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 Table of Contents  
Year : 2023  |  Volume : 38  |  Issue : 1  |  Page : 32-38

Active range of motion of bilateral hip joint in young adults with chronic low back pain versus healthy controls: A comparative study

1 Department of Orthopaedics, Teerthanker Mahaveer Medical College & Research Centre (TMMC&RC), Moradabad, Uttar Pradesh, India
2 Department of Radiodiagnosis, Saraswati Institute of Medical Sciences, Hapur, Uttar Pradesh, India

Date of Submission06-Jan-2023
Date of Acceptance19-Feb-2023
Date of Web Publication20-Apr-2023

Correspondence Address:
Naman Kumar Parakh
Department of Orthopaedics, Teerthanker Mahaveer Medical College & Research Centre (TMMC&RC), National Highway 24, Delhi Rd, Bagadpur, Moradabad 244001, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jbjd.jbjd_2_23

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Background: Loss of quality of life, increased medical costs, and time away from work are all linked to chronic low back pain (CLBP). CLBP is recognized as a complex problem due to its biopsychosocial character. To remedy the issue of this incapacitating condition, it is critical to pinpoint potential contributing elements. The intersegmental parts of the kinematic chain connecting the lumbopelvic and knee joints are the hip joints. This complex runs in unison during both practical and leisurely physical activity. Materials and Methods: This was a single-center, observational study conducted in young adult patients with nonspecific CLBP and healthy controls who were compared for their active range of motion in bilateral hip joints. Results: There was no significant difference in the mean ages and gender distribution in both groups. The flexion, extension, internal rotation, external rotation, and abduction range of motions at bilateral hips were significantly reduced in the case group as compared with the healthy control group. Conclusion: The lumbopelvic compensation in the patients with CLBP affects the range of motion at the hip joint due to kinematic of the lower body musculature. The restriction in movement increases with the activities involving excessive hip joint motions.

Keywords: Active range of motion, chronic low back pain, lumbopelvic kinematics

How to cite this article:
Saraf A, Parakh NK, Mahipal V, Sandhu AS, Aggarwal T, Gupta P. Active range of motion of bilateral hip joint in young adults with chronic low back pain versus healthy controls: A comparative study. J Bone Joint Dis 2023;38:32-8

How to cite this URL:
Saraf A, Parakh NK, Mahipal V, Sandhu AS, Aggarwal T, Gupta P. Active range of motion of bilateral hip joint in young adults with chronic low back pain versus healthy controls: A comparative study. J Bone Joint Dis [serial online] 2023 [cited 2023 Jun 7];38:32-8. Available from: http://www.jbjd.in/text.asp?2023/38/1/32/374424

  Introduction Top

More people are disabled by low back pain (LBP) than by any other condition, making it a serious health concern. Every four out of five adults may suffer with back pain in their lifetime, making it one of the most prevalent musculoskeletal illnesses.[1]

Nonspecific chronic low back pain (NSCLBP) continues to be a disabling disorder that limits everyday physical activity and quality of life for those affected, despite recent efforts to unravel the underlying process. Mechanical variables, among other etiological factors, are extremely important for the development and persistence of CLBP symptoms. Numerous studies have concentrated on the connection between the hip joint’s mobility and back ache due to the continuity of anatomy in the lumbopelvic region with hip articular area.[2]

The intersegmental parts of the kinematic chain connecting the lumbopelvic and knee joints are the hip joints.[3]

Studies on the link between the hip and LBP generally operate under the premise that altered lumbopelvic mechanics may result from inadequate hip function. As a result of this relationship, decreased hip rotation range of motion (ROM) plays a crucial role in CLBP dysfunction. Even when hip ROM is unrestricted, altered hip and lumbopelvic region coordination may lead to an increased mobility in lumbar and pelvic region. Active ROM at a joint refers the range of mobility at a joint that is achieved by using own muscles and does not require any external support. This differs from the passive ROM, which is the motion at hip achieved with support by someone or something.[4]

The values for normal active ROM at the hip joint vary with different studies. The most reliable values in the same are as follows: flexion 115°–125°, extension of 10°–15°, medial rotation of approximately 45°, lateral rotation of approximately 45°, abduction of 40°, and adduction of 40°.[5]

At present, management of CLBP is usually focused on the back pain component only. By finding the correlations between LBP and hip joint mobility, future researchers will be benefitted in formulating a broader protocol of management for hip related issues in patients with CLBP.

  Materials and Methods Top

This was an observational study performed in 373 patients coming to the Department of Orthopaedics during a duration from December 2020 to June 2022 after receiving clearance from Institutional Ethics Committee. All young adult patients complaining of chronic pain in lower back between the age of 18 and 35 years were included in the case group. Subjects who gave consent and had no complains of pain in lower back region exceeding 7 days in the preceding 12 months were included in the control group. A goniometer was used to assess movements at the hip of the included subjects. It has shown positive credibility and coinciding ratoinality.[13]

Range of active movements during flexion, extension, external rotation, and internal rotation, abduction and adduction in both hip joints were assessed and recorded.

The subject was asked to lie down in supine position with knee flexed at 90° and was asked to bring the knee as close to the chest as possible for flexion measurement. The examiner had to fix the opposite pelvis to avoid any compensatory movements.

The subjects were then asked to flex both the knee and the hip to 90°.

For external rotation measurement, the subject was asked to move the toes inwards as much as possible.

For internal rotation measurement, the individual was asked to move their toes externally.

The subject was then asked to lie prone for extension measurement, and was asked to lift their heel up with the knee locked. For adduction, we asked the subject to extend and slightly lift leg to clear the opposite foot. We placed one hand over the opposite iliac crest and then asked them to move the leg medially across the midline.

For abduction, we placed one hand on the iliac crest of opposite side and asked the subject to slightly lift and move the leg laterally from the midline.

All movements were then performed on both legs and the angle between the resting and end positions were measured using a goniometer.

The measurements were taken by three different observers in the presence of a qualified orthopedic surgeon and the readings recorded. Mean of the three readings was also calculated and recorded. Rom in the cases and healthy controls were compared for bilateral hip joints.

  Results Top

There was no significant difference in the age or gender distribution in the study population. The mean age of the case group was 26.98 years whereas the average age of the control group was found to be 27.14 years [Table 1]. The males and females in the overall study group comprised of 52.5 % and 47.5% respectively. Of this, the gender distribution in case group had a female preponderance 54% whereas the males were in majority in the control group (60%) [Table 2]. When comparing the range of motion between cases and controls, the mean flexion, extension and internal rotation were reduced in both the hips in the case group as compared to the control group [Table 3] and [Table 4].
Table 1: Distribution of study population according to mean age in cases and controls

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Table 2: Distribution of study population according to gender

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Table 3: Distribution of study population according to ROM in right hip

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Table 4: Distribution of study population according to ROM in left hip

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On assessment of the ROM of hip joint in males among both groups, the flexion, extension and internal rotation were significantly reduced in both the right and left hips in the cases as compared to the controls [Table 5] and [Table 6]. Similarly, the females in the case group showed significantly decreased range of motion in the bilateral hips in the flexion, extension and internal rotation movements as compared to the females in the control group [Table 7] and [Table 8].
Table 5: Distribution of study population according to ROM in right hip (males)

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Table 6: Distribution of study population according to ROM in left hip (males)

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Table 7: Distribution of study population according to ROM in right hip (females)

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Table 8: Distribution of study population according to ROM in left hip (females)

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  Discussion Top

This research compared the variations rotational mobility of the hip between back pain patients and healthy controls. The body of research finds various end-range hip rotation ROM patterns in those with back pain and subjects without pain.[6]

In current research, the difference in distribution of males and females between case and control groups was insignificant. Literature points towards a female preponderance in the subjects with CLBP even though there is a stronger association between the disc space and back pain in male population. This could be postulated to be due to the comparatively low tolerance of pain among women. Although, it has been seen that males have more stiffness and restriction of the bilateral lower limbs and are more affected by the lumbar flexion syndrome.[7]

Due to increased stiffness, heavy muscle mass and cross-sectional area in the lower limbs in males, the compensation by the lumbopelvic musculature is seen earlier and therefore there is increased limitation of movement in the male population as compared to females.[8],[9]

Flexion at the hip is significantly reduced in the case group. This may be due to the weakness and decreased activity of primary hip flexor, the psoas major muscle. This weakness causes an activation of nociceptors in the soft tissue around the lumbopelvic region and leads to further mechanical instability.[8]

Studies have shown that the decrease in the extension is due to abnormal patterns of muscle activation which mainly involves the lumbar erector spinae (LES) and lumbar multifidus (LM) muscle in the LBP patients. The LBP patients activate the LES during hip extension to compensate the weakened hip extensors. But on chronic longstanding pain, this compensation decreases and causes an overall decrease in the hip extension ROM in CLBP patients. The findings of this research also demonstrate that the hip extension asymmetrical and is correlated with pain severity & disability during tasks requiring hip extension.[10]

The internal and external rotation at the hips are also affected in patients with CLBP. These restrictions were due to the abnormal muscular coordination between the hip and lumbopelvic regions. This could be due to increased technical demand which causes higher stress over the non-dominant side which later causes musculoskeletal adaptations like muscle tightness and hence, limited hip mobility. when the hip joint motion is restricted, trying to rotate the hip repeatedly has the ability to put strain on the pelvis and lumbar region and transfer forces there. It is hypothesised that the development of high-stress regions over the lumbar spine and surrounding region contributes to minute trauma, hence, rotational restrictions in the hip joints in the patients with CLBP.[6],[11]

Increased activation of the gluteus medius muscle in patients with CLBP when they shifted from single to double leg stance. Aberrant patterns of activation in the agonist and antagonist abduction muscle groups in CLBP patients leads to symptoms of LBP which includes a restriction in the abduction at the hip joint.[12],[13]

The major symptoms in these patients included pelvic malalignment, asymmetrical lower limb posture, gluteal muscle weakness, hamstring, psoas and quadratus lumborum muscle tightness, and weakness in lower abdominal musculature. All these factors lead to an overall restriction in the mobility of hip joints in these patients.[14]

Extreme postures typically cause an increased hip rotation in a particular direction, along with a reduction of hip mobility over the other direction. This occurs because of the way the hips are positioned relative to one another. Changes of this kind in the mobility of the hip would almost certainly result in a movement of the mid-length position in the hip direction that has a higher mobility.

The findings of our research will have important implications for clinical practice since they show that restricted hip joint extension has a significant impact on lumbar rotation compensation and that the degree of asymmetry influences pain intensity.

  Conclusion Top

Compared with patients without LBP, those with chronic or recurrent LBP report a higher disparity in activity levels between sport-related activities and the majority of daily tasks (work and non-sporting leisure). When doing lower limb movement assessments, both individuals with and without LBP exhibit comparable movement patterns. In those who play an RRS, an LBP condition may develop or remain due to a disparity between the relative quantity and character of the physical activities contributing to an overall activity level, as well as a repetitive movement patterns.

These results imply that the clinical assessment of active people with CLBP may want to take into account passive hip extension as a significant variable. Hip mobility constraints and how they can affect assessments of strength and probable Sacro-Iliac Joint involvement may be vital to take into account. The link between measures and intervention options may need more research in the future.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Meucci RD, Fassa AG, Faria NMX Prevalence of chronic low back pain: Systematic review. Rev Saude Publica 2015;49:E360-410.  Back to cited text no. 1
Hayden JA, Wilson MN, Riley RD, Iles R, Pincus T, Ogilvie R, . Individual recovery expectations and prognosis of outcomes in non‐specific low back pain: prognostic factor review. Cochrane Database Syst Rev 2019;2019:CD011284.  Back to cited text no. 2
Krishna HS, Pramod PV, D’souza CJ, Thomas S, Babu A Hip rotation range of motion: A comparison between healthy individuals and patients with chronic low back pain. Int J Sci Healthc Res 2020;5:160-4.  Back to cited text no. 3
Harris-Hayes M, Sahrmann SA, Van Dillen LR Relationship between the hip and low back pain in athletes who participate in rotation-related sports. J Sport Rehabil 2009;18:60-75.  Back to cited text no. 4
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;10:13-20. Erratum in: Int J Sports Phys Ther 2015;10:572.  Back to cited text no. 5
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. 6
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. 7
Jung SH, Kwon OY, Yi CH, Cho SH, Jeon HS, Weon JH, et al. Predictors of dysfunction and health-related quality of life in the flexion pattern subgroup of patients with chronic lower back pain: The STROBE study. Medicine (Baltimore) 2018;97:e11363.  Back to cited text no. 8
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. 9
Wattananon P, Silfies SP, Tretriluxana J, Jalayondeja W Lumbar multifidus and erector spinae muscle synergies in patients with nonspecific low back pain during prone hip extension: A cross-sectional study. PM&R. 2019;11:694-702.  Back to cited text no. 10
Cejudo A, Moreno-Alcaraz VJ, Izzo R, Santonja-Medina F, Sainz de Baranda P External and total hip rotation ranges of motion predispose to low back pain in elite Spanish inline hockey players. Int J Environ Res Public Health 2020;17:4858.  Back to cited text no. 11
Penney T, Ploughman M, Austin MW, Behm DG, Byrne JM Determining the activation of gluteus medius and the validity of the single leg stance test in chronic, nonspecific low back pain. Arch Phys Med Rehabil 2014;95:1969-76.  Back to cited text no. 12
Bussey MD, Kennedy JE, Kennedy G Gluteus medius coactivation response in field hockey players with and without low back pain. Phys Ther Sport 2016;17:24-9.  Back to cited text no. 13
McGregor AH, Hukins DW Lower limb involvement in spinal function and low back pain. J Back Musculoskelet Rehabil 2009;22:219-22.  Back to cited text no. 14


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]


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