Low back pain is a big topic. It is estimated 84% of all individuals will experience low back pain at some point in their lives, and 23% of those cases will be chronic (Roach, et.al, 2015). The different mechanisms for pain has been the subject of many books, and the different approaches to treatment of low back pain can result in heated discussions about which way is best. The reality, of course, is everybody is different, and what works really well for some people may not work as well for others. Deadlifts are a wonderful exercise, and many people with low back pain will find this works wonders to make their backs feel better; however, there will always be one person for whom this isn’t the best choice at this moment, and deadlifting will make him feel worse. Some fall into the extension camp, others into the flexion camp, and then there is Hodges work, which has been interpreted many different ways, to support many different theories. Everyone that works with individuals suffering from chronic low back pain in the fitness setting should study the work of McGill, Hodges, McKenzie, Hruska, Kolar and Sahrmann to understand some of the different lenses under which low back pain can be viewed.
The fact that pain is multi-faceted needs to be recognized by practitioners that work with individuals suffering from any sort of chronic issue. The work of Lorimer Mosely, Todd Hargrove, and Douglas Nelson all begins to shed light on some of the biological, psychological, and social aspects of pain. I am going to examine one small piece of the low back pain puzzle, by examining the possible connection between low back pain and hip mobility. If you suffer from chronic low back pain, please explore a variety of modalities- there is something out there that will help, but it may require some trial and error to find what works and what doesn’t. If you are a practitioner that works with people with chronic low back pain, maintain an open mind and study many different modalities. The ability to explore low back pain through multiple lenses can be invaluable in finding the right intervention for the person in front of you.
There are several muscles located in the hip, and I have discussed the anatomy of the hips in previous blogs. When you think about the lumbar spine (which is the general area most of us think of when we consider low back pain), it attaches to the sacrum, which attaches to the pelvis. The femur inserts into the acetabulum of the pelvis and forms the hip joint. It makes sense intuitively that if there is pain located in the low back, there may be a direct influence on how the hip moves. According to Roach et.al, current research on low back pain and hip function focuses primarily on motor control and strength deficits of the gluteus maximus and gluteus medius, with some attention given to transverse plane hip range of motion. Significant asymmetries have been noted in hip internal rotation, external rotation, and total rotation in adult athletes suffering from non specific low back pain, suggesting a connection between low back pain and hip mobility.
It is also documented that 23-69% of individuals suffering from chronic low back pain demonstrate lumbar instability during flexion and extension movements (Lee and Kim, 2014). The common ways to assess for lumbar instability include the passive straight leg test, range of motion in the lumbar segments, and hip internal rotation (Corkery, et.al, 2014). It is interesting that 2 of the 3 previously mentioned tests are checking movement at the hip, further demonstrating the relationship between the hips and the lumbar spine. The problem with numbers like this is a) there is a large difference between 23% and 69% and b) lumbar instability is defined in passive positions. How this translates into actual loading and movement could (and perhaps should) be debated. In addition, it is impossible to really know if the lack of rotation in the hips came before the low back pain or as a result of the low back pain. Arguments could be made for both situations. Hayes, et al., (2009) suggests limited hip mobility alters mechanical forces on the lumbopelvic region, contributing to low back pain. Some schools of thought would argue the lack of hip joint mobility and the common asymmetries are related to positional influences of the pelvis, femur, and thorax. Lack of hip mobility can be the result of a number of factors, including muscular or neuromuscular issues, joint capsule stiffness, or bony abnormalities.
The next question is why does any of this matter? Basically, the more we treat the body as an integrated system that can move each limb independently in a variety of different ways, the more options we have to find a way to move or hold ourselves in a manner that is less painful. If we only know how to pick something up by rounding our lumbar spine, for example, learning how to move the hips independently from the spine allows for another option that might feel better. Plus, the more mobility we have and control over that mobility, we can begin to move in a less rigid, more fluid way. We run into trouble when we move in the same way over and over again. Unfortunately, our culture is set up for a lack of movement variety. We sit with our legs in front of us, walk on smooth surfaces with no incline, and get up from chairs that are hip height with our feet pointing directly ahead of us. To counteract this lack of moving, we go to the gym and get on machines that go straight ahead, and move our arms directly in front of us. Unless we go searching for ways to add variety to our movement routines, everything is very linear. We can begin to speculate this lack of movement variety feeds into a more rigid way of moving. Our nervous system isn’t getting enough movement input to keep actions like hip abduction, adduction, and internal rotation in our movement vocabulary. It takes a conscious effort to build these types of movements into our lives. Beginning to slowly integrate movement variety, being mindful of how they make you feel and emphasizing an element of control is a great place to start. This can segue into building strength in a variety of positions which generally gives an overall sense of superhumaness (not a word, I know, but it should be).
Low back pain is complex, but if we step back, integrate movements slowly from the head to the feet, and shift our thinking from “we must stretch this and strengthen this,” to “how can I improve movement quality at this joint?” we might begin to make a small difference for the person in front of us. As someone that works with a fair number of clients that originally come in with low back pain, experience has taught me that teaching dissociation of the hips and ankles and improving mobility in these two areas can dramatically improve a person’s ability to execute exercise without pain. Of course, so can breathing. The ability to integrate and move fluidly is dependent on all of the parts, and yes, the hips probably matter.
Yours in health and wellness,
*I will be posting a Youtube video in the next week that examines hip versus back motion, with some ideas on how to cue and teach differentiating, along with a short exercise sequence, if you are interested in more information.
Roach, S.M., San Juan, J.G., Suprak, D.N., Lyda, M., Bies, A.J., & Boydston, C.R., (2015). Passive hip range of motion is reduced in active subjects with chronic low back pain compared to controls. The International Journal of Sports Physical Therapy, 10(1), 13-20.
Lee, S.w., & Kim, S.Y., (2015). Effects of hip exercises for chronic low-back pain patients with lumbar instability. Journal of Physical Therapy Science, 27, 345-348.
Corkery, M.B., O'Rourke, B., Viola, S., Yen, S., Rigby, J., Singer, K., & Thomas, A., (2014). An exploratory examination of the association between altered lumbar motor control, joint mobility, and low back pain in athletes. Asian Journal of Sport Medicine, 5(4).
Harris-Hayes, M., Sahrmann, S.A., & Van Dillen, L.R., (2009). Relationship between the hip and low back pain in athletes who participate in rotation-related sports. Journal of Sport Rehabilitation, 18(1), 60-75.