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.