Hip Rotation and Lower Back Pain
Here is an interesting study I found regarding lower back pain being related to problems at the hip. Read at least the bolded bits, and see underneath for my comments! :
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. 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.
Ellison et al 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 others 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. 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 coworkers 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, Cibulka 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, Warren 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.
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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
This is one of the major issues that a biomechanics screen deals with, looking specifically at piriformis. To give a short background, the biomechanics screening process came about as Martin Haines (who’s been doing physio work for years with the likes of Arsenal and UK Athletics) noticed that the same problems were coming up again and again. Over time and through trial and error he also found the things that most commonly caused problems and also what worked to resolve those problems. This is a very powerful tool, to have a screen and then a specific technique related to that screen that has been statistically proven to have good results in improving the results of that screen. This means that it is possible to use the system and do a lot less fumbling in the dark with the majority of problems.
Anyway, two tests on the basic screen specifically test Piriformis/Hip Rotation, which is linked with pain and disfunction throughout the body if not working correctly. We don’t test so much for range of motion as per the study above, but more if the hip is able to function correctly or if there is muscle spasm. Another common symptom of the hip not working correctly is that it ends up stuck in a certain position, which can end up with one of the legs looking longer than the other. A lot of people prescribe orthotics for this ‘problem’, seemingly without knowing or looking into the fact that the leg length can be changed within minutes by releasing piriformis. In one of the pictures on the Biomechanics page you can see the difference in leg lengths achieved in 2 minutes by using anti-spasm exercises. This was using no massage or stretching.