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455
ORIGINAL ARTICLE
Correlation between Hip Rotation
Range-of-Motion Impairment and Low Back Pain.
A Literature Review
Meissam Sadeghisani1(A,E), Farideh Dehghan Manshadi1(A),
Khosro Khademi Kalantari1(D), Abbas Rahimi1(F), Neda Namnik2(F),
Mohammad Taghi Karimi3(D), Ali E. Oskouei4(E)
1Department of Physiotherapy, Rehabilitation Faculty of Shahid Beheshti University of Medical Sciences, Tehran, Iran
2Rehabilitation Faculty of Ahvaz Jundishapour University of Medical Sciences, Ahvaz, Iran
3Rehabilitation Faculty of Isfahan University of Medical Sciences, Isfahan, Iran
4Physical Medicine and Rehabilitation Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
SUMMARY
Background. Hip rotation range-of-motion (ROM) impairment has been proposed as a contributing
mechanical factor in the development of low back pain (LBP) symptoms. There is a hypothesis which suggests
that a limited range of hip rotation results in compensatory lumbar spine rotation. Hence, LBP may develop as
the result. This article reviews studies assessing hip rotation ROM impairment in the LBP population.
Material and methods. The MEDLINE and EMBASE databases were searched without time restriction.
Two authors independently selected related articles using the same search strategy and key words.
Results. Among 124 articles 12 met the review inclusion criteria. The results of the studies are assessed in
three sections, investigating the relationship between low back pain and 1) hip internal rotation ROM, 2) hip
external rotation ROM and 3) hip total rotation ROM. Asymmetrical (right versus left, lead versus non-lead)
and limited hip internal rotation ROM were common findings in patients with LBP. Reduced and asymmetri-
cal total hip rotation were also observed in patients with LBP. However, none of the studies explicitly reported
limited hip external rotation ROM.
Conclusion. The precise assessment of hip rotation ROM, especially hip internal rotation ROM, must be
included in the examination of patients with LBP symptoms.
Key words: low back pain, range of motion, hip, rotation
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aTraumatologia Rehabilitacja
© MEDSPORTPRESS, 2015; 5(6); Vol. 17, 455-462
DOI:10.5604/15093492.1186813
112 Sadeghsiani:Layout 1 2015-12-22 12:10 Strona 1
BACKGROUND
Low back pain (LBP) is one of the most prob-
lematic conditions in the populations of both devel-
oped and developing countries [1, 2]. LBP is the pri-
mary cause of functional limitation in people under
45 years old [3]. The prevalence of low back pain in
various populations and study groups varies between
14.4% and 85% [2-4]. Thus, LBP places a heavy
direct and indirect burden on the individuals, their
families, societies and the governments.
LBP with its biopsychosocial nature has been
known as a multidimensional problem [5-7]. Identi -
fying the potential contributing factors is essential in
solving the problem of LBP [7]. Among various eti-
ological factors, mechanical factors play an impor-
tant role in the induction and persistency of LBP
symptoms [4]. Symptoms in mechanical LBP nor-
mally begin or intensify with physical activities and
are relieved by rest [4]. Through identifying the me -
chanical contributing factors that are associated with
a risk of LBP and possibly correcting them, we may
be able to help the people suffering from LBP.
The hip joints are the intersegmental elements
between the lumbopelvic and knee joints [8]. Thus,
the lumbopelvic-hip-knee complex forms a kinemat-
ic chain whose activity is co-ordinated during func-
tional and recreational physical activities [9-17].
The re fore, the role of the lumbopelvic-hip movement
impairments, such as hip ROM restriction, has been
an interesting subject of many studies [18-22].
Due to the connection between the hip joints and
the lumbopelvic region described above, hip rotation
ROM impairments have been suggested as an impor-
tant dysfunction in LBP [15,23]. Limited hip rotation
is well documented in different categories of LBP
patients [16,24-27]. It has been proposed that a re -
duced hip rotation ROM may be compensated for by
excessive lumbopelvic rotation. A greater magnitude
of lumbopelvic rotation may be associated with mi -
cro trauma and, eventually, LBP [16]. There is some
evidence that shows that increasing hip rotation
ROM is associated with improving functional per-
formance and relieving pain in patients who suffer
from LBP [28-30].
The indices of hip internal, external and total ro -
tation ROM may be related to LBP. Numerous inves-
tigators have explored the role of hip rotation ROM
impairment in LBP. In this review, we turn our atten-
tion to studies that examined active/passive hip inter-
nal, external and total rotation ROM in people with
LBP. Therefore, the present article reviews studies
that assessed hip rotation ROM impairment in LBP
patients.
MATERIAL AND METHODS
The search strategy in our review was based on
an electronic database search of titles and abstracts.
The source databases were MEDLINE and EMBASE
without time restriction. The key words used were:
hip, low back pain, rotation and range of motion. The
search was limited to studies published in English.
Case reports were not included. Studies which exam-
ined hip rotation ROM during functional activities or
in patients with a history of lower extremity injury
were excluded. In addition, studies which included
pathological causes of LBP were not included in the
review. In the initial stage of database search, a total
of 124 articles were identified. Then, their abstracts
and titles were reviewed, and full texts of the studies
that were related to our review were accessed. Of
124 articles relating to low back pain and hip rotation
ROM, a total of 12 studies met our inclusion criteria.
To confirm the accuracy of the search strategy, a sec-
ond investigator re-reviewed the articles using the
same query terms as listed above. The stages of the
article selection process are presented in Figure 1.
The results of the studies are presented in three
sections, investigating the relationship between low
back pain and 1) hip internal rotation ROM, 2) hip
external rotation ROM and 3) hip total rotation ROM
(Table 1).
Relationship between hip internal rotation
ROM and low back pain
Ellison and his coworkers observed that in a pop-
ulation of 50 people with LBP, the number of pa -
tients who had a lesser hip internal rotation ROM
than hip external rotation ROM was higher com-
pared with a group of 100 people without LBP [31].
In this study, the passive internal and external hip
rotation ROM of patients with LBP who were re fer -
red for physical therapy was measured with an incli-
nometer. Although the direction of lumbar spine im -
pairment and specific activities of the patients were
not described, lesser hip internal rotation and more
asymmetrical hip rotation were common findings in
the groups with LBP.
A deficit in hip internal rotation ROM was also
observed in two studies of Vad et al. [26, 27]. One
study compared the pattern of hip internal rotation
between asymptomatic and LBP symptomatic pro-
fessional tennis players. The LBP individuals had
a history of LBP with a disability of more than two
weeks [27]. Another study by Vad et al. enrolled 42
professional golfers (14 with LBP and 28 without
LBP) [26]. In both studies, passive hip internal rota-
tions of were measured on both sides of the body and
Sadeghisani M. et al. Hip Rotation ROM and Low Back Pain
456
112 Sadeghsiani:Layout 1 2015-12-22 12:10 Strona 2
similar results were observed. Moreover, limited lead
hip internal rotation and greater asymmetry of hip
internal rotation (right versus left) were reported in
the athletes with LBP [26, 27].
Alemida et al. investigated differences in active
and passive hip internal, external and total rotation
ROM among 21 low back pain patients and 21 healt -
hy subjects [32]. All participants of this study were
judo athletes. Hip rotation ROM was measured by
photogrammetry. In relation to hip internal rotation
ROM, the LBP group demonstrated limited active
hip internal rotation on the dominant side and re du -
ced passive hip internal rotation of both sides.
Restriction in hip internal rotation and asymmetrical
hip rotation between the dominant and non-dominant
side were presented as mechanical factors in LBP
development in judo athletes [32].
Mellin et al. measured, by using an inclinometer,
the hip internal and external rotation ROM of a pop-
ulation of workers (301 males and 175 females) who
had a history of at least 2 years of LBP symptoms
[33]. Based on the results of this study 1) males have
a lesser range of hip internal rotation in comparison
to females, 2) in the males group, there was a reverse
relationship between hip internal rotation ROM and
LBP, and 3) males have a greater magnitude of hip
external rotation ROM in comparison to females.
The authors believe that limited hip internal rotation
ROM in males may function as a risk factor that pre-
disposes them to LBP.
In a 1998 study by Cibulka et al., passive hip
internal and external rotation ROM of 100 people
with low back pain (24 subjects without sacroiliac
involvement and 76 subjects with sacroiliac involve-
ment) was measured by a goniometer [24]. Patients
of both genders participated in the study. The dura-
tion of symptoms was less than 3 weeks and the pa -
tients were undergoing treatment. No specific activi-
ties of the patients were mentioned. Statistical analy-
sis of data revealed that 1) overall hip internal rota-
tion ROM was significantly smaller than hip external
rotation ROM and 2) the group with symptomatic
sacroiliac joint involvement had significantly less
hip internal rotation unilaterally whereas the LBP
group without sacroiliac dysfunction had bilaterally
smaller hip internal rotation ROM. Based on the
results, a unilateral and bilateral deficit in hip inter-
nal rotation ROM was presented as a factor that may
contribute to the development of lumbar spine and
sacroiliac dysfunctions and, ultimately, to pain.
Sadeghisani M. et al. Hip Rotation ROM and Low Back Pain
457
Fig. 1. The stages which were selected in this review study
112 Sadeghsiani:Layout 1 2015-12-22 12:10 Strona 3
Lumbopelvic and hip rotation motion differences
between males and females were investigated in
a study by Hoffman et al, [34]. In total, 59 people
with chronic LBP, including 30 men and 29 women,
participated in this study. The patients performed an
active hip internal rotation test in the prone position.
Kinematic data were recorded by a motion analysis
system. Lumbopelvic rotation ROM and hip internal
rotation ROM were measured. Statistical analysis
revealed that men had significantly less hip internal
rotation in comparison to women. The authors of this
study believe that men might be at greater risk of
LBP than women due to smaller hip internal rotation
ROM.
Sadeghisani M. et al. Hip Rotation ROM and Low Back Pain
458
Tab. 1. Cross sectional studies: LBP and hip rotation range of motion
112 Sadeghsiani:Layout 1 2015-12-22 12:10 Strona 4
This review of the literature relating to hip inter-
nal rotation ROM reveals a strong link between lim-
ited hip internal rotation ROM and LBP. This kind of
hip impairment may be unilateral or bilateral. Re -
duced hip internal rotation ROM was observed dur-
ing active and passive hip rotational tests. Men in
comparison to women had lesser hip internal rotation
ROM. Accordingly, men may be at greater risk of
developing LBP associated with hip internal rotation
ROM. A deficit in hip internal rotation ROM was
observed in LBP people both engaged and not en -
gaged in rotational demand activities. Accordingly,
assessment of hip internal rotation ROM must be
applied carefully in both these groups of LBP people.
Relationship between hip external rotation
ROM and low back pain
Scholtes and her associates assessed the differen -
ce in hip external rotation ROM between healthy and
LBP people [35]. This study enrolled 91 subjects (50
people with LBP who were involved in rotation-re -
lated activities and 41 people without LBP symptoms
who were not involved in rotation-related activities).
The patients had a history of chronic and recurrent
LBP symptoms. They performed an active hip exter-
nal rotation test in the prone position. Kinematic data
in relation to hip external rotation and pelvic rotation
were captured by employing a motion analysis sys-
tem. After data processing and statistical analysis, no
difference in hip external rotation ROM was observ -
ed between people with and without LBP. However,
Sadeghisani M. et al. Hip Rotation ROM and Low Back Pain
459
Tab. 2. Cross sectional studies: LBP and hip rotation range of motion
112 Sadeghsiani:Layout 1 2015-12-22 12:10 Strona 5
compared to healthy people, LBP people had a great -
er magnitude and earlier lumbopelvic rotation during
the test.
A study of Gombatto et al. from 2006 investigat-
ed sex differences in lumbopelvic and hip rotation
motion during an active hip external rotation test
[12]. All of the participants (27 men and 19 women)
regularly participated in rotational demand sports
activities. The patients had a history of chronic and
recurrent LBP symptoms. The subjects were asked to
externally rotate their hips in the prone position. Ki -
nematic data were recorded with a motion analysis
system. After data processing, hip external rotation
ROM was measured. The results of this study show -
ed no difference in hip external rotation ROM be -
tween men and women. However, men demonstrated
a greater percentage of their maximum lumbopelvic
rotation in the first 60% of the test.
Differences in the hip and lumbopelvic move-
ment patterns between two groups of LBP people
were investigated in a study by Van Dillen et al. [13].
Participants of this study were 13 subjects with lum-
bar rotation syndrome and 26 subjects with rotation
and extension syndrome who had chronic or recur-
rent LBP. An active hip external rotation test was
performed and kinematic data were collected using
a motion analysis system. Based on the kinematic
comparison, there were no differences between the
two groups in regard to hip external rotation ROM
and lumbopelvic motion.
As mentioned earlier, there was no difference in
hip external rotation ROM between healthy individ-
uals and people with LBP, men and women and also
different subgroups of LBP people. However, in
these studies the pelvis was free to move and the
average values of bilateral hip rotation were used in
statistical analysis.
Two studies used the FABERE test to examine
hip external rotation ROM. During the FABERE test,
subjects lie in the supine position while the hip joint
is held in flexion, abduction and external rotation.
Then, the distance from the knee to the horizontal
plane is measured [26]. Limited hip external rotation,
abduction and flexion is manifested by an increase in
the knee to horizontal distance [26]. An increase in
the FABERE distance was established in LBP golfers
and tennis players. In one study, the FABERE distance
on the dominant side in golfers with LBP was signifi-
cantly greater than in golfers without LBP [26]. In
another similar study, tennis players with LBP demon-
strated a greater FABERE distance in comparison to
asymptomatic people. In both studies, players with
LBP displayed asymmetry of the hip FABERE dis-
tance between the lead and non-lead hips [26, 27].
Because the FABERE distance depends on hip
external rotation, flexion and abduction ROM, we
cannot exactly state that an increase in the FABERE
distance is a result of limited hip external rotation
ROM.
Overall, as the results of these studies indicate,
there is weak evidence supporting a relationship be -
tween LBP and deficits, limitations, in hip external
rotation ROM. In other studies, there was no differ-
ence in hip external rotation ROM between people
with and without LBP symptoms [12, 32, 35, 36].
Relationship between total hip rotation
ROM and low back pain
Van Dillen et al. compared the passive hip rota-
tion motion difference between people with and with -
out LBP who participated in rotational demand sports
activities [16]. A total of 48 subjects (24 people with
LBP and 24 people without LBP) were requested to
participate in the study. Measures of passive hip in -
ter nal and external rotation ROM were obtained with
an inclinometer. The results of this study demon-
strated that the symptomatic group had less total hip
rotation, reduced left total hip rotation and more
asymmetry of total rotation (left versus right).
Limited total hip rotation ROM in LBP group was
also demonstrated in a study by Alemida et al. [32]
involving 42 judo athletes (21 athletes with LBP and
21 athletes without LBP). LBP patients had a history
of LBP in the past year. Measures of hip internal and
external rotation ROM were obtained using comput-
ed photography in passive and active movements.
Ba sed on a comparison between the symptomatic
and asymptomatic groups, athletes with LBP had less
active and passive total rotation on the non-dominant
side and limited passive total hip rotation. Ac cord -
ingly, a deficit in total hip rotation and asymmetry
between the limbs was reported as a contributing fac-
tor of LBP in the athletes who practised judo.
RESULTS
As the results of the reviewed studies show, re -
duced hip internal rotation ROM and asymmetrical
hip internal rotation ROM (left versus right or domi-
nant versus non-dominant) are two common findings
related to hip rotation ROM impairment that are con-
sistently found in people with LBP. Moreover, a de -
ficit in hip internal rotation ROM was also observed
in some case studies [28-29]. In these case studies,
the treatment plan recommendation to improve hip
rotation ROM was followed by a positive result [28-
29]. In one study, a golfer player who experienced
chronic golf-related LBP had bilateral hip internal
Sadeghisani M. et al. Hip Rotation ROM and Low Back Pain
460
112 Sadeghsiani:Layout 1 2015-12-22 12:10 Strona 6
rotation ROM restriction. However, the pain was im -
mediately and completely resolved by a treatment
that focused on increasing hip internal rotation ROM
[37]. In a similar case study, an increase in right hip
internal rotation as a part of the plan of care led to
a significant improvement in the functional ability of
a 42-year-old man with a history of LBP [29]. Thus, it
seems that there is a strong relationship between LBP
and restriction in hip internal rotation ROM and asym-
metrical hip internal rotation ROM (left versus right).
Two studies that measured total hip rotation ROM
reported reduced total hip rotation, due to possible
restriction in hip internal rotation ROM, and asym-
metry of total hip rotation ROM (left versus right or
dominant versus non dominant).
Only in 2 studies in which the hip external rota-
tion measurement was obtained indirectly (through
the FABERE test), a decrease in hip ROM was re -
ported in LBP groups [26, 27]. No evidence shows
a direct relationship between LBP and limitation in
hip external rotation.
CLINICAL APPLICATION
The precise identification of factors contributing
to LBP is an important step in the management of
LBP sufferers [7,38-39]. In most cases, mechanical
factors have a strong influence on LBP [4]. As the
results of the reviewed studies have shown, impair-
ment in hip rotation ROM such as limited and asym-
metrical hip internal rotation and total hip rotation
must be considered an important contributing me -
cha nical factor that may be related to LBP symptoms
in symptomatic patients. These findings are poten-
tially important in people with LBP who regularly
participate in rotational demand activities [16].
It is not surprising that management strategies
focused on improving hip rotation ROM were fol-
lowed by short- and long-term positive results in pa -
tients with LBP [29-30,37]. Accordingly, an exa mi -
nation of the hip rotation ROM must be included in
the assessment of patients with LBP, especially among
patients who engage in repeated hip and trunk rota-
tion motion activities [16]. If, during the examination
of a patient with LBP, a clinician or physical thera-
pist encounters an impairment in hip rotation ROM
(limitation or asymmetry), he/she must establish
a logical relationship between the LBP and hip rotation
impairments and then attempt to resolve the LBP
symptoms by improving hip joint rotation ROM.
CONCLUSION
Based on these observations, we conclude that
there is a close and strong link between LBP and lim-
itation in hip rotation ROM, especially hip internal
rotation ROM. This evidence is very clear in patients
with LBP who regularly participate in sports activi-
ties which require repeated hip and lumbar rotation
motion. Although asymmetrical hip rotation ROM
and reduced total hip rotation ROM were observed in
patients with LBP, there is no direct evidence point-
ing to the importance of hip external rotation ROM
in the population of patients with LBP. Accordingly,
hip rotation ROM assessment must be included in the
examination of LBP sufferers.
It is worth mentioning that in all of the studies
reviewed, hip rotation ROM measurement was carried
out during non-functional tests. It appears that this gap
may be resolved by further studies that will investigate
the hip rotation ROM in LBP sufferers during func-
tional activities such as a walk ing.
Sadeghisani M. et al. Hip Rotation ROM and Low Back Pain
461
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Sadeghisani M. et al. Hip Rotation ROM and Low Back Pain
462
Adres do korespondencji / Address for correspondence
Farideh Dehghan Manshadi,
e-mail: sadeghi.m@sbmu.ac.ir
tel: +989137716567
Liczba słów/Word count: 4365 Tabele/Tables: 2Ryciny/Figures: 1Piśmiennictwo/References: 40
Otrzymano / Received 10.05.2015 r.
Zaakceptowano / Accepted 30.07.2015 r.
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