What's The Deal With Hip Internal & External Rotation?

As I near my 2 year mark in clinical practice, you start to realize trends. Sometimes these trends solidify what we already know, align greatly with what we are already practicing, and allow us to continue down the beaten path.  However, there are things we begin to see as key indicators on how an injury occurred, things that are so simple, they often get overlooked in a treatment plan.  Today I want to briefly discuss an item that falls under both of these categories.  

Hip range of motion (ROM) is often taken for granted, until that time comes where one side is severely restricted and we are unable get up off the floor without the use of our hand, or the assistance from another.   As I have progressed clinically, hip ROM started as just something to jot down in a patients notes, but has quickly become one of the first areas I look to and address for nearly all of the low back pain** and lower extremity complaint (acute and overuse) patients that come into our clinic.  

The problem we see is that the restriction is never symmetrical, causing compensatory patterns that quickly lead to injuries and confused patients. While getting you out of pain is our job, our goal is education and prevention.  Below are some great stretches and mobility movements that are not only easy to perform, but effective is restoring symmetrical movement.  Enjoy.  

Learn, Practice, Perform!  

Level 1 Hip Internal & External Rotation

Internal Rotation Hang

Setup: Lie flat on back with knees bent and feet about 6 inches wider than shoulder/hip width.

Step 1: Allow knees to ‘hang’ inward, letting gravity to do the work.  We want to sit here for 1-2 minutes.  

Step 2: If you get bored, slowly and gently, swing the legs/pelvis back and forth to induce some extra motion into internal rotation.   

External Rotation/Mobilization Stretch

Setup: Lie flat on back with the leg being treated in a flexed hip position and the non-treated leg lying flat on the floor.  

Step 1:  Pull the foot of the flexed hip leg toward the mid-line and up toward the torso, you should begin to feel this over the posterior hip in the external rotators and glutes.  

Step 2: Pull the knee toward the OPPOSITE shoulder and hold for a 3-5 count, release and repeat 10 times on each side.  


Level 2 Hip Internal and External Rotation

Internal Rotation with band assistance.

Setup:  Our setup is the same as the ER exercise in level one.  This time with a band wrapped around the mid-foot and tracing the outside of the leg.  

Step 1:  The band provides a mechanical advantage and when pulled over the knee and across the body, provides assisted over-pressure into hip internal rotation.  

External Rotation: Pigeon Pose

Setup:  In a modified lunge position, externally rotate the treated leg and and sit back with the non-treated leg extended behind you.  

Step 1:  Begin with the foot of the treated leg near mid-line (easier) and begin to bring your torso closer to the ground while maintaining a straight spine.  

Step 2:  As this movement becomes easier, our goal is to get the treated lower leg perpendicular to your torso and away from the pelvis. Again, push the torso down toward the ground with a straight spine.  


Level 3 Internal/External Rotation - 90/90 Get-up to 1/2 kneeling  

Setup:  Sitting up tall with a straight spine, the forward leg positioned in external hip rotation and the leg 'coming through' in internal hip rotation. The lead leg foot should be close to midline and near the other leg making this a closed position.  

Step 1:  Push into the ground with the outer knee of the forward leg and bring the rear leg around to the front, landing in a lunge/half kneeling position.

Step 2:  In a slow and controlled manner, return to the starting position...enjoying the eccentric phase.  

** A 2015 study out of the Shahid Beheshti University of Medical Sciences found that Asymmetrical and limited hip internal rotation ROM were a common finding in patients with LBP.  Another study from The Sahmyook University Department of Physical Therapy found that hip mobilization brings positive effects on pain, function and psychological factors for patients with chronic low back pain, causing them to strongly recommend hip mobilization as an effective treatment method in treating chronic low back pain. 

Hamstring: Proximal Strain & Tendinopathy

As the weather cools down, a thought of last year comes to mind.  During this time I was beginning my sports residency in St. Louis under one of the best conservative care sports physicians I have had the pleasure to work with.  Of all the cases we encountered, one injury (many actually) sticks out as a very common occurrence this time of the year….Proximal Hamstring Strain & Tendinopathy.  

Hamstring injuries can be a beast; they drag you down mentally and physically as treatment tends to draw out and disrupt your training plans and goals.  They present with pain and tenderness near the gluteal fold and over the posterior thigh, making it sometimes difficult to run, ride, walk and even sit.  What I would like to do here today is briefly (as a longer post is to come later) give you some basic suggestions based on research findings, what patients have responded positively to, as well as what to do about your training and overall fitness.

There are many misconceptions out there about hamstring tightness and what can be done about it.  What we do know is that stretching, and stretching, and stretching the hamstrings some more, trying your hardest to touch the floor is not very effective, even counterproductive (1).  It may lengthen the muscle for a short period of time but the stress it places on the enthesis and the myotendinous junction could set you up for further injury if care is not taken.  

In the acute or reactive phase of a hamstring tendinopathy, there are a few key thoughts to consider that can aid in recovery.  At REVIVE Sport & Spine we focus on treating our athletes while keeping them active in sport but sometimes a decrease in activity is needed while a select few may need to shut down for a few weeks.  When working with tendinopathy issues, offloading the tendon from compressive and tensile loads is key (2).  Compressive loads are just what they sound like, anything that can compress the muscle or tendon such as sitting.  Tensile loads on the other hand are more dynamic in nature including activities like running and jumping.  Our goal in maintaining activity during treatment is to decrease both compressive and tensile loads while completely eliminating movements that combine the two such as hill running, static stretching and over striding (common with treadmill running, one reason I dislike this winter running option and also what I believe causes so many proximal hamstring issues in the winter months).  What can you do for activity during treatment?  Running on flat, soft surfaces at a decreased intensity and lower volume is one option.  Begin strengthen the hamstrings, gently with slow progression, utilizing isometric and eccentric type exercises (3) while also decreasing the time spent compressing the tendon in activities like sitting and static stretching.  Besides, too much sitting is just not good for your health in general!

While this is just the tip of the iceberg, we will dive deeper into hamstring issues in the near future focusing more on possible causes and some ideas as to what you can do to speed up your progress.  We will look at glute strength, hamstring exercise progression, the effect of tight hip flexors and weak abdominals as well as anterior pelvic tilt and poor lumbopelvic stability.  

As always, be sure to consult your personal physician before taking on any exercise or self prevention plan, self diagnosis and treatment is never a good option.  If you feel you are developing a hamstring issues and want to get ahead of it quickly, the team at REVIVE Sport & Spine is ready to help you build and get the most out of your winter training.  Happy Holidays and Happy Movement!



  1. Sole G, Milosavlijevic S, Nicholson H, Sullivan J.  Selective Strength Loss and Decreased Muscle Activity in Hamstring Injury.  J Orthop Sports Phys Ther 2011;41(5):354–363, Epub2 February 2011. doi:10.2519/jospt.2011.3268

  2. Cook JL, Purdam C.  Is Compressive Load a factor in the Development of Tendinopathy?  Br J Sports Med.  2012 Mar;46(3):163-8. doi: 10.1136/bjsports-2011-090414.

  3. Jayaseelan DJ, Moats N, Ricardo CR.  Rehabilitation of Proximal Hamstring Tendinopathy utilizing eccentric training, lumbopelvic stabilization, and trigger point dry needling.  Journal of Orthopaedic and Sports Physical Therapy.  2014 Mar;44(3):198-205. doi: 10.2519/jospt.2014.4905. Epub 2013 Nov 21.