Physical Therapy in Sport 10 (2009) 131–135

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Physical Therapy in Sport

journal homepage: www.elsevier.com/ptsp

Original research

The relationship between hip rotation range of movement and low back pain
prevalence in amateur golfers: An observational study
Eoghan Murray, Emma Birley, Richard Twycross-Lewis, Dylan Morrissey*
Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Bancroft Road, London E1 4DG, United Kingdom

a r t i c l e i n f o a b s t r a c t

Article history: Objective: To investigate whether amateur golfers with self-reported low back pain have reduced hip
Received 21 May 2009 rotation compared to asymptomatic controls.
Received in revised form Design: Observational case-control study.
26 August 2009
Setting: Data collection took place at 2 amateur golf clubs in southern England.
Accepted 27 August 2009
Participants: On initial contact, all participants completed a screening questionnaire used to allocate
participants into LBP (n ¼ 28) and control groups (n ¼ 36). LBP group were found to be heavier than
Keywords:
controls (t ¼ 2.242, 95% CI 0.763–13.332) but were matched for age, height, handedness, handicap,
Golf
Low back pain rounds played per week and years of play.
Hip Main outcome measures: Primary outcome measures were lead and non-lead hip medial and lateral
Rotation rotation in 0 of flexion as measured by inclinometer. Secondary measures included inter and intra-rater
reliability.
Results: The LBP group had significantly reduced lead hip passive (LBP 21.14  10.17 ; controls
31.06  8.06 , t ¼ 4.228, 95% CI 14.621–5.205) and lead hip active medial rotation (LBP
21.46  10.01; controls 28.06  7.49 , t ¼ 2.908, 95% CI 11.147–2.036) compared to controls. No
between group differences were found in non-lead hips or any passive or active lateral rotation
measures.
Conclusion: Although there is lack of causality between LBP and hip rotation, the deficit in lead leg medial
hip rotation in amateur golfers who suffer LBP may be relevant for screening or treatment selection.
Ó 2009 Elsevier Ltd. All rights reserved.

1. Introduction order to develop sports-specific preventative and therapeutic

Golf is a sport with a significant risk of injury (Theriault &
Lachance, 1998). Injury rates are high as amateur participation rates
are high and increasing (McHardy, Pollard, & Luo, 2007). Low back
pain (LBP) is the most common injury and accounts for 25–36% of
all reported injuries in golfers, however, the aetiology remains
unclear (Fradkin, Cameron, & Gabbe, 2005; Gluck, Bendo, & Spivak,
2008; Gosheger, Liem, Ludwig, Greshake, & Winkelmann, 2003;
Lindsey & Horton, 2002; McHardy et al., 2007). There is a need to
determine whether golf-specific factors are associated with LBP in
* Corresponding author. Centre for Sports and Exercise Medicine, 1st Floor, Mann
Ward, The Royal London (Mile End), Queen Mary School of Medicine and Dentistry,
Bancroft Road, Mile End, London E1 4DG, United Kingdom. Tel.: þ44 0208 223
8459; fax: þ44 0208 223 8930.
E-mail addresses: eoghanmurrey@hotmail.com (E. Murray), ha03271@qmul.ac.
uk (E. Birley), r.twycross-lewis@qmul.ac.uk (R. Twycross-Lewis), dylan.morrissey@
thpct.nhs.uk (D. Morrissey).
strategies.
There is theoretical evidence that golf swing mechanics may
play an important role in the development of LBP (Batt, 1992, 1993;
Gluck et al., 2008; Vad, Bhat, Basrai, Gebeh, Aspergren, & Andrews,
2004). The swing, which is a complex multi-dimensional move-
ment, involves repeated co-ordinated action of the entire kinematic
chain including significant force and movement generation in the
shoulders, cervical spine, knees, and lumbo-pelvic area (McCarroll,
Retting, & Shelbourne, 1990; McHardy & Pollard, 2005). It has been
suggested that limitation of movement in one part of the kinetic
chain during the swing may predispose to injury (Lindsey & Horton,
2002, McHardy, Pollard, & Luo, 2006). For example, decreased hip
rotation may lead to over-rotation of the spine in order to
compensate and produce the entire swing.
The link between incidence of LBP and reduced lead leg hip
rotation has been demonstrated amongst professional tennis
players (Vad, Gebeh, Dines, Altchek, & Norris, 2003) and professional
golfers (Grimshaw & Burden, 2000; Vad et al., 2004). Whilst it has
been stated that amateur golfers demonstrate higher torque forces

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132 E. Murray et al. / Physical Therapy in Sport 10 (2009) 131–135
in the lumbar spine than professional golfers (Lindsey & Horton,
2002, Vad et al., 2004), the relationship between incidence of low
back pain and hip rotation, particularly lead leg hip rotation, in
amateur golfers has yet to be explored. Evidence of the relationship
between reduced medial hip rotation and increased low back pain in
non-sporting populations has been well documented (Cibulka,
Sinacore, & Cromer, 1998; Ellison, Rose, & Sahrman, 1990; Mellin,
1988). The aim of this study was, therefore, to determine if a signif-
icant difference in lead leg medial hip rotation existed between and
within groups of amateur golfers with and without LBP.
2. Method
2.1. Design
Observational case-control study.
2.2. Participants
64 amateur golfers (43 men and 21 women, range 18–70 years
of age) were sequentially recruited using advertising posters from
two English golf clubs from January 2007 to April 2008. The study
was approved by Queen Mary’s University Research Ethics
committee, permission was granted by the golf clubs and written
informed consent was obtained from each subject. Participants
were included if they had a history of LBP (LBP group) within the
last 12 months prior to taking part or had no such history (control
group). Participants were also included if they were currently
suffering from LBP. Golfers with LBP due to a clear traumatic event
or history of spinal surgery were excluded to ensure only repeated
use injuries were included. The injury duration had to be greater
than 2 weeks to exclude incidental pain as per previous methods
(Vad et al., 2004).
Each participant completed a screening questionnaire which
included participant characteristics including 1) anthropometric
and golf participation data and 2) self-reported LBP in the past 12
months. LBP was defined as ‘any pain or dysfunction of the lower
back that impacted the golfer’s ability to practice or perform during
the study period and/or the last 12 months’. Participants were also
asked to describe and locate their injury on a body chart (Sugaya,
Tschiya, & Moriya, 1998). Based on the results of the screening
questionnaire 28 golfers were allocated to the LBP group and 36 to
the control group.
2.3. Outcome measures
The primary outcome measures were lead and non-lead hip
medial and lateral rotation as measure by clinical inclinometer.
Testers (EM and EB) were blinded to group allocation of each
subject. Further questionnaire responses were anonymised. To
assess the intra- and inter-tester reliability of the primary outcome
measure, reliability between EM and EB was carried out prior to
data collection. 12 normal subjects underwent the full series of
passive and active hip rotation measures by 1 examiner of 2 occa-
sions, 2 weeks apart, and examiner 2 on the 2nd occasion. Two-way
intra-class correlation coefficients (Shrout & Fliess, 1979) were
calculated for all measures.
All subjects were required to wear non restrictive clothing and,
prior to measurement, performed a standardised 5 min warm up
on a static exercise bike. Measurements took place with the subject
in the prone position (Fig. 1), chosen rather than supine as it has
been shown to be more reliable (Cibulka et al., 1998; Ellison et al.,
1990). In order to localise the measure to the hip joint the pelvis
was stabilised with a belt at the level of the posterior inferior iliac
spines (Cibulka et al., 1998). The measured hip was placed in 0 of
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Fig. 1. An illustration demonstrating the start point of the technique used to measure
medial and lateral hip rotation using an inclinometer.
abduction and knee flexed to 90 . The contralateral hip was
abducted to 30 (Cibulka et al., 1998, Ellison et al., 1990). An
inclinometer was positioned immediately proximal to the medial
malleolus. The leg was then passively moved to produce medial and
lateral rotation with the range of movement (ROM) being recorded
to the nearest degree at the point of resistance (Fig. 1). Final passive
ROM was decided when resistance was met or compensatory
movement at the pelvis became evident. For active measurements,
participants were instructed to repeat the movements to the end of
available ROM. Passive and active measurements were obtained for
both right and left sides. Three measurements were taken for each
manoeuvre and a mean was obtained. Total medial and lateral hip
rotation was defined as the sum of both left and right measure-
ments (Coplan, 2002). Order of measurement was not randomized,
therefore, each subject repeated the same test procedure in the
same order.
2.4. Data analysis
Intra- and inter-tester reliability between the two examiners
was carried out prior to data collection. 12 normal subjects
underwent the full series of passive and active hip rotation
measures by examiner one on two occasions, 2 weeks apart, and
examiner two on the second occasion. Intra-class correlation
coefficients were calculated for all measures (Table 2).
A sample size calculation was carried out with data from Vad
et al. (2004), who measured a mean difference of 5.1 in lead hip
rotation and 0.2 in non-lead hip rotation between symptomatic
and asymptomatic players, which determined that 10 golfers were
required in each group to detect a significant difference in hip range
of motion of 5 with 80% power. Kolmogorov–Smirnov tests
showed the rotation measures were normally distributed. Data was
plotted as mean (SD) for passive and active medial and lateral
rotation for the lead and non-lead hips. Inter group measures were
analysed by independent samples t-tests and intra group measures
were analysed by paired samples t-tests.
3. Results
Subject characteristics are given in Table 1. No significant
differences between groups were found with the exception of body
weight for which the LBP group was significantly heavier than the
control group (t ¼ 2.242, 95% CI 0.763–13.332).
 E. Murray et al. / Physical Therapy in Sport 10 (2009) 131–135 133

Table 1
Anthropometric and golf participation data of both the LBP and control groups
(mean  SD). (*p < 0.05).

Variable LBP group (n ¼ 28) Control group (n ¼ 36)

Age 56.4  8.4 54.3  14.4
Gender M:F 26:2 32:4
Height (cm) 179.1  8.7 176.8  7.8
Weight (kg) 85.2  14.5 * 78.2  10.2
Handedness R:L 25:3 33:3
Handicap 15.1  5.6 15.7  6.5
Rounds per week 2.0  0.9 2.1  1.1
Years of play 27.3  11.3 22.9  15.6

3.1. Reliability

Excellent agreement was shown for both intra-tester reliability

and inter-day reliability measures. Intra-class correlation coeffi-
cients (ICCs) for active medial and lateral rotation measurements
ranged from 0.91 to 0.99 respectively. For passive medial and lateral
rotation measures, ICCs ranged from 0.83 to 0.99 respectively, all of
which were significant (p < 0.001 for all measures) (Table 2).

Fig. 2. A box and whisker plot showing the mean passive and active medial hip
3.2. Between group comparisons rotation measures of both groups (median  interquartile ranges) (*p < 0.05,
**p < 0.001).
3.2.1. Medial rotation
The LBP group had a 10 deficit of mean passive medial rotation
of the lead hip with respect to controls (t ¼ 4.352, 95% CI
14.621–5.205). The active range deficit was 7 (t ¼ 3.014, 95% 1.907–5.550 and t ¼ 0.198, 95% CI 3.669–4.455 respectively).
CI 11.147–2.036). No difference was found for the same This is depicted in Fig. 4.
measures of the non-lead hip (t ¼ 0.888, 95% CI 6.578–2.530; No significance differences were found within the control group
t ¼ 0.142, 95% CI 4.985–4.350 respectively). This is depicted in for either medial or lateral hip rotation. There was no difference
Fig. 2. between lead and non-lead hip passive medial or lateral rotation
(t ¼ 0.541, 95% CI 4.090–2.368 and t ¼ 0.863, 95% CI 2.066–
3.2.2. Lateral rotation 5.122). No statistical differences were found within this group with
Mean lateral hip rotation measures of both groups are shown in regards to active rotation measures (medial t ¼ 1.121, 95% CI
Fig. 3. No statistically significant difference was seen between the 4.450–1.284 and t ¼ 0.319, 95% CI 4.093–2.982).
two groups for passive or active lateral rotation of the lead
(t ¼ 0.446, 95% CI 2.928–4.571; and t ¼ 1.931, 95% CI 0.155–8.901
respectively). Similarly, no difference was found when comparing
passive and active non-lead hip lateral rotation (t ¼ 0.220, 95% CI
4.361–5.417 and t ¼ 1.482, 95% CI 1.182–8.031 respectively). This
is depicted in Fig. 3.

3.3. Within group comparisons

The LBP group had a 7 deficit of mean passive medial hip

rotation between the lead and non-lead hip (t ¼ 6.659, 95% CI
11.446–6.054). The active medial range deficit was 9
(t ¼ 4.196, 95% CI 11.700–4.196). No difference was found for
the same measures of the lateral rotation range (t ¼ 1.002, 95% CI

Table 2
Range of intra-class correlation coefficients as measured by clinical inclinometer.

Measurement Intra-tester reliability Inter-tester reliability

ICC values (3,1) ICC values (3,2)
Active medial 0.99 (95% CI 0.969–0.994) 0.98 (95% CI 0.963–0.993)
rotation
Active lateral 0.98 (95% CI 0.947–0.990) 0.91 (95% CI 0.804–0.960)
rotation
Passive medial 0.99 (95% CI 0.970–0.994) 0.94 (95% CI 0.869–0.974)
rotation
Passive lateral 0.95 (95% CI 0.878–0.976) 0.83 (95% CI 0.641–0.921)
Fig. 3. A box and whisker plot showing the lateral hip rotation measures of both
rotation
groups (median  interquartile ranges).

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134 E. Murray et al. / Physical Therapy in Sport 10 (2009) 131–135
Fig. 4. A box and whisker plot showing mean passive hip rotation measures of both
hips within the LBP group (median  interquartile ranges) (*p < 0.05).
4. Discussion
The results of this investigation revealed that amateur golfers
who suffer from LBP have significantly reduced lead hip medial
ROM in neutral flexion-extension compared to controls. Within the
LBP group there was also a reduced lead hip medial rotation as
compared to the non-lead hip. These results support the findings of
studies carried out on sedentary subjects, which found links
between reduced hip medial ROM and the incidence of LBP
(Cibulka et al., 1998; Ellison et al., 1990; Mellin, 1988). Similar
findings were reported in professional tennis players where players
with LBP had a reduced medial hip ROM in the lead leg compared to
asymptomatic controls (Vad et al., 2003).
The correlation between reduced medial hip rotation and LBP in
professional golfers has already been established. Vad et al. (2004)
speculated that the cause may be the repeated pivoting movement of
the golf swing which causes high torsional forces on the lead hip.
Ultimately, it is plausible that this could lead to micro-trauma and
capsular contracture, causing a hip movement deficit. To compensate
for this, over-rotation of the spine may occur during the swing and
lead to LBP (Vad et al., 2004). Other evidence to support this link
between hip ROM and LBP in golfers comes in a case report by
Grimshaw and Burden (2000) who found that increasing hip ROM
resulted in significantly reduced LBP. Their case study concerned to
the kinematics of the golf swing in a professional golfer who suffered
LBP before and after a 3 month intervention of coaching to modify the
golf swing. After modification, the golfer was observed to have
a greater hip range of motion during the backswing (pre-mod-
ification ¼ 32.0 ; post-modification ¼ 44.8 ) and a concomitant
decrease in shoulder rotation (pre-modification ¼ 104.7 ; post-
modification ¼ 79.7 ). Significantly, the golfer in question ceased to
experience LBP. The authors concluded that the golfer may have
suffered higher compressive and torsional loads in the lumbar spine
as well as increased muscle activity of the musculature of the lower
back prior to coaching modification. The results of the current
investigation imply this relationship can also be applied to the
amateur golfing population, although it is not clear whether the
relationship between LBP and lead hip medial rotation ROM is causal
or associative.
The prone position was chosen to measure medial hip rotation,
in order that the results could be compared with those of previous
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studies. Clinicians often measure hip rotation in supine with the hip
flexed to 90 or prone with the hip in neutral, depending on which
is most relevant to a given patient’s presentation. The golf swing is
performed with the hip joint initially flexed to w40 , with the
backswing and follow through positions requiring relatively more
extended hip positions hence justifying the choice of examination
position (Gluck et al., 2008). It may be that measurement of hip
rotation in flexion would yield different information and should be
considered in future studies.
Injuries amongst amateur golfers are likely to include sub-
optimal swing mechanics in their aetiology (Gosheger et al., 2003;
McHardy et al., 2006; Vad et al., 2004). Many factors may contribute
to a poor swing including increased lateral bending, supra-maximal
rotation of the spine (Lindsey & Horton, 2002) and muscle
recruitment problems (Watkins, Uppal, Perry, Pink, & Dinsay, 1996).
These factors, along with poor core stability (Horton, Lindsey, &
Macintosh, 2001), have the potential of increasing loads on the
lumbar spine and thus increasing the potential for injury. Reduced
medial hip ROM could, therefore, be secondary to LBP.
Future studies are needed in order to better understand the
causal relationship between reduced ROM and LBP. Motion analysis
of the golf swing would enable further understanding of where
movements occur during the swing that may lead to LBP and/or
reduced hip rotation. The combination of muscle recruitment anal-
ysis by surface electromyography (sEMG) and hip ROM measures
would give further insight and allow causality to be inferred.
This study was not without limitations. The cohort was drawn
from only 2 clubs who may have differed from the norm. The
measures from the two clubs did not differ however, and the results
are consistent with those in the literature meaning that the findings
are likely to be generalisable.
The study also used a self-reported participant injury history
without any formal diagnosis of injury. Self report relies on
subjective recall and memory. It is, therefore, possible that partic-
ipants may not have been allocated to the appropriate group due to
either over or underestimating the severity of LBP. No attempt was
made to categorise or diagnose each injury making it difficult to
determine any independent variable. Ideally, radiographs of lumbar
spine and hips should be taken of each participant to exclude
diagnoses of osteoarthritis, etc, which could be potential con-
founding factors. Location of LBP was recorded by use of a body
chart; however, no attempt was made to correlate location of pain
with severity of injury.
A possible confounding factor in this study is the significant
difference in weight between groups. The LBP group was on
average heavier than the control group. Interestingly, studies have
shown that BMI is negatively correlated to the incidence of LBP in
golfers (Evans, Refshauge, Adams, & Aliprandi, 2005; Lindsey &
Horton, 2002) making it unclear as to the importance of this vari-
able within our study.
The results of the current investigation show a statistically
significant relationship between lead hip medial rotation deficits
and LBP suggesting that decreased lead medial hip ROM may be
a function of LBP, however the causal relationship remains
unknown. Measures for non-lead medial, as well as lead and non-
lead lateral hip rotation, were not significant and were not there-
fore found to be associated with incidence of LBP. Future studies are
indicated to examine whole body kinematics during the golf swing
in order to better understand this relationship.
Ethics
In accordance with the Declaration of Helsinki (1964), ethical
approval was granted by Queen Mary Research Ethics Committee
(QMREC2008/83) for use of human subjects.
 E. Murray et al. / Physical Therapy in Sport 10 (2009) 131–135
Conflict of interest statement
None.
Funding
Funding was provided through a bursary from Queen Mary,
University of London.
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