIRD) to lower back pain/issues. Going to start […]

  4. The Hip-Back Connection : Survival of the Fittest: Experience Life Magazine says:

    […] in Experience Life, I came across a post from Dan Lorenz, MS, PT, ATC/L, CSCS, called “Low-Back Pain and Hip Motion Correlation.” Though it’s a pretty dense read — OK, it’s a really dense read, my eyes […]

  5. […] A lot of athletes also have a hip asymmetry where they have more mobility in one hip versus the other.  If your bike position puts you at the fringe end of mobility on one hip but not the other you may end up with a hip rotation on the bike where only one side of the back hurts, saddle soreness more on side of the sit bones than than the other, and a functional leg length discrepancy.  Hip asymmetry is one of the leading causes of back pain in the general population and is something that should be assessed when setting up your bike.  If you want to go full geek I recommend reading the study here, here, and this research review here. […]

Comments are closed.