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Hip range of motion and low back pain
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Hip range of motion and low back pain - April 15, 2005 3:22:00 AM
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Alex Brenner PT MPT OCS
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I have read in some research articles that one of the predisposing factors in lower back pain may be limited or excessive hip joint range of motion.
The interesting thing about this, to me, is that we don't really have a good grasp of what normal hip range of motion should be. The American Academy of Ortho Surgeons reports normal medial and lateral hip rotation ROM to be equal. The committe on Medical Rating of Physical Impairment describes normal as being more lateral than meidal hip rotation ROM.
In an older study, Barbie-Ellison et al, Physical therapy, 1990; Vol 70(9):537-541 found 4 distinct patterns of hip range of motion in patients with and without low back pain. They found the most prevelant pattern in normals (labeled Patern II) was internal rotation (IR) 45 degrees and External rotation (ER) 15 degrees. The most prevelant pattern in those with low back pain was exactly the opposite (labeled pattern III) 15 degrees IR and 45 ER.
I know there are many "biomechanical" minds here on rehab edge. Does anyone have any thoughts on this. Does this make sense biomechanically? Does excessive hip range of motion predispose you to have low back pain?
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Alex Brenner, PT, MPT, OCS
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Re: Hip range of motion and low back pain - April 15, 2005 3:40:00 AM
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SJBird55
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Have you ever observed what you thought might be a "normal" population from above? Look out the window of some building and watch people walk down on the street below. It is amazing to me how many different movement patterns you'll see. I'd love to be above and have a partner down on the street communicating with headsets or something and picking out people to question or interview. From above, it is so much easier actually seeing movements in the transverse plane and in the frontal plane. I wasn't really actually keeping track, but there was definitely a group people that walk along with one hip in a significantly noticeable amount of lateral rotation compared to the opposite extremity. And it wasn't just seeing the hip laterally rotated that would catch my eye necessarily, but the movement pattern of their gait was different. Sorry, I can't explain it, but it was one of those times that I wished I had a video camera so I could replay it in slow motion. I wasn't allowed to sit there and observe for long enough to figure out what I may have been seeing, but there was something different.
I had asked Childs about the hip rotation component in their clinical prediction rule... I guess their still looking into an explanation for why.
Maybe it isn't the excessive rotation that is the key, but maybe it is the location of the femoral head and the forces that are distributed through it during weightbearing that is more important?
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Re: Hip range of motion and low back pain - April 15, 2005 4:07:00 AM
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Jon Newman
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I've noted that folks who have an apparent retroverted hip often are unable to lay prone with full hip extension. Their pelvis is up off the table forming a triangle (their knees and trunk forming the base and their trochanters at the peak).
I haven't noticed a specific pain pattern to this however, just a structural one.
jon
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Re: Hip range of motion and low back pain - April 15, 2005 7:30:00 AM
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JLS_PT_OCS
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Well, I think that there may be a relationship for some people, and I think anecdotally I have noted people with chronic low back pain seem to have stiff hips.
I am aware of at least one study that correlated hamstring stiffness (not length) with LBP, but as I recall the sample sizes were not impressive.
I consider this like I would a risk factor for an organic disease. It is something that is possibly correlated, is not the total picture, but bears mention in both treatment and education approaches to chronic low back pain.
Sahrmann states, I think interestingly, that if two moving segments contribute to a motion, the most flexible or least stiff of the two will contribute the most motion.
So, in the case of LBP, I relate this to all planes of movement, and note that for most global motions that the L Spine has, the hips can contribute to that motion.
For example, if you are bending forward on a hip that has some stiffness into flexion (from joint or muscle stiffness, or just a bad motor pattern), then logically more motion would be demanded of the Lx spine to allow more motion. Do this for 30 or 50 years, and that progressive mechanical deformation may be a part of why we see so much lower lumbar spine disease. ??
Clinically, I have found my chronic back pain patients (especially males) have a difficult time differentiating hip motion from lumbar motion, and they initiate forward bending or other motions from the Lx spine instead of hips.
So.... my long term treatment of these patients always includes motor retraining, and learning to bend, squat, pivot, and rotate while moving more from the hips and less from the spine. Sort of a stabilization approach. In this case, according to Sahrmann's statements, I am reducing the mechanical deformation of the spinal segments by creating more stiffness there (and thus less movement) and improving flexibility of the hips (and thus more movement there).
I think that handing out "stretching" exercises can not really address this, so I use them sparingly, if at all.
I have found better results using a motor reeducation type approach, a la lumbar stabilization.
Thoughts?
J
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Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Hip range of motion and low back pain - April 15, 2005 12:18:00 PM
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Barrett
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Alex,
What of the well documented effect of hip internal rotation on the sacral plexus?
Have the patient lie supine and observe where their feet land. Adduction and internal rotation of the hip as an habitual pattern of use (not necessarily their available range) is easily seen by both therapist and patient. The more symptomatic side will almost always be displayed as the toes pointed toward the ceiling.
I don't see "restricted" hip range in the joint as a common problem-I see a system trying to change but stuck in relative internal rotation. Of course, how you go about changing that is a whole other issue.
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Re: Hip range of motion and low back pain - April 17, 2005 4:53:00 PM
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jbeneciuk
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Jason:
As you mentioned above: "one study correlated hamstring stiffness (not length) with LBP"...I notice that Sahrmann refers to muscles being "stiff" and not "short" also...
**my questions to you are:
1) Clinically, how can we determine the difference between "stiffness" from "shortness"....let us use the hamstrings as an example
2) From a physiological perspective; what is the difference ??
jbeneciuk
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Re: Hip range of motion and low back pain - April 18, 2005 3:38:00 AM
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JLS_PT_OCS
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jben-
I have kind of been wrestling with this concept stiffness vs shortness myself.
I really thought of them the same until I had read some of her work, and looked up some of her citations from the biomechanics world.
A short muscle would be one that did not have what we judge to be "normal" length. All these "muscle length tests" we use and were taught (Ober, Thomas, etc.) are checking length.
I'm not sure how useful these tests really are.
I can check hamstring length by putting supine patient in the 90/90 position and checking popliteal angle.
A stiff muscle would be one that has greater than normal resistance to passive stretch. This has nothing to do with length. This may be a sign that the muscle is not functioning properly. I could pick up stiffness by noting the resistance to any passive stretch and any symptom provocation.
I'm not sure entirely what I would do with that information, but placed in the context of the movement impairment model, it seems to make sense.
I cannot really explain it as I don't fully understand it myself, nor can I advocate it as a first line evaluation method, because I haven't seen much convincing evidence on it yet. But it is an interesting paradigm of thought.
J
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Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Hip range of motion and low back pain - April 18, 2005 3:47:00 AM
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srcase
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Wouldn't it have to do with abnormal tone?? If the muscle is "stiff", it is neurologically facilitated and less able to passively lengthen. If it is "weak", it is neurologically inhibited and less able to full contract. That has been my understanding (without getting into all the muscle spindle stuff).
I think a "short" muscle has to do with the connective tissue around every fiber, bundle of fibers, bundle of bundles, etc. If the connective tissue is short, the muscle will not be able to lengthen even though it may have a good "signal" from the nerve because of passive resistance. A true "short" muscle would be a contracture and we all know that is a real difficult thing to treat. Most people's hamstrings are not contracted, they are simply "stiff" having forgotten how to dynamically lengthen (eccentrically) under load.
Just my thoughts...
Sarah
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Re: Hip range of motion and low back pain - April 18, 2005 7:02:00 AM
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JLS_PT_OCS
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I think that's a good way to approach it, but also don't think anyone, least of all me, knows for sure.
I think we have all found some striking strength increases in our patients sometimes in very short periods of time.
That this is a reflection of a neural adapatations I think is obvious to us, and I think that is what Sahrmann is getting at.
She is advocating we approach it from the standpoint Sarah mentioned, if I understand her correctly.
J
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Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Hip range of motion and low back pain - April 18, 2005 7:49:00 AM
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Barrett
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Not having heard Sahrmann speak recently, I'm wondering if she has yet begun to refer to the mountainous pile of research offered to the neurologic community by those who have fought in the neurobiologic revolution since the mid-70s-not to be too dramatic about that.
The concepts of "muscle imbalance," "stretch weakness" and disciplined, consciously controlled "proper posture" have all seriously been called into question if not completely refuted by many researchers and the authors of the books bringing their work to light. The very relevance of flexibility as measured goniometrically or maintained with regular stretching has been shown to have no relation to injury prevention and may even retard performance (NOI's site discussed this at lenghth some time ago). In the end, we must wonder what it is we're seeing when we look, feeling when we palpate and actually changing with our interventions, successful or not.
Adhereing to the notion that "short" muscles account for the patient's problem and need stretching is a big mistake, it seems. Not that this practice will disappear anytime soon.
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Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: Hip range of motion and low back pain - April 18, 2005 8:03:00 AM
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Shill
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Barrett,
with your views on movements being inherent, why do you suppose that people often complain of "tightness" in the periscapular region, when in reality, they are loose as geese. I often see them contorting themselves to "loosen up" these areas, often in ways that could be viewed as stretches. These are things they seem to do without being told to by anyone, they "feel they need to" do it. Where does this type of movement fall within your inherent movement scheme, as in my eyes, it seems rather unhelpful (as in, pain overall never changes because of these movements) for these people to be stretching things that arent tight. Im with you on stretching being over rated in most cases.
Thanks,
Steve
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Steve Hill PT
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Re: Hip range of motion and low back pain - April 18, 2005 8:06:00 AM
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JLS_PT_OCS
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Barrett-
I haven't had the opportunity to hear her speak, so I can't say for sure.
I do interpret her book and her exercise programs as centering on motor control of movement and not "stretching" what is "tight".
I am beginning to see the problems with such an approach as "stretching", and I am sort of on the cusp of this new paradigm in my clinical practice. It has been interesting.
I do agree that not many of us really think twice about what we think we are feeling, seeing, and changing. That is indeed unfortunate.
J
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Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Hip range of motion and low back pain - April 18, 2005 8:37:00 AM
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coreconcepts
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I have acouple of comments to add to this discussion, acknowledging first that I am out of my league here in terms of knowledge, experience and education.
Firstly, it has been my experience that clients who present with LBP have poor inner hip range control. They typically have (in addition to poor inner unit activity) weak glute med, inner range glute max and tight TFL.
With regards to the length/tension subject - I have had clients test ideal in terms of length (hamstrings), whilst there is a functional movement restriction due to "stiffness". The hamstrings are notorious for this phenomenom as they have a high degree of spindle fibers. Perhaps a way to determine excess stiffness is to first have the client/patient actively flex the hip in a supine, neutral spine, straight-leg position - note range and then passively push further until the point of discomfort. I guess the question remains, though - what do you do with a "stiff" muscle? I am sensing the stretching alone may not be indicated, whereas it would be effective for a short/tight muscle or in cases of contracture.
BTW, I also believe that excessive ROM could be problematic for LBP as there is commonly a loss of strength in the functional ROM.
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Re: Hip range of motion and low back pain - April 18, 2005 10:56:00 AM
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Barrett
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Coreconcepts,
Why would a loss of strength have anything to do with backache?
How does "inner range control" contribute to low back pain?
What of the relatively simple concept of mechanical deformation within sensitive tissues?
Shill,
This is a common question at workshops and I can certainly understand why. I answer with a couple more questions (not always a popular approach, but if people don't like it I refer them to Socrates).
If this ego-driven, habitual, willful, forceful and repetitive movement were especially corrective to the involved tissue, why doesn't it seem to help for more than a very brief period of time? If it doesn't work, why do therapists do it and over and over for their own problems in the absence of any real result?
My answer is that the effort is encouraged by a culture that knows nothing about the underlying problem (an abnormal neurodynamic) and therapists are more likely to be driven by the culture than their own literature.
Ideomotor correction does not resemble what you see people doing in a number of ways and these are described in "The Characteristics of Correction" on my site. Briefly, they are warming, softening, spontaneity and effortlessness. These are not experienced when people do what you describe and I work hard to get my patients to stop that useless movement and devote their time to something else.
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Barrett L. Dorko P.T.
http://barrettdorko.com
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Re: Hip range of motion and low back pain - April 18, 2005 12:38:00 PM
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coreconcepts
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Hello Barrett,
Thank you for your questions. I wasn't trying to suggest an absolute cause and effect relationship of poor gluteal musculature/inner range control so much as I was providing feedback from an observational standpoint. I do feel, however that this area is at least partially responsible in the overall LBP spectrum. In terms of a biomechanical/kinetic chain rationale, the gluteus maximus/medius are lumbopelvic global stabilizers that when contracting, counteract the pelvis' tendency to anteriorly rotate. At the same time, the oblique and transverse abdominal musculature contract. This action tightens the fascia surrounding the erector spinae musculature and takes pressure off of the low back.
So while weak glutes may not be exclusively to blame for LBP, it is likely a factor in many cases. Janda has indicated that weak abdominal musculature (abdominal obliques & transverse abdominals), weak gluteus musculature, weak quadricep musculature, tight erector spinae musculature and tight hamstrings are precursors to lower back injury. Because our daily activites promote the chronic lengthening of the glute max/med - they become weak.
In terms of mechanical deformation? Sounds good to me - but would you consider that glute max/med strength could at least contribute to, or exacerbate this predisposing condition?
Lewit K. Manipulate Therapy in Rehabilitation of the Locomotor System, 2nd edition. Butterworth-Heinemann Ltd., 1991, p. 14-32, 126.
Janda V. Muscle strength in relation to muscle length, pain and muscle imbalance. In: Harms-Rindahl K (ed.) Muscle Strength. New York: Churchill Livingstone, 1993.
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Re: Hip range of motion and low back pain - April 18, 2005 1:31:00 PM
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srcase
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All this talk of Janda reminds me of my research thesis in PT school, in which I tried to find a correlation between muscle balance and LBP in adolescents. I had previously done a huge literature search and could not find any well-conducted studies that showed a correlation. The only variable that I found correlated with LBP was age. The same was true of my research, only age correlated with LBP. After giving my entire presentation to the faculty and other students, someone from my class raised her hand and asked, "what is the clinical relevance of this?" in a snide tone (implying that it had no relevance). I can't remember my reply, only that I intuitively knew that this was hugely relevant, but I couldn't quite put my finger on why. Now I am starting to get the picture.
Sarah
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Re: Hip range of motion and low back pain - April 18, 2005 1:47:00 PM
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coreconcepts
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Sarah,
Thanks for the feedback - very interesting. Is that to say that there are no well-conducted studies to validate the research of inner unit stabilization/resequencing and its effect on low back pain? What about the research of Jull, Hides and Richardson? I believe Sahrmann and Bergmark in addition to Janda were also pioneers of this philosophy. Maybe an Aussie physio can jump in on this one - it seems to form a large basis of their practice there.
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Re: Hip range of motion and low back pain - April 18, 2005 4:25:00 PM
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srcase
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Richardson and others showed that altered timing of the transversus was present in those with LBP. I have not read all of their studies, however, so I am not sure if they had any research relating muscle length or strength to LBP. That is what I was looking at (in my primitive little study). I do agree that Janda was a pioneer in looking at neurological inhibition of antagonistic or synergistic muscles, but I still don't think anyone has proven that a certain patterns exist with LBP. Where's Jon the linkmaster when we need him??
Sarah
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Re: Hip range of motion and low back pain - April 19, 2005 8:35:00 AM
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JLS_PT_OCS
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Janda has interesting theories, but unfortunately, while his theories make some sense, there is no evidence to support his conclusions. I agree that much of this may be the inherent difficulty in studying the construct as a whole. I have found some of his concepts useful in the treatment of individual patients at certain times.
CoreConcepts- you shouldn't quote book chapters in an attempt to support your points. Anyone can write anything in a book. That doesn't make it correct. :)
I agree with your theory about the role of the gluteal muscles, I think there's something to that. We should keep in mind that it is only a theoretical construct and not "the way things work" or the complete story.
What do you mean by "inner unit control"?
I think there is significant evidence to support the use of lumbar stabilization programs in rehab of back injuries, and the research by Richardson et al describes that quite nicely. We use it quite a bit in our clinic. But as far as treating hip pain goes, there seems to be little evidence to guide us.
But while I don't consider Sahrmann's book authoritative or the ultimate answer (especially because there isn't a lot of research out on it yet), it does provide an interesting paradigm through which to view a possible solution. Especially when evidence provides so little in the way of guidance.
J
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Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Hip range of motion and low back pain - April 19, 2005 9:32:00 AM
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Geert Jeuring
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Hello Forum,
First off all, Janda is dead, and since he has reached an acceptable age (somewhere between 80 and 90) I´m not all that sorry about it, because he unchained a lot of nonsense in our area of expertise.
The main thing I´ve noticed about Hips and Low backs, is that when a person who is normally able to extend his Lower back isn´t, he or she is limited in her Hipflexion. This is logical, because it doesn´t matter if you flex the hip or nutate the pelvis (nutation of the pelvis goes with a extension of the lower back). A very secure way to mobilize the lower back is to bring the hip in the end range of motion (flexion) and after that ask the patient to extend (hollow) his Lower back. After a couple of repetitions the hip ist mostly significantly more mobile in flexion. This treatment is more succesfull with women, who normally have more ROM in Extension of the lower back as in man.
Greetings
Geert
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