Passive hip rotation range of motion in LPGA golfers

Abstract

Background: Participation in sports place specific demands on the musculoskeletal system that, over time, may cause modifications in soft-tissue. These modifications may result in alterations in range of motion that ultimately may compromise performance and/or contribute to injury. Although there is evidence in the literature regarding side-to-side joint range of motion differences in overhead athletes, it is unknown if a similar modification occurs in the lower extremity. Purpose: Examine bilateral, passive hip rotation range of motion in LPGA golfers. Methods: 31 right-handed LPGA Tour golfers (mean age 32 ± 6.8 yrs, ht. 167.6 ± 6.9 cm, wt. 65.4 ± 9.4 kg) had passive hip rotation (ROM) measured prone using a goniometer. Results: Eight golfers had a side-to-side difference of five degrees or more for internal rotation range of motion. Ten golfers had a side-to-side difference of more than five degrees for external rotation range of motion. Conclusion: Almost one-third of the LPGA golfers had asymmetrical external rotation hip rotation range of motion. Additionally, one-fourth of them had asymmetrical internal rotation range of motion. As previous studies have established, a correlation between hip rotation range of motion asymmetry and low back pain, these findings may have considerable clinical relevance. These results suggest that professional golfers complaining of low back pain need to have an evaluation of their hip rotation range of motion, and employ appropriate interventions to restore and maintain symmetrical ROM.

Full text

Clinical Kinesiology 62(2); Summer, 2008 9
Passive Hip Rotation Range of Motion in LPGA Golfers
Heather R. Gulgin, Ph.D.1 and Charles W. Armstrong, Ph.D.2
1Grand Valley State University, Allendale, MI 49401 and 2University of Toledo, Toledo, OH
43606
ABSTRACT
Background: Participation in sports place specific demands on the musculoskeletal system that, over time, may
cause modifications in soft-tissue. These modifications may result in alterations in range of motion that ultimately
may compromise performance and/or contribute to injury. Although there is evidence in the literature regarding
side-to-side joint range of motion differences in overhead athletes, it is unknown if a similar modification occurs in
the lower extremity. Purpose: Examine bilateral, passive hip rotation range of motion in LPGA golfers. Methods:
31 right-handed LPGA Tour golfers (mean age 32 ± 6.8 yrs, ht. 167.6 ± 6.9 cm, wt. 65.4 ± 9.4 kg) had passive hip
rotation (ROM) measured prone using a goniometer. Results: Eight golfers had a side-to-side difference of five
degrees or more for internal rotation range of motion. Ten golfers had a side-to-side difference of more than five
degrees for external rotation range of motion. Conclusion: Almost one-third of the LPGA golfers had asymmetrical
external rotation hip rotation range of motion. Additionally, one-fourth of them had asymmetrical internal rotation
range of motion. As previous studies have established, a correlation between hip rotation range of motion
asymmetry and low back pain, these findings may have considerable clinical relevance. These results suggest that
professional golfers complaining of low back pain need to have an evaluation of their hip rotation range of motion,
and employ appropriate interventions to restore and maintain symmetrical ROM.
Key Words: golf, asymmetry, repetitive motion
INTRODUCTION
In healthy adult subjects, joint range of motion
(ROM) has been shown to be relatively symmetrical
(3, 5, 6, 8, 13, 27). For example, it would be
expected that the amount of hip internal rotation (IR)
on the left side would be equal to the amount of IR
on the right side. Participation in sports places
specific demands on the musculoskeletal system that
may cause modifications in soft-tissue over time.
Some of the demands imposed by some sports are
applied to the body in an asymmetrical fashion,
which may influence the pattern of soft-tissue
modification. For example, athletes who participate
in sports requiring repetitive unilateral rotational
movement, such as tennis and baseball have
experienced differences in their side-to-side
(bilateral) joint ROM (4, 9, 17, 19). Although this
phenomenon has been associated with overhead
sports and the upper extremity, little is known about
similar modifications in the lower extremity ROM in
sports that involve asymmetric movement in the
lower extremities.
A popular sport that involves asymmetric lower
extremity transverse plane motion is golf. Typically,
in golf, a slow passive backswing in one direction is
followed by a very dynamic and ballistic downswing
in the opposite direction. While both internal and
external hip rotation occurs during both phases of the
swing, the demand on the involved muscles, as well
as stress on the other soft-tissues, is asymmetric.
Unpublished data by Gulgin (16) has found the trail
(right) hip undergoes 8.9 ± 4.8 degrees of pelvic-on-
femoral IR during backswing and 14.9 ± 9.6 degrees
during the downswing. The lead (left) hip undergoes
29.7 ± 11.3 degrees of pelvic-on-femoral ER during
the backswing, and 34.8 ± 11.7 degrees of IR on
downswing. Thus, the hips do experience different
ROM during the full golf swing.
Professional golfers play four to five complete
rounds (18 holes) each week throughout the duration
of the competitive golf season. A Tour player may
play between 20-30 tournaments per year, which
could add up to anywhere from 80-150 rounds of golf
each year. In addition to all of the competitive golf
that is played, most professionals spend many hours
each week on the practice range. Thus, the golf
swing is repeated literally hundreds of times each
week, with the hips experiencing different range of
motion, or undergoing an asymmetrical movement
pattern.
Joint ROM depends upon the shape of the bony
articulating surfaces (mainly inherited), the collagen
structure making up the joint capsule, ligaments,
muscles (inherited), and the neuromuscular tone
(mainly acquired by means of training) (11). Thus, it
may be inferred that the only modifiable factor,
which may alter joint ROM is that attributed to some
degree of training. Athletes who participate in a
sport competitively over several years, are likely to
be involved in routine training regimes that may
place repetitive stress on a particular joint in the
body. The involved repetitive movements and
resulting forces may cause a modification in joint
ROM.

Clinical Kinesiology 62(2); Summer, 2008 10
Figure 1. Prone Hip Rotation Range of Motion Measurement
The hip, spine, and pelvis function as a unit in
the overall kinetic chain. Lack of motion in one
segment is typically compensated for by another
segment in this unit. However, the resulting
imbalance in joint mobility may lead to injury. For
example, several investigators (1, 7, 25) have
demonstrated an association with hip rotation ROM
asymmetry and back pain. Their findings
demonstrated that patients who had low back pain
show evidence of more external rotation (ER) than IR
in each hip. Although two of the studies show that
there were no differences in the side-to-side ER or
IR, another study has shown that a unilateral
limitation in hip rotation ROM (i.e. side-to-side
differences) has been observed in patients with
sacroiliac joint dysfunction (7). These studies
suggest that asymmetry in the ROM at one joint can
contribute to pain or dysfunction at another joint.
Consequently, a golfer with an existing ROM
asymmetry at the hip may well be placing increased
stress on the lower back, and in doing so, increasing
the chance for injury.
Previous studies have reported that the most
common site of injury among both professional and
amateur golfers is the back region (15, 21-23).
Interestingly, there has not been much reported about
the hip region in relation to injuries in golfers (2, 12,
22, 23, 30). One particular study, however, has
examined the association between hip rotation
asymmetry and golfers with episodes of low back
pain (LBP) (31). These investigators measured hip
rotation ROM on a sample of PGA players (31), and
found that right-handed golfers with LBP had a
significant decrease in the lead (left) hip IR ROM
when compared to the trail (right) side. The
asymptomatic golfers demonstrated a similar trend,
although the side-to-side difference was not
significant. The authors suggested that the
asymmetrical repetitive rotations involved in golf
may have caused micro-trauma to the soft-tissue
(joint capsule), which responded by scarring down or
tightening, and thus limiting the joint ROM. In
addition to the hypothesized capsular tightening, the
authors suggest that there may have been
hypertonicity in the lead hip external rotators.
While there is some data indicating that golfers
may evidence hip rotation ROM asymmetries, the
degree of asymmetry and its occurrence among
professional golfers is unknown. Thus, the purpose
of this study was to examine the passive hip rotation
(internal and external) ROM in a group of
professional female golfers, to determine if bilateral
differences exist.
METHODS
Subjects. Passive hip rotation ROM was
evaluated in 31 LPGA Tour golfers (mean age 32 ±
6.8 yrs, ht. 167.6 ± 6.9 cm, wt. 65.4 ± 9.4 kg) who
were participants in the Owens Corning Classic
Tournament in Toledo, Ohio. The duration of the
competitive playing experience in the LPGA golfers
was 16.58 ± 6.48 years, and all golfers were right-
handed. All of the LPGA participants were
Caucasion-American or Caucasian-European, with
the exception of one Asian-American. Prior to
participation, subjects signed a written consent form
as approved by the University of Toledo Human
Subjects Research Board.
Protocol. All subjects were given an overview
of the procedures, with the opportunity to ask
questions prior to data collection. The golfer’s
measurements were taken on site at the tournament.
For all subjects, passive hip joint rotation ROM was
measured on a firm treatment table.
Instrumentation. A standard plastic 360°
goniometer with one degree intervals was used for all
measurements. In addition, a seatbelt strap was also
used to secure the pelvis during the measurements,
which were made with the subject in a prone
position.
Procedures. The same clinically trained
investigator took all the measurements three times in
each direction bilaterally, while the order of
measurement (side and direction) was randomized.
Intra-rater reliability (ICC’s) were (right = 0.984; left
= 0.961) and (right = 0.905; left = 0.968) for IR and
ER respectively. The subjects were measured with
the knees in 90° of flexion (13), and a seat belt strap
was secured over the posterior superior iliac spine
region (for stabilization) of the subject. The fulcrum
of the goniometer was placed on the tibial tuberosity,
with the moving arm aligned along shaft of tibia
midway between the two malleoli, and the stationary
arm perpendicular to the ground (Figure 1). Each
subject was verbally and visually instructed to make
sure the anterior superior iliac spines remain level in

Clinical Kinesiology 62(2); Summer, 2008 11
Table 1. Player’s Descriptives
LPGA golfer Back Pain
(Side) Location Hip Pain Stretching
Routine Strength Train
for Hip & Back Age
(Yr.) Height
(Cm) Weight
(Kg)
Subject # 1 Bilateral Low Back No Yes No 24 152.4 84.1
Subject # 2 No NA Right Yes No 29 165.1 68.2
Subject # 3 No NA No Yes Yes 37 162.5 60.4
Subject # 4 No NA No Sometimes Yes 34 165.1 60.4
Subject # 5 Left Low Back Left Yes Yes 39 165.1 54.5
Subject # 6 No NA No Yes Yes 27 157.5 57.7
Subject # 7 Bilateral Low Back No Yes Yes 35 175.3 68.2
Subject #8 No NA No Yes Yes 25 167.6 59.1
Subject # 9 Not given Upper Back No No No 32 182.8 68.2
Subject # 10 Middle Low Back No Yes Yes 26 172.7 54.5
Subject # 11 Not given Low Back Left Yes No 30 165.1 75
Subject # 12 No NA No Yes Yes 31 170.2 68.2
Subject # 13 No NA Left Yes Yes 25 170.2 79.5
Subject # 14 Not given Low Back No Yes No 39 175.2 93.2
Subject # 15 Right Low Back Right Yes No 32 170.2 65.9
Subject # 16 Not given Low Back No No No 50 166.3 70.9
Subject # 17 Right Low Back No Yes Yes 36 152.4 61.3
Subject # 18 No NA No Yes Yes 26 172.7 59.1
Subject # 19 Not given Low Back Bilateral Yes Yes 38 165.1 61.3
Subject # 20 Right Low Back Right Yes Yes 39 170.2 79.5
Subject # 21 Bilateral Low Back No Yes Yes 33 180.3 71.8
Subject # 22 Bilateral Low Back No Yes No 41 172.7 63.6
Subject # 23 Not given Low Back No Yes Yes 21 175.3 62.2
Subject # 24 Right Low Back No Yes Yes 29 160.0 55.4
Subject # 25 No NA No Yes Yes 28 157.4 56.8
Subject # 26 Left Low Back No Yes Yes 18 162.5 54.5
Subject # 27 Not given Low Back No Yes Yes 33 157.5 58.2
Subject # 28 Right Mid back No Yes Yes 37 170.2 72.7
Subject # 29 Left Low Back Left Yes Yes 24 165.1 60
Subject # 30 No NA No No No 34 147.3 67.2
Subject # 31 No NA No Yes No 40 167.6 56.8
the transverse plane, and measurement was stopped
when pelvic movement (shifting) was necessary for
additional rotation. The mean of three trials for each
subject was used for data entry.
RESULTS
The LPGA players descriptives, such as height,
weight, and age are found in Table 1. In addition,
participants responses to questions about back pain,
hip pain, stretching routine, and strength training
routine are reported in Table 1. The golfers hip
rotation ROM are reported in Table 2, with the bold
type representing the golfers who demonstrated a
side-to-side difference of five degrees or more in
their respective measurements.
Eight LPGA golfers had a five degree or more
side-to-side difference in their hip IR ROM (seven of
those had self-reported low back pain (LBP)). Ten
LPGA golfers had a five degree or more side-to-side
difference in their hip ER ROM (seven of those had
self reported LBP). When examining total hip ROM
on each side, seven golfers were found to have a side-
to-side difference of five degrees or more (six of
those had self reported LBP).
Of all the LGPA golfers, 18 out of 31 had self-
reported LBP. Of those, seven (subjects # 5, 10, 11,
15, 17, 20, 23) had a five degree or more difference
in IR ROM, while seven (subjects # 1, 5, 11, 14, 17,
19, 21) had a five degree or more difference in ER
ROM. When comparing total hip rotation ROM, six
(subjects # 1, 10, 11, 15, 19, 20) of those golfers with
reported LBP had a side-to-side difference of five
degrees or more.

Clinical Kinesiology 62(2); Summer, 2008 12
Table 2. Player’s Passive Hip Rotation ROM
LPGA golfer Right Medial
Rotation
(deg.)
Left Medial
Rotation
(deg.)
Right Lateral
Rotation
(deg.)
Left Lateral
Rotation
(deg.)
Total Right
Hip ROM
(deg.)
Total Left
Hip ROM
(deg.)
Subject # 1 51.3 50.3 30.6 37 81.9 87.3
Subject # 2 56.6 53.3 42.6 42.6 99.2 95.9
Subject # 3 47.6 46.6 36.6 35.6 84.2 82.2
Subject # 4 44 40 39.6 40 83.6 80
Subject # 5 53 58.3 39.6 33.6 92.6 91.9
Subject # 6 33.3 46.3 39.6 30.3 72.9 76.6
Subject # 7 51 50.6 39.3 42.6 90.3 93.2
Subject #8 44 45.3 40.6 36.6 84.6 81.9
Subject # 9 56.6 60.3 40 40.6 96.6 100.9
Subject # 10 41.3 46.3
35.3 37.3 76.6 83.6
Subject # 11 24.3 39 31.3 23.6 55.6 62.6
Subject # 12 35.3 38.6 31.6 29.6 66.9 68.2
Subject # 13 35.3 32.6 30 29.6 65.3 62.2
Subject # 14 41.3 40.6 39 49 80.3 89.6
Subject # 15 28.3 59.3
43.6 43.6 71.9 102.9
Subject # 16 40.3 40 46 44.6 86.3 84.6
Subject # 17 45.6 54.6 49.6 40.3 95.2 94.9
Subject # 18 58 59.3 27.3 29 85.3 88.3
Subject # 19 56.6 52 47.6 40.6 104.2 92.6
Subject # 20 54 48.6
41 40 95 88.6
Subject # 21 38 40 41 35.6
79 75.6
Subject # 22 39.3 40.6 45 43.3 84.3 83.9
Subject # 23 66.3 57.6
20.3 25 86.6 82.6
Subject # 24 51 48.3 54.6 52.6 105.6 100.9
Subject # 25 55.3 51.6 60 55.6 105.3 107.2
Subject # 26 51.3 53 51.3 49 102.6 102
Subject # 27 60.3 56.3 76 79 136.3 135.3
Subject # 28 58.6 55.3 46 45.3 104.6 100.6
Subject # 29 55.6 57.6 72 70.6 127.6 128.2
Subject # 30 56.3 53.3 38.6 50.3 94.9 103.6
Subject # 31 56.6 52 43.3 49.6 99.9 101.6
Table 3. Passive Hip Rotation ROM Comparing Self-reported LBP & No LBP Groups.
Group Right Internal
Rotation
(deg.)
Left Internal
Rotation
(deg.)
Right External
Rotation
(deg.)
Left External
Rotation
(deg.)
Total Right
Hip ROM
(deg.)
Total Left
Hip ROM
(deg.)
LBP 47.2 ± 10.8 49.6 ± 7.1 44.6 ± 13.4 43.7 ± 13.6 91.7 ± 19.0 93.3 ± 16.9
No LBP 49.0 ± 9.6 48.8 ± 8.2 39.7 ± 8.1 39.6 ± 8.8 87.9 ± 13.5 88.4 ± 14.4
LBP = low back pain

Clinical Kinesiology 62(2); Summer, 2008 13
Thirteen LPGA golfers had no reported LBP. Of
those, one (subject # 6) had a five degree or more
difference in IR ROM, while three golfers (subjects #
6, 30, 31) had a five degree or more difference in
their ER ROM. When
comparing total hip rotation ROM, only one of those
golfers (subject # 30) had a side-to-side difference of
five degrees or more.
When comparing the hip rotation ROM among
the golfers with self-reported LBP and those without
LBP, the available ROM for each measurement is
nearly identical, except that the LPGA golfers
without LBP had approximately four degrees less ER
hip rotation ROM, which also gave them less total
hip ROM (Table 3). Most of the LPGA golfers hip
rotation ROM values are within norms of 32-50
degrees (3, 14, 27-29), but there were a few LPGA
golfers who fell outside the norms for IR and ER hip
rotation ROM.
Approximately one-fourth of the LPGA golfers
in this study demonstrated a side-to-side difference in
their hip IR ROM. Approximately one-third of the
LPGA golfers demonstrated side-to-side differences
in their hip ER ROM. Twenty-two percent of the
LPGA golfers had more than five degree side-to-side
difference in their total hip ROM.
The golfers who had a noticeable difference in
hip rotation ROM when comparing side-to-side, were
mostly those who had self reported back pain.
However, of the golfers who had no back pain or did
not report any back pain, but presented a side-to-side
difference of five degrees or more in joint ROM, two
of those (subjects # 11, 19) actually had self-reported
hip pain.
In summary, most of the healthy golfers (with no
reported back or hip pain) had symmetrical hip
rotation ROM, and those who had a noticeable
difference of five degrees or more had reported some
back or hip pain.
DISCUSSION
Since there is evidence which demonstrates that
athletes who participate in repetitive overhead
motions have acquired an adaptation in their side-to-
side shoulder joint ROM (4, 9, 18, 19), it was
hypothesized that there would be a noticeable
difference in the golfer’s side-to-side transverse plane
hip rotation ROM. Prior to this point, only one other
study has addressed the hip rotation ROM of golfers
(31). Vad et al. (31) found that the lead (left) hip in
golfers with low back pain demonstrated a decrease
in the amount of IR relative to the trail (right) hip,
whereas those without back pain did not have a
significant side-to-side difference in their transverse
plane hip rotation ROM. The results of the current
study on LPGA golfers with self-reported low back
pain do not show the same trend. Of the LPGA
golfers who reported low back pain, eight of the 18
had slightly less IR ROM on the left (lead) hip, but
the other 10 actually demonstrated more IR ROM on
the left hip. However, when examining the LPGA
golfers in this study who did not report low back
pain, the results are consistent with Vad et al. (31), as
they had symmetrical hip rotation ROM.
The comparison across studies may not be
entirely appropriate, as Vad et al. (31) measured
prone hip rotation ROM actively, and the method of
assessment was passive in the current study. We felt
that the passive measure is more indicative of the
actual anatomical limit, whereas the active ROM
measurement may be affected by the participant’s
strength and motivation, and thus not a true measure
of the structural or soft-tissue limit. Regardless of
the method of measurement, neither study cannot
definitively determine if the current back pain made
the difference in their measured ROM, or whether
their asymmetry existed prior to, and was
contributing to the development of their low back
pain.
Although the mechanical properties of the non-
contractile soft tissue (i.e. ligaments and capsule) are
suggested to be mainly inherited, these still may
undergo modification in response to the stress placed
upon them. Mueller and Maluf (26) have proposed a
“physical stress theory” that occurs to biological
tissue. Depending on what specific adaptations are
occurring to the soft-tissue structures, the risk of
injury could be changing as well. For example, in
spite of the low reported rates of hip injuries, there
have been a handful of professional golfers with hip
pathology requiring arthroscopic surgery (20). Thus,
if there is a “loosening” of the joint capsule, and
more movement of the femoral head, this could be
associated with labral fraying (24).
Overhead athletes participating in baseball and
tennis have shown significant side-to-side differences
as a result of their repetitive sport participation. We
speculate that one reason for the lack of such large
changes in side-to-side ROM of the lower extremity
relative to the changes seen in the upper extremity
may be due to the difference in rotational velocities
achieved during the particular sport movements. For
example, shoulder IR velocities of the throwing arm
of a baseball pitcher have been reported to be as high
as 7,430 ± 1,270 degrees/second (10), while the
pelvis rotational velocities only reached 670 ± 90
degrees/second in the same individuals (10).
Although there are known values for pelvis rotational
velocities in baseball players, there is no current data
concerning the golfer’s hip rotational velocities
during the full golf swing. Obtaining the actual
pelvis-on-femoral rotational velocities during the full

Clinical Kinesiology 62(2); Summer, 2008 14
golf swing is an area for future research to more fully
understand the stress placed on the hip.
CLINICAL IMPLICATIONS
We measured passive hip rotation ROM (prone)
in LPGA golfers to determine if side-to-side
symmetry existed. Most of the LPGA golfers that
demonstrated side-to-side difference of five degrees
or more had self reported low back pain. Since back
pain in golfers is the leading injury complaint, and
the fact there is an association with hip rotation ROM
asymmetry and back pain, this issue should not be
overlooked. Professional golfers complaining of low
back pain need to have an evaluation of their hip
rotation ROM, and take appropriate interventions to
restore and maintain symmetrical ROM.
ACKNOWLEDGMENTS
The authors would like to thank the LPGA
organization for allowing access to these athletes
during the Tournament week.
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AUTHOR CORRESPONDENCE:
Heather R. Gulgin
Grand Valley State University
Biomedical Sciences Department
1 Campus Dr. Padnos 218
Allendale, MI 49401
Ph # 616-460-4639
Email: hgbuckeye@yahoo.com