Movement Assessment Article Archives

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Low Back Pain and Hip Motion Correlation

Today’s post comes from Dan Lorenz, MS, PT, ATC/L, CSCS.  Dan is a graduate of the sports physical therapy fellowship at Duke University and is currently a sports medicine specialist at Providence Medical Center.  He has great experience with a wide variety of orthopedic and sports medicine patients, including stints with the US Olympic Training Center, Chicago White Sox, and most recently the Kansas City Chiefs.

RESEARCH UPDATE: The Effect of Hip Rotation Deficits on Low Back and SI joint Pain

DSC02377 Low back pain (LBP) is arguably one of the most common diagnoses treated by rehabilitation specialists.  LBP constitutes a perplexing problem that can exact enormous human and societal costs, and whose successful evaluation and treatment continue to elude the efforts of those who care for these patients.1 A myriad of potential causes of low back pain exists, but evidence is mounting to support the possibility that low back pain may be a result of hip rotation deficits. Several investigators have reported that LBP may be related to hip pain secondary to limited range of motion in the hip.2-6

Ellison et al2 sought to determine the prevalence of passive hip rotation deficits in healthy subjects (n=100) and those with low back pain (n=50). Researchers suggested that there was an association between those with hip rotation ROM imbalance and the presence of LBP. 48% of subjects with LBP had increased lateral rotation than medial rotation of the hip.

Vad and others7 investigated hip rotation deficits in a group of professional golfers to determine if these deficits correlated to LBP. LBP is the most common musculoskeletal complaint experiences by both amateur and professional players.8 Forty-two male, professional golfers were categorized as having no history of back pain or those with a history of low back pain greater than two weeks affecting play within the past year. 33% of golfers had previously experienced LBP. Researchers found that a statistically significant correlation was observed between a history of LBP and decreased lead hip internal rotation and FABER’s position distance, and lumbar extension loss.

Cibulka and coworkers9 investigated rotation deficits of the hip with those experiencing signs/symptoms suggestive of sacroiliac joint (SIJ) dysfunction. In one-hundred male and female patients with low back pain, unilateral hip rotation deficits were found to correlate with SIJ dysfunction. In those with LBP but without evidence of SIJ dysfunction, significantly greater hip external rotation than internal rotation bilaterally, whereas those with LBP and signs suggesting SIJ dysfunction had significantly more external rotation than internal rotation unilaterally. Specifically, the deficit was observed on the side of the posterior innominate.

In a case study, Cibulka10 describes the treatment of a patient who had signs/symptoms of a sacroiliac component of LBP. The patient described right low back pain and evaluation of this patient found excessive right hip lateral rotation and limited right hip internal rotation. Of note, the patient frequently crossed his right leg over his left leg. After restoring hip rotation and SIJ dysfunction via manual therapy techniques, the patient no longer complained of LBP. The case suggests that hip rotation asymmetry may contribute to the SI component of LBP.

Finally, Warren11 also described a patient case with SIJ dysfunction and concomitant asymmetrical hip rotation deficits. After six physical therapy visits focusing on stretching, manual therapy, and postural education, hip rotation ROM was restored and the patient resumed full-time work and golf without back pain.

Based on this summary of relevant research, it appears that evidence supports the relation of deficits in hip rotation to both LBP and SIJ pain. Specifically, it appears that a loss of internal rotation is implicated in these cases. Biomechanically, this finding in the physical examination is plausible. Using gait as an example, a decrease in hip internal rotation will not allow the pelvis to rotate over the stance limb, thereby limiting the coupling mechanics (a whole other discussion!!) of the sacrum and lumbar spine. Additionally, muscles in the low back, like the multifidus, will not achieve their normal length-tension relationships. Potentially, that could also be a source of low back pain. The lack of motion in the sacrum and low back may lead to degenerative changes and excessive compression of the facets on one side. The clinical significance then is that the therapist must screen every patient for hip rotation deficits in cases of SIJ or LBP.

EDITOR NOTE: Very interesting research Dan, thanks for sharing with us.  As many of your know, I am a big advocate of the biomechanical factors associated with pathology.  That is why I like the works of Porterfield & DeRosa and McGill so much.  We talk so much about the “core’s” influence on the distal extremities, but there would be an obvious inverse relationship as well.  These studies certainly make me want to examine the lower extremities in more detail in my low back pain patients.  I would challenge us all to critically exam our patients to see what lower extremities alignments (pes planus/cavus, leg length discrepancies, tibial/femoral rotation, genu valgum/varus/recurvatum, etc.) have an immediate impact on hip rotation and subsequently low back pain.  The days of heat packs, ultrasound, massage, and ESTIM for low back pain are over!

REFERENCES:

  1. Porterfield JA, DeRosa C. Mechanical low back pain: Perspectives in functional anatomy. 2nd ed. Philadelphia: WB Saunders, 1998.
  2. Ellison JB, Rose SJ, Sahrmann SA. Patterns of hip rotation range of motion: a comparison between healthy subjects and patients with low back pain. Phys Ther. 1990; 70(9): 537-541.
  3. Chesworth BM, Padfield BJ, Helewa A, et al. A comparison of hip mobility in patients with low back pain and matched healthy subjects. Physiotherapy Canada. 1994; 46: 267-74.
  4. Friberg O. Clinical symptoms and biomechanics of lumbar spine and hip joint in leg length inequality. Spine. 1983; 8: 643-51.
  5. Mellin G. Correlation of hip mobility with degree of back pain and lumbar spinal mobility in chronic low back pain patients. Spine. 1988; 13: 668-670.
  6. Offierski CM, MacNab I. Hip-spine syndrome. Spine. 1983; 8: 316-321.
  7. Vad VB, Bhat AL, Basrai D, et al. Low back pain in professional golfers: the role of associated hip and low back range of motion deficits. Am J Sports Med. 2004; 32(2): 494-497.
  8. Batt ME. Golfig injuries: an overview. Sports Med. 1993; 16: 64-71.
  9. Cibulka MT, Sinacore DR, Cromer GS, Delitto A. Unilateral hip rotation range of motion asymmetry in patients with sacroiliac joint regional pain. Spine. 1998; 23: 1009-1015.
  10. Cibulka MT. The treatment of the sacroiliac component to low back pain: a case report. Phys Ther. 1992; 72: 917-922.
  11. Warren PH. Management of a patient with sacroiliac joint dysfunction: a correlation of hip range of motion asymmetry with sitting and standing postural habits. J Man Manip Ther. 2003; 11: 153-159.

Ellison JB, Rose SJ, Sahrmann SA (1990). Patterns of hip rotation range of motion: a comparison between healthy subjects and patients with low back pain Phys Ther DOI: 2144050

Assessing and Treating Dysfunction of the Gluteus Medius

The October 2008 issue of the Journal of Strength and Conditioning has an impressive review article of the anatomy, function, assessment, and strengthening of the gluteus medius from a group of clinicians in New Zealand.  The authors do a good job reviewing some of the basic anatomy and function of the muscle and relating this information to research reports looking at dysfunction and treatment of the muscle for several lower extremity injuries.

I think this is a great topic of discussion as the role of the gluteus medius in normal function and rehabilitation has been receiving attention lately as attention is being paid to strengthening and training the body in the frontal plane of motion and out of the sagittal plane.

gluteus medius

The Role of the Gluteus Medius

When you really break down the function of the gluteus medius, you see that it is far more valuable as a pelvis and lower extremity dynamic stabilizer than it is a pure hip abductor.  This is apparent when looking at the mechanism of a Trendelenburg Gait.  The role of the gluteus medius during activities such as walking and running is to dynamically stabilize the pelvis in a neutral position during single leg stance.  As you can see in the photo below, weakness of the right gluteus medius will cause the left hip to drop when standing on the right limb.  Conversely, athletic patients are often masters of compensation and may be able to keep the pelvis in neutral while the lower leg will adduct and internally rotate.

weak gluteus medius

In addition, the role of the gluteus medius as an external rotator of the hip when the hip is in a position of flexion is also important to consider.  These factors together are likely why dysfunction of this muscle is commonly found in several pathologies, such as iliotibial band, patellofemoral injuries, ACL, and ankle injuries.

Assessment of the Gluteus Medius

The authors describe several methods of evaluating the gluteus medius.  These include:

  • Standard manual muscle testing of hip abduction in sidelying.  Because the gluteus medius also has an effect on other hip motions, I often recommend a full testing of hip flexion, abduction, ER, IR, and extension as well.
  • Double- to single-leg stance test.  Simply a test such as the photo above.  The patient is instructed to stand on one limb and pelvis orientation is documented.
  • The authors also recommend adding an upper body movement to the single-leg stance test. This will further challenge the patient, specifically the athletic patient.  During this, the patient is instructed to balance on one limb while reaching the arms overhead and leaning away from the stance leg.  This will move the patient’s center of gravity further away from the stance limb and require a greater amount of gluteus medius stabilization to avoid the dropped pelvis position.
  • In addition to the above described, I would also recommend that patients should be observed during several functional activities, especially if a specific activity tends to exacerbate symptoms.  This could include eccentric step-downs, front lunges, or even running and jumping activities for athletes.  Watching the kinematics of the pelvis and lower body closely can be very beneficial.  Personally, I often try to video tape these movements as well.  For my athletes I have sophisticated camera systems but I also travel with a simple flip cam that I plug in to my laptop and quickly record and view back with my patients.  I actually do not like the actual Flip cams, the angle of the lens is terrible.  I actually use and really love the Creative Vadocheck it out on Amazon.  In addition to having a better wide angle lens, I can control the video quality.  It is inexpensive, small, portable, plugs into my computer for charging, and shots great video.  In just a few minutes I have a great quality video to watch with my patients.  I try to take it a step further a draw on my videos and photos as well.

trendelenburg during step down

Treating the Gluteus Medius

While the beginning of the paper provides a brief, yet basic, review of the normal anatomy, function, and potential for injury implications of gluteus medius weakness, the strength of the paper lies in the later half that reviews the evidence behind some exercises designed to strengthen the gluteus medius.

The authors provide a thorough table that lists the many exercises described for gluteus medius strengthening.  Most of these are basic recommendations, such as sidelying hip abduction straight leg raises and standing hip abduction.  However, the authors combine the work and recommendations of three articles to develop a gradually progressive exercise program.

The progression is designed to gradually enhance motor control, endurance, and strength.  The program is broken down into three phases:

  • Phase I: Nonweightbearing and basic weightbearing exercises such as clam shell exercises, sidelying hip abduction, standing hip abduction, and basic single leg balance exercises. Criteria to progress to stage II is that the patient can hold their pelvis level during single leg stance for 30 seconds.
  • Phase II: The second stage progresses the weight-bearing exercises and gradually progresses stability exercises by (a) translating the center of gravity horizontally via stepping and/or hopping exercises; (b) reducing the width of the base of support, (c) increasing the height of the center of gravity by elevating the arms and/or hand-held weights, or (d) performing the exercises on unstable surfaces.
  • Phase III: The third stage is used for athletes and designed to prepare them for function, sport-specific movement patterns.

I agree with this progression but think that the authors are missing one key point regarding training of the gluteus medius.  Because it is such a valuable component of dynamic pelvis and lower extremity stability.  I also would encourage clinicians to also incorporate exercises designed to promote hip stability during normal sagittal plane movements such as squatting.  To do this, I often just simply incorporate a piece of exercise tubing around the distal thigh (just higher than the knee) of the patient during exercises such as mini-squats, wall squats, and leg press.  The patient is instructed to isometrically set the hips in a neutral position while performing the exercise.  Cueing is often needed at first to be sure that the patient does not let their hips drip into adduction and internal rotation.  I have found great success in this type of exercise as it required the hips to dynamically stabilize against a hip adduction/internal rotation moment during common functional activities.

band around knee leg press

There is also a section that reviews some of the available evidence behind choosing sets, repetitions, frequency and duration of rehabilitation programs.  Overall, a great review of some of the basics regarding the gluteus medius and definitely a great starting point to develop a comprehensive rehabilitation or injury prevention program.

Check out my other post on an article reviewing more great information on gluteus medius exercises and gluteus maximus exercises.

 

Presswood L, Cronin J, Keogh J, Whatman C (2008). Gluteus Medius: Applied Anatomy, Dysfunction, Assessment, and Progressive Strengthening. Strength and Conditioning Journal, 30 (5), 41-53

 

Images from: Prevent Disease, UWO

 

Want to learn more about how to get the most out of the hips and glutes?  I have two great inner circle webinars on My Top 5 Tweaks to Enhance Hip Exercises and How Pelvic Position Influences Lower Extremity Stretching.  Click here to learn more about my Inner Circle and how you can gain access to these webinars and more for only $5.