Hip internal rotation (IR) is an often overlooked and under-discussed topic when it comes to low back and knee pain although it can often have a major impact on an individual’s symptoms.
Limited hip internal rotation’s impact on knee pain
Anterior and lateral knee pain which many attribute to the IT band can be due to limited hip internal rotation.
The IT band is a very thick and strong piece of fascia that has been shown to take ~2,000 lbs of force to deform only 1%(1). Therefore the IT band being “tight” is highly unlikely.
Rather than the IT band getting tight causing pain, the IT band is being put on tension due to the muscles that connect to it, TFL and glute max/med, becoming over active.
The glute max and TFL are like bungee cords, attached to the pelvis and blending into the IT band. The IT band is like a steel chain attached to the glute max/med, TFL and anchored to the tibia, femur and patellofemoral ligament.
When those bungee cords tense up they pull on the chain increasing stress on the knee.
Rather than attaching the chain (IT band) and trying to roll it or stretch it, going after the bungee cords (glute max/med and TFL) is much more efficient and effective to reduce pain and improve function/performance.
Limited hip internal rotation’s impact on low back pain
Limited hip IR or limited hip range of motion in general can impact the low back by causing an increased demand on the lumbar spine for motion. Over time the low back can become irritated due to these increased demands.
For example, if you have a group of people working on a project and only ⅓ of the group is doing the necessary work to complete the project while the other ⅔ are slacking off and not doing any work. Who is likely to complain, feel stressed and overworked? The ones doing the work. This same concept can apply to the relationship between the hip and low back.
Limited hip mobility can also have a negative impact on strength training mechanics and athletic performance. Many rotational sports require a significant amount of hip IR i.e. golf, tennis, pickleball, soccer, baseball etc. to get into the bottom of a squat or perform a proper deadlift.
What causes limited hip mobility?
Aside from a traumatic injury causing structural changes, limited hip mobility is something that doesn’t occur overnight. Rather it comes from chronic movement and postural dysfunction.
With how our society is structured many of us spend the majority of our time seated, whether it’s driving, working at a computer, eating, watching TV or playing video games; the majority of many Americans’ waking hours are spent in a seated position.
These extended periods of prolonged sitting overtime can result in overactivation of hip flexors and underactivation of hip extensors.
This can result in limited hip extension and internal rotation.
How to assess at home?
Seated active internal rotation
Sit on both hands on an elevated surface so that your feet are not touching the floor.
Rotate one foot laterally as far as you can without lifting your leg or shifting your weight off of your hand(s).
With ideal hip IR you should be able rotate your foot out to a 45 degree angle relative to the start position.
* A PT evaluation to determine if you have limited hip IR is ideal as there may be a variety of factors impacting joint mobility and it can be challenging to assess on your own.
How to improve hip internal rotation?
Below are a few of my favorite exercises to improve hip internal rotation. Although they are not the end all be all they are a good place to start.
90/90 breathing with squeeze and heel dig
Lay on your back with your feet elevated so your hips and knees are at ~90 degrees.
Engage your core pressing your low back into the floor.
Take a deep breath filling up your lungs.
Squeeze your knees together and dig your heels down as if you were going to lift your hips and slowly exhale.
Kickstand to hip internal rotation 2-3×8
Load all of your weight onto one foot, slight knee bend, with the other foot behind you with your toes on the floor for balance.
Hold the position until you feel your stance leg hip engage then rotate your hips towards your stance leg and hold for 5 seconds.
Single leg RDL 2-3×8
Standing on one leg with a slight bend in your knee, engage your core and hinge forward.
Maintain a neutral spine, flat back, throughout the movement while keeping your hips and shoulders square.
Your shoulders, hips and knee of the non stance leg should remain in a straight line throughout the movement.
Low back and knee pain may not be due to an issue directly in those areas and hip mobility and strength should always be assessed as it may be a factor.
Inability to get into back swing or follow through on a golf swing may be due to limited hip IR.
Mobility limitation at any joint will lead to increased stress on the surrounding joints and proximal areas should always be assessed to get to the root cause of the issue.
Mason Goldbach is a doctor of physical therapy, he has training in Functional Dry Needling and Blood Flow Restriction and is certified as a Strength and Conditioning Specialist (CSCS) and Corrective Exercise Specialist (CES.)