Limited hip range of motion causing back pain

Ross Hauser, MD & Danielle Matias, PA-C

This article is part of a series of articles on the interrelationship between hip and low pain.

Other articles include:

We are going to start with a June 2023 study in the journal Advanced Biomedical Research (1). Here researchers examined and assessed the controversies surrounding the connection between reduced range of motion in the hip and reduced motion as a cause of low back pain and degenerative spine disease. For people who have hip pain and reduced motion, and who also suffer from back pain, there should be no controversy. Where the controversy lies is in how to treat problems of hip-spine pain and where the origins of this pain come from.

The researchers of this study write: “Our findings in the current study determined a remarkable restriction in lateral hip rotation in subjects with low back pain compared to healthy subjects.

restriction in lateral hip rotation
Measuring lateral motion of the hip

Numerous studies have shown a correlation between low back pain and restricted hip rotation range of motion, but the results are controversial. . .” Why would these results be considered controversial? The reason is that some research suggests no connection. Some research suggests that people do not always show low back pain when hip range of motion is present, other researchers suggest that the connection between low back pain and hip pain is often missed and that the back pain is a problem of the back and the hip pain is the problem of the hip and no connection exists.

In this paper, the researchers ran across this controversy and offered an explanation. Here is what they wrote: “In general, we found no significant differences between the cases and control groups in the assessment of internal rotation range of motion.  (As opposed to significant differences in low back pain patients and reduced hip range of motion patients in the measure of lateral hip rotation). They recognized that their own findings were at odds with previous research, more specifically previous research which assessed athletic populations. The researchers then concluded: “It should be noted that we evaluated subjects without sports activities while those who participated in sports activities performed the specific movements in a wide range of motion. It is the probable reason for controversies in the other studies. Therefore, our outcomes can be generalized to people with low back pain who do not exercise regularly.”

In other words, the controversy may lie in active people versus non-active people in the assessment of reduced hip range of motion causing back pain. However, regardless, low back pain caused patients to have “remarkably restricted hip lateral rotation range of motion.”

So what does all that mean? Look for a connection between low back and hip pain.

What are we seeing in this image?

This image is being used to demonstrate the interrelationships between the thoracic spine, lumbar spine, and the hips and normal or abnormal movement. In this example, the skeleton is trying to touch its toes. There are three different lumbopelvic rhythms or movements used to bend the trunk forward and toward the floor with knees held straight, a normal kinematic strategy used to bend the trunk from a standing position. A limited flexion in the hips (caused for example by tight hamstrings or other impediments) that great affection is required of the lumbar and lower thoracic spine. C. With limited lumbar mobility, greater flexion is required of the hip joints. In B and C, the dashed line circles and arrows indicate regions of restricted mobility.

the interrelationships between thoracic spine, lumbar spine, and the hips and normal or abnormal movement

The most common compensatory scenario seen in chronic hip pain cases is lumbar hyperextension, anterior pelvic tilt, gluteus muscle weakness, femur internal rotation, knee valgus stress and lateral patellar displacement, tibial internal rotation, medial ankle collapse (and instability) and foot hyper pronation.

There are lots of theories as to why this occurs. I believe it either begins with knee medial ligament laxity or anterior hip laxity. Since joint instability is a progressive disorder, it is safe to assume that if medial knee instability develops first and it is not addressed appropriately, it will progress to medial ankle instability and anterior hip instability. The body compensates for this with tibial and femur internal rotation and lumbar hyperextension to allow the body to stay upright and walk. Those with these issues can undergo chiropractic manipulation for the lumbar and pelvic distortions or start an exercise program of gluteus medius strengthening, balance work, and core strengthening. This will all help, but it is not going to stop the collapse of the medial knee, ankle, and anterior hip. It will slow the progression, but unfortunately, it will still progress. In patients we see with this degenerative condition we stabilize the joints with Prolotherapy and then start an active guided and targeted exercise program. Then, the muscles strengthening will work more efficiently because the underlying joints are stable. Trying to rehab unstable joints by exercise simply just doesn’t work. Please see my article Hip pain and hip instability | What happens if hip muscles are weak?

Learning points summary:

  • Hip-spine syndrome is a pain syndrome characterized by injuries in both the hip and the low back that impact each other.
  • At 0:27 of the video, the interactions of the hip and the spine are demonstrated with a model of the pelvis.
  • Hip-spine syndrome commonly involves your hip and your sacroiliac joint or even the low back part of your spine. When you develop injuries or degenerative wear and tear in both the hips and the low back, these injuries impact each other. The back pain can make the hip pain worse, the hip pain can make the back pain worse as the degenerative disease is accelerating in both areas.
  • Many times we will see a patient in the office. They will have a very specific diagnosis that their problems all come from the hip, or they will have a very specific diagnosis that their problems are all coming from the lower back. After we do a physical examination and talk to the patient about their medical history, it is clear that this patient has issues in both the hip and spine.
  • Often we find that patients have completed a conservative care treatment course for their lower back or they have completed a conservative care treatment course for their hip, yet they still have pain. In this situation, conservative care may have been directed at the wrong pain triggers.
  • In patients like this, we treat the hip, spine, sacroiliac joint, and sacrum areas with Prolotherapy to bring stability into the area by restoring normal function to damaged or weakened spinal and hip ligaments.  (The treatment is explained below in greater detail).
  • At Caring Medical we have a very high success rate in treating patients effectively and alleviating their chronic pain with Prolotherapy.

In this next section, we will explore research leading up to clinical observations in helping patients with hip and low back pain problems.

Understanding the reduced range of hip motion causing more lower back pain

The above 2023 paper cited this research from doctors at Washington University School of Medicine in St. Louis and Northwestern University Feinberg School of Medicine. In this study, the researchers wrote in The Journal of Orthopaedic and Sports Physical Therapy (2) of patients with hip-spine syndrome with known hip arthritis and reduced range of hip motion.

  • They found on examination, 101 patients  with hip arthritis (68 women, 33 men) with an average age of 47.6 years:
    • 81 (80%) had reduced hip flexion;
    • 76 (75%) had reduced hip internal rotation.

The researchers concluded: “Physical examination findings indicated hip dysfunction is common in patients presenting with low back pain. Patients with low back pain and positive hip examination findings have more pain and worse function compared to patients with low back pain but without positive hip examination findings.’ In other words, people with low back pain and hip pain have a worse function than patients with low back pain without hip pain.

Also citing this research was a July 2022 paper led by the University of California, San Francisco and published in the European Spine Journal (3) looking for how the body compensates for motion where hip and spine pain are present and “to understand how different spinal disorders and levels of pain severity relate to unique compensatory biomechanical behaviors.”

In this study, 44 non-specific low back pain and 42 spinal deformity low back pain patients were assessed. To be brief, as demonstrated in this image below showing anterior or “front-side” segment imbalance, the skeleton is pushing forward, the whole body can compensate. In the current study we are discussing, the researchers suggested that advanced osteoarthritis or patients with spinal deformity and low back pain have greater peak spine torque (more rotational strength on rotation) compared to non-specific low back pain patients. (the body was compensating for spinal malalignment).

Spinal deformity low back pain patients also had 11.8% greater hip torque (the hip was compensating on rotation) and 86.7% greater knee torque (the knee was compensating) compared to non-specific low back pain patients.

What does this all mean? Something that should be obvious to many of you. When you have low back pain, the hips compensate and bring stress on themselves, the knees compensate and bring stress on your selves, and equally, it can be said vice-versa. Low back pain can cause hip pain, hip pain can cause back pain, back pain can cause knee problems, and knee problems can cause back and hip pain.

Ischiofemoral impingement causing lumbar pathology

In a January 2017 paper titled: The Hip-Spine Effect: A Biomechanical Study of Ischiofemoral Impingement Effect on Lumbar Facet Joints, Doctors at Baylor University and the University of Texas (4) found a relation between ischiofemoral impingement and lumbar facet joint load during hip extension.

They suggested that limited terminal hip extension due to simulated ischiofemoral impingement significantly increases L3-4 and L4-5 lumbar facet joint load when compared with non-ischiofemoral impingement hips.

This study directly links ischiofemoral impingement to increased lumbar facet loads and supports the clinical findings of ischiofemoral impingement causes lumbar pathology. Assessing and treating hip disorders that limit extension could have benefits in patients with concomitant lower back symptoms.

A July 2022 paper in the Journal of Orthopaedic Case Reports (5) discusses how it may be possible for a patient to have spinal surgery while their pain is coming from a different source. Mainly fragility fractures of the pelvis. The paper’s authors wrote: “The clinical symptoms of fragility fractures of the pelvis are frequently vague and nonspecific. Moreover, the symptoms of fragility fractures of the pelvis can mimic lumbar spine pathologies. Therefore, accurate diagnosis of fragility fractures of the pelvis is often difficult and the fracture may be misdiagnosed as lumbar degenerative disease.”

An international team of researchers conducted computer model tests to assess the roles of the hip/spine ligaments in pelvic unalignment. Publishing in August 2022 in the Journal of Anatomy (6), the researchers found ligaments to be important.

“The alteration in mechanical properties of posterior (back) pelvis ligaments may cause a biased pelvis (twisted or tilted) deformation which, in turn, may contribute to hip and spine instability and malfunction.  . . The deformation of the lumbopelvic complex relative to a given load was predominant in the medial plane (A medial or body split in the middle vertical deformity can be the left side higher than the right side pelvic deformity). The effect of unilateral resection (releasing or cutting the ligaments on one side to “even things up” on deformation appeared to be counterintuitive (not good common sense), suggesting that ligaments have the ability to redistribute the load and that they play an important role in the mechanics of the lumbopelvic complex.”

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If you have questions about your back and pain and how we may be able to help you, please contact us and get help and information from our Caring Medical staff.

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1 Nekoie FK, Mohammadi HK, Afshari-Safavi A, Jalali HM, Taheri N. Assessment of hip range of motion limitations in cases with low back pain based on the classified movement system impairment. Advanced Biomedical Research. 2023 Jun 1;12(1):169. [Google Scholar]
2 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. journal of orthopaedic & sports physical therapy. 2017 Mar;47(3):163-72. [Google Scholar]
3 Nyayapati P, Booker J, Wu PI, Theologis A, Dziesinski L, O’Neill C, Zheng P, Lotz JC, Matthew RP, Bailey JF. Compensatory biomechanics and spinal loading during dynamic maneuvers in patients with chronic low back pain. European Spine Journal. 2022 Jul;31(7):1889-96. [Google Scholar]
4 Gómez-Hoyos J, Khoury A, Schröder R, Johnson E, Palmer IJ, Martin HD. The Hip-Spine Effect: A Biomechanical Study of Ischiofemoral Impingement Effect on Lumbar Facet Joints. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2017 Jan 31;33(1):101-7. [Google Scholar]
5 Ohyama S, Inoue M, Nakajima T, Kubota G, Ohtori S, Aoki Y. Cooccurrence of Fragility Fracture of the Pelvis with Lumbar Degenerative Disease: A Case Report. Journal of Orthopaedic Case Reports. 2022 Jul;12(7):93. [Google Scholar]
6 Henyš P, Ramezani M, Schewitz D, Höch A, Möbius D, Ondruschka B, Hammer N. Sacrospinous and sacrotuberous ligaments influence in pelvis kinematics. Journal of Anatomy. 2022 Aug 20. [Google Scholar]




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