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Adv Biomed Res 2023,  12:169

Assessment of hip range of motion limitations in cases with low back pain based on the classified movement system impairment

1 Department of Physical Therapy, School of Rehabilitation Sciences, Isfahan University of Medical Sciences, Isfahan, Iran
2 Musculoskeletal Rehabilitation Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
3 Department of Biostatistics and Epidemiology, Faculty of Health, North Khorasan University of Medical Sciences, Bojnurd, Iran

Date of Submission04-Oct-2022
Date of Acceptance24-Jan-2023
Date of Web Publication30-Jun-2023

Correspondence Address:
Dr. Navid Taheri
Department of Physical Therapy, School of Rehabilitation Sciences, Isfahan University of Medical Sciences, Isfahan, Postal Code - 8175945315
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/abr.abr_337_22

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Background: The hip joint's limitation causes lumbopelvic compensatory motions, accumulating tissue stress on the lumbar spines. It is essential and valuable to evaluate hip rotation range of motion (ROM) in different low back pain (LBP) classifications to understand them and plan the best exercise program. This study aimed to compare hip rotation ROM between subjects with and without LBP classified in movement system impairment (MSI).
Materials and Methods: In this cross-sectional study, 100 subjects with LBP were classified into different MSI subgroups (mean age of 41.66 ± 7.82 years), and 100 healthy subjects (mean age of 38.96 ± 8.84 years) participated. Passive and active hip medial and lateral rotations ROM in prone and supine positions for dominant and non-dominant lower limbs were measured.
Results: Generally, in the LBP group, minimal lateral rotation as compared to controls in movement tests measuring hip rotation ROM actively and passively, in prone and sitting positions, and for dominant and non-dominant limbs (P < 0.05). There were no significant differences among the LBP subgroups (P > 0.05).
Conclusions: Due to LBP, regardless of the MSI categories, remarkably restricted hip lateral rotation ROM.

Keywords: Classification, hip joint, low back pain

How to cite this article:
Khayam Nekoie F, Kouhzad Mohammadi H, Afshari-Safavi A, Mahdidust Jalali H, Taheri N. Assessment of hip range of motion limitations in cases with low back pain based on the classified movement system impairment. Adv Biomed Res 2023;12:169

How to cite this URL:
Khayam Nekoie F, Kouhzad Mohammadi H, Afshari-Safavi A, Mahdidust Jalali H, Taheri N. Assessment of hip range of motion limitations in cases with low back pain based on the classified movement system impairment. Adv Biomed Res [serial online] 2023 [cited 2023 Sep 26];12:169. Available from:

  Introduction Top

Chronic low back pain (CLBP) is one of the most common musculoskeletal problems. Difficulties in managing this problem have made it a challenge for all professionals working on spine care.[1] Although various treatment approaches such as massage, laser therapy, and electrotherapy have been raised, exercising seems more productive, and its consequences are more permanent than other treatment methods.[2] Due to the anatomic proximity and interconnection of the hip joint and lumbopelvic region, excessive or reduced hip range of motion (ROM) can play a role in LBP development or inherent.[3] It is a fact noted that in exercise programs for LBP.

It is proposed that hip motion limitation causes lumbopelvic compensatory motions, which lead to the accumulation of tissue stress on the lumbar spine.[4],[5],[6] Hence, LBP may develop as a result; however, it may occur in turn to LBP symptoms, as well.[4]

Moreover, it is proposed that applying classification-based treatment in CLBP leads to significant improvement. Evaluating hip rotation (ROM) in different LBP classifications may be more practical and valuable to understand them and plan the best exercise program. The Movement System Impairment (MSI) approach is a biophysically based classification system grounded on symptoms, patterns of movements, and alignments identified by a standardized clinical examination. It emphasizes the role of exercise in producing impairments and abnormalities.[7] It classifies people with LBP into subgroups, including lumbar flexion (Flex), lumbar extension (Ext), lumbar rotation (Rot), lumbar flexion-rotation (Flex-Rot), and lumbar extension-rotation (Ext-Rot) syndromes.[8]

Few studies have investigated hip ROM dysfunction in MSI subgroups.[4],[9] A study evaluated hip stiffness patterns in patients with Flex-Rot or Ext-Rot syndrome. It concluded that considerable unidirectional hip motion loss in the sagittal plane is a common finding.[9] Another study found no difference in external hip rotation in lumbar Rot syndrome and lumbar Ext-Rot syndrome subgroups.[4]

Even though the hip rotation ROM in the LBP group and Rot-based MSI categories has been evaluated, there is no study on hip rotation ROM assessment in other lumbar MSI subgroups. Finding any relationship between MSI categories and hip motion loss in the transverse plane can help plan a complete and proper exercise program for CLBP. This study aimed to compare the active and passive sides of hip rotation ROM in various conditions in subjects with and without LBP who do not participate in any sports activity.

  Materials and Methods Top


This cross-sectional study recruited 100 subjects (42 men and 58 women) with LBP and 100 subjects (52 men and 48 women) without LBP according to inclusion and exclusion criteria.

Patients with the age range of 20-55 years old and body mass index (BMI) of 22-25 kg/m2 who had a medical history of LBP in the last three months[10] or half of the days in the previous six months.[11] It included a history of acute pain in the lumbar, hips, and knees in the recent two weeks.

Besides, age- and BMI-matched cases without any history of LBP in the recent three months[12] were recruited as the control group.

Subjects with the following problems were excluded from the study: leg or thigh pain,[13] positive straight leg raise (SLR) test or severe neurological symptoms,[14] history of tumor, infection, or fracture in lumbar spines, hips, and knees,[4],[15] previous spinal, hip or knee surgery,[4],[16] rheumatoid arthritis, ankylosing spondylitis, marked kyphosis or scoliosis,[4],[15] pain or neural deficit limited hip ROM measurement,[10] professional sports activities,[15] and lower-extremity impairment (e.g., leg length discrepancy),[4] any history of acute pain in the lumbar, hips and knees in the recent two weeks[10] and pregnancy.[4]

The Ethics Committee of Isfahan University of Medical Sciences approved the study protocol under opinion number IR.MUI.REC.1395.3.520. The study protocol met the Helsinki declaration criteria; therefore, I explained it to the study participants and requested them to sign the written form of participation.

Sampling method

The participants were recruited from patients referred to the outpatient physiotherapy clinic of Isfahan University of Medical Sciences, through convenience, with a non-randomized sampling method.

Data collection

There were two components of tests that were completed in one session by the primary investigator. The tests included MSI assessment in the LBP group and hip rotation ROM measurements in both LBP and control groups.

MSI assessment

Subjects in the LBP group were examined according to the MSI classification.[8],[10] The examination tests are shown in [Table 1] and include the movements and positions. For each activity, monitored symptoms, the pattern of signs, and body alignments. Based on the subject's history and examination results, all the issues were classified into one of the three MSI categories [Table 1].
Table 1: Movement system impairment findings in different position tests

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Hip rotation measurements

Hip rotation ROM was measured using a baseline digital inclinometer. Subjects were requested to wear non-restrictive clothing and performed a standardized 5-minute warm-up on a static exercise bike.[17],[18] Measurements took place in the prone and sitting positions non-randomly. In the horizontal position and lying on a treatment table, the pelvis was stabilized using a belt at the level of the posterior inferior iliac spine.[18] The measured hip was placed in 0° of abduction and flexed the knee to 90°. Another hip was identified in 30° of kidnapping. The inclinometer was positioned 10 cm distal to the tibial tuberosity.[18],[19] After zeroing the inclinometer to a fixed vertical reference, passively moved the leg to achieve medial and lateral rotation to the point of the first resistance feeling.

In contrast, no pelvic rotation has occurred.[10],[17] For active measurement, subjects were instructed to reach the end available ROM.

For the sitting position, the issue sat on a firm chair in an upright position and a belt fixed thigh. The subjects were instructed not to lift their pelvis and bend backward. The measured hip was placed in 0° of abduction and adduction and flexed the knee to 90°. The inclinometer's position and testing procedure were like the prone position test. It obtained Measurements for both dominant and non-dominant sides. It took three measurements for each class and side, and the mean was recorded.[18]

Statistical analysis

All Statistical analyses were performed using the Statistical Package for Social Sciences (SPSS) version 20 (SPSS Inc., Chicago, IL, USA) software. An analysis of covariance (ANCOVA) was used to compare the average values of the hip rotation ROM between groups, and age, weight, and height were used as the covariates. Also, the differences among the subgroups of LBP were compared using analysis of variance (ANOVA) with a Bonferroni adjustment and set the significance level at 0.05.

  Results Top

One hundred subjects with LBP and 100 healthy subjects with a mean age of 40.31 ± 8.33 years and mean weight of 73.44 ± 13.15 kg, and evaluated mean height of 169.05 ± 9.59 cm in this study. It found no significant differences in age, weight, or size between the two groups (P > 0.05). The comparison of demographic information is illustrated in [Table 2].
Table 2: Demographic information of the subjects

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All of the subjects were classified based on MSI classification. There were 37 subjects in Flex-based, 55 subjects in Ext-based, and eight subjects in the Rot-based syndrome subgroup.

To determine the inter-rater reliability, a pilot study of 10 subjects was performed in which repeated each measurement three times within a week interval. The intra-tester reliability measures (Interclass correlation) for all the studied variables were excellent.

The results showed that in the majority of the movements, significantly restricted lateral hip rotation in the active and passive, prone and sitting positions, and dominant and non-dominant lower limb, among patients with LBP as compared to the control group (MPrPaN: P = 0.011; LPrAD: P = 0.002: LPrAN: P = 0.005; LPrPaD: P = 0.006; LPrPaN: P = 0.001; LSAD: P = 0.037; LSAN: P = 0.025 and LSPaN: P = 0.008) [Table 3]; although passive medial rotation in the prone position of non-dominant limb (MPrPaN) and passive lateral rotation in sitting position of non-dominant limb (LSPaD) movements were not consistent with the overall results.
Table 3: Comparison of different rotations of hip joint in the LBP and control groups

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The outcomes also demonstrated that except for passive lateral rotation in the prone position in non-dominant limb (LPrPaN) movement, there were no differences in other hip rotation movements among the MSI subgroups (P value > 0.05) [Table 4].
Table 4: Comparison of different rotations of hip joint in MSI subgroups of LBP

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  Discussion Top

Our findings in the current study determined a remarkable restriction in lateral hip rotation in subjects with LBP compared to healthy subjects. Numerous studies have shown a correlation between LBP and restricted hip rotation ROM, but the results are controversial.[11],[20],[21],[22] Vad et al.[23] reported limitations in different directions, including flexion and abduction. Also, external rotation through the FABER test can be due to hip external rotation restriction. However, some studies have demonstrated considerable limitations not only in lateral rotation but in other directions, as well.[24]

In general, we found no significant differences between the cases and control groups in the assessment of internal rotation ROM. These outcomes were inconsistent with some of the studies in the literature, which assessed athletic populations. For instance, Vad et al.[23] evaluated tennis players, and in another study, the golfers were considered.[25] Both studies observed significant limitations in the passive bilateral hip internal rotation. These findings were confirmed by the studies performed on amateur golfers[17] and judo players[15] in both active and passive internal rotation examinations.

It should note that we evaluated subjects without sports activities while those who participated in sports activities performed the specific movements in a wide ROM. It is the probable reason for controversies in the other studies. Therefore, our outcomes can be generalized to people with LBP who do not exercise regularly.

We also measured hip rotation ROM in subjects with classified LBP in the current study. Subgrouping increases sample homogeneity, which can better explain the relationship between hip function and LBP. Besides, performed the assessments actively and passively in flexed and extended hip positions (prone and sitting positions), involving different shortened and elongated muscles and other tissues, but found no difference. It is hypothesized that hip rotation ROM differs in different subgroups, but practically, there was no significant difference in these categories. Due to the overlapping in the subjects assigned to 3 assessed categories in this study. The subjects were also divided into five primary subgroups; however, they found no differences again.

In contrast to our findings, Van Dillen and colleagues showed different hip and lumbopelvic rotation motion timing in the Rot and Ext-Rot subgroups. It may have occurred due to the assessment of athletes and emphasis on muscle timing; however. The mention might have found these movement patterns because of symptoms irrelevant to LBP.[4]

Other investigations have revealed that greater lumbopelvic rotation during lateral hip rotation[26],[27] can lead to the deterioration of symptoms. It may cause avoidance of lateral hip rotation in cases with LBP.

Another theory about the etiology of LBP targets the shortness of the iliotibial band, tensor fasciae late, and piriformis muscle in flex-Rot, Ext-Rot, and Rot subgroups. It is probably another causative reason leading to limited hip external rotation.[27]

The pain level was not rated, which can be a limiting factor to voluntary muscle contractions. To generalize the outcomes limited the number of subjects in some subgroups. Moreover, using an objective method to measure ROM may be more valid.

In summary, we found significant restriction in lateral hip rotation in cases presenting LBP. Besides, we found no significant differences in hip ROM among the LBP patients according to MSI subgroups.

  Conclusion Top

Due to LBP, regardless of the MSI categories, was remarkably restricted hip lateral rotation ROM. There were no significant differences among the LBP subgroups. Future studies need to investigate hip rotation ROM in different classifications to recognize the fundamental role of the hip joint in LBP.

Financial support and sponsorship

Isfahan University of Medical Sciences sponsored the current study.

Conflicts of interest

There are no conflicts of interest.

  References Top

Fairbank J, Gwilym SE, France JC, Daffner SD, Dettori J, Hermsmeyer J, et al. The role of classification of chronic low back pain. Spine 2011;36:S19-42.  Back to cited text no. 1
Van Dillen LR, Norton BJ, Sahrmann SA, Evanoff BA, Harris-Hayes M, Holtzman GW, et al. Efficacy of classification-specific treatment and adherence on outcomes in people with chronic low back pain. A one-year follow-up, prospective, randomized, controlled clinical trial. Man Ther 2016;24:52-64.  Back to cited text no. 2
Chaitow L. Is a postural-structural-biomechanical model, within manual therapies, viable? A JBMT debate. J Bodywork Mov Ther 2011;15:130-52.  Back to cited text no. 3
Van Dillen LR, Gombatto SP, Collins DR, Engsberg JR, Sahrmann SA. Symmetry of timing of hip and lumbopelvic rotation motion in 2 different subgroups of people with low back pain. Arch Phys Med Rehabil 2007;88:351-60.  Back to cited text no. 4
Vad VB, Bhat AL, Basrai D, Gebeh A, Aspergren DD, Andrews JR. Low back pain in professional golfers the role of associated hip and low back range-of-motion deficits. Am J Sports Med 2004;32:494-7.  Back to cited text no. 5
Burns SA, Cleland JA, Rivett DA, Snodgrass SJ. Examination procedures and interventions for the hip in the management of low back pain: A survey of physical therapists. Braz J Phys Ther 2019;23:419-27.  Back to cited text no. 6
Van Dillen LR, Sahrmann SA, Norton BJ, Caldwell CA, McDonnell MK, Bloom NJ. Movement system impairment-based categories for low back pain: Stage 1 validation. J Orthop Sports Phys Ther 2003;33:126-42.  Back to cited text no. 7
Sahrmann S. Diagnosis and Treatment of Movement Impairment Syndromes. New York: Elsevier Health Sciences; 2002.  Back to cited text no. 8
Kim M-H, Yi C-H, Kwon O-Y, Cho S-H, Cynn H-S, Kim Y-H, et al. Comparison of lumbopelvic rhythm and flexion-relaxation response between 2 different low back pain subtypes. Spine 2013;38:1260-7.  Back to cited text no. 9
Zafereo J, Devanna R, Mulligan E, Wang-Price S. Hip stiffness patterns in lumbar flexion-or extension-based movement syndromes. Arch Phys Med Rehabil 2015;96:292-7.  Back to cited text no. 10
Roach SM, San Juan JG, Suprak DN, Lyda M, Bies AJ, Boydston CR. Passive hip range of motion is reduced in active subjects with chronic low back pain compared to controls. Int J Sports Phys Ther 2015;10:13.  Back to cited text no. 11
Delitto A, George SZ, Van Dillen L, Whitman JM, Sowa G, Shekelle P, et al. Low back pain: Clinical practice guidelines linked to the international classification of functioning, disability, and health from the orthopaedic section of the American Physical Therapy Association. J Orthop Sports Phys Ther 2012;42:A1-57.  Back to cited text no. 12
Khan A, McLoughlin E, Giannakas K, Hutchinson C, Andrew J. Hip osteoarthritis: Where is the pain? Ann R Coll Surg Engl 2004;86:119-21.  Back to cited text no. 13
Van Dillen LR, Bloom NJ, Gombatto SP, Susco TM. Hip rotation range of motion in people with and without low back pain who participate in rotation-related sports. Phys Ther Sport 2008;9:72-81.  Back to cited text no. 14
Almeida GPL, de Souza VL, Sano SS, Saccol MF, Cohen M. Comparison of hip rotation range of motion in judo athletes with and without history of low back pain. Man Ther 2012;17:231-5.  Back to cited text no. 15
Seeley MK, Umberger BR, Shapiro R. A test of the functional asymmetry hypothesis in walking. Gait Posture 2008;28:24-8.  Back to cited text no. 16
Murray E, Birley E, Twycross-Lewis R, Morrissey D. The relationship between hip rotation range of movement and low back pain prevalence in amateur golfers: An observational study. Phys Ther Sport 2009;10:131-5.  Back to cited text no. 17
do Carmo Carvalhais VO, de Araújo VL, Souza TR, Gonçalves GGP, de Melo Ocarino J, Fonseca ST. Validity and reliability of clinical tests for assessing hip passive stiffness. Man Ther 2011;16:240-5.  Back to cited text no. 18
Araújo VL, do Carmo Carvalhais VO, dos Santos TRT, Gonçalves GGP, Prado LS, Fonseca ST. Characterization of hip passive stiffness of volleyball, basketball and futsal young athletes. Phys Ther Sport 2013;14:227-31.  Back to cited text no. 19
Chesworth BM. A comparison of hip mobility in patients with nonspecific low back pain. Physiother Can 1994;46:267-74.  Back to cited text no. 20
Scholtes SA, Gombatto SP, Van Dillen LR. Differences in lumbopelvic motion between people with and people without low back pain during two lower limb movement tests. Clin Biomech 2009;24:7-12.  Back to cited text no. 21
Sahrmann S, Azevedo DC, Dillen LV. Diagnosis and treatment of movement system impairment syndromes. Braz J Phys Ther 2017;21:391-9.  Back to cited text no. 22
Vad V, Gebeh A, Dines D, Altchek D, Norris B. Hip and shoulder internal rotation range of motion deficits in professional tennis players. J Sci Med Sport 2003;6:71-5.  Back to cited text no. 23
Wk Lee S, Kim SY. Effects of hip exercises for chronic low-back pain patients with lumbar instability. J Phys Ther Sci 2015;27:345-8.  Back to cited text no. 24
Vad VB, Bhat AL, Basrai D, Gebeh A, Aspergren DD, Andrews JR. Low back pain in professional golfers: The role of associated hip and low back range-of-motion deficits. Am J Sports Med 2004;32:494-7.  Back to cited text no. 25
Gombatto SP, Collins DR, Sahrmann SA, Engsberg JR, Van Dillen LR. Gender differences in pattern of hip and lumbopelvic rotation in people with low back pain. Clin Biomech 2006;21:263-71.  Back to cited text no. 26
Prather H, Cheng A, Steger-May K, Maheshwari V, Van Dillen L. Hip and lumbar spine physical examination findings in people presenting with low back pain, with or without lower extremity pain. J Orthop Sports Phys Ther 2017;47:163-72.  Back to cited text no. 27


  [Table 1], [Table 2], [Table 3], [Table 4]


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