PART 1
Hips Don’t Lie
Throughout the past few years of practice I have come across a myriad of musculoskeletal conditions from the low back all the way down to the feet all of which have a common denominator. That being hip girdle inhabitation or weakness namely the gluteal muscles: Gluteus Maximius, Medius and Minimus as well as lesser known deeper muscles commonly referred to as the Deep lateral rotators or Deep 6.
This inhibition in greatly due the fact that we sit on these muscles entirely too much and are less active. In fact, our butts are getting more contact time with a chair than our feet have in contact with the ground. I often say half-jokingly, yet half serious that the best chair is the one you don’t sit in too often. This is usually accompanied by a blank stare. What you will see, more often times than not, is someone sitting with the “computer guy posture” demonstrating the rounded lower back, kyphotic or flexed upper back, rounded shoulders and forward head posture. Hopefully to a lesser degree than the gentleman below (and hopefully with some clothes on).
This posture can lead to a whole host of issues including but not limited to neck, shoulder, upper/lower back and LE pain. Certainly, a better way to sit is seen is seen above along with proper ergonomics (i.e seat height, screen height, etc). But this doesn’t address the fact that our hip flexors become shortened and tight which in turn limits the amount the hip extends. End range hip extension is where the superficial superficial gluteal muscles function best and is often inhibited because it doesn’t have adequate extension range of motion.
Other reasons for poor gluteal activation come from poor movement patterns. Commonly with lower back pain patients, we refer to this ‘gluteal amnesia’. What we typically see with these patients is that they forget how to use their glutes are often asking the hamstrings and low back muscles (erector spinae) to do their job. Take the case of a patient trying to get out of a chair. They will most commonly use their hamstrings and little to no glute involvement to arise from the seated position. This is many times when a patient state they have tight or short hamstrings, when in fact they are experiencing overworked hamstrings. If you passively elevate their straight leg (knee straight) you will commonly see is they have more than adequate hamstring length but in their minds the stetching helps (only temporarily). But I can tell you from clinical experience, just by activating and strengthening their glutes, their hamstrings miraculously “loosen” without any isolated hamstring stretching.
Let’s take the patients with stiff lumbar erectors (extensor muscle group just to the side of the spine). Lay people tend to presume that having a strong back is protective and by doing “Back exercises” such as good mornings or strengthening of these lumbar extensors they can rehab their back to health or prevent injury. I agree to a certain extent that a foundational strength is a must but can tell you I have seen more often times than not it is the strong backs that have become injured. Research and clinical experience have shown that healthy backs dissipate or spare loads from spine and force the glutes to do the majority of the load. The erectors have less of work capacity and endurance thus when they become overworked (sound familiar) or overloaded the back pays the price. The other main reason that low backs get chewed is from excessive motion forced by a lack of hip and thoracic mobility. We will speak about that in another installment.
Needless to say the majority of patients with lower back pain exhibit poor lifting mechanics and hinge at their low back (likely part of the reason they got injured in the first place.) Everyone knows to lift with their knees, right? Better, yes, but that will just give you early knee arthritis! The most efficient way to lift is to hinge from the hips, maintaining neutral spine, and lift with your hips. The common hip hinge can be easily taught with a dowel behind you or maintaining three points of contact (head, upper back and sacrum). See exercise program.
I somewhat commonly see patients who have tried therapy in the past regarding knee related conditions but are still unable to participate in the activities they enjoy such as running, biking, and sporting activities. Some common conditions that are often mistreated or have misdirected focus include patella femoral syndrome (PFS) and Iliotibial band syndrome
Patella femoral syndrome was commonly thought to occur because of weakness in the quadracep muscle, more specifically the vastus medialis portion. The original theory was that the patella was mis-tracking laterally in the trochlear notch because the medial quad wasn’t doing its share of the work. That myth has been dispelled with current research of Chris Powers and shows that in fact the powerful glute muscles are not controlling adduction and internal rotation moment well enough allowing patella (knee cap) to rub against the femur. Through Powers and others’ work, “the illusion of lateral patella tracking is a function of the femur that is “tracking” aberrantly, not the patella.” Strengthening of the deep lateral rotators and hip abductors is most often the key and missing link in addressing the true biomechanical dysfunction. I have seen numerous patients coming from other clinics with this condition who have undergone the old quad/VMO stand-by with little success and have successfully gotten back to their desired activity with a hip based approach.
The second condition commonly mistreated is iliotibial band syndrome. This was originally thought to be a friction syndrome and the result of the distal band snapping back and forth on the side of the knee. This is still commonly treated with IT band stretches, ultrasound therapy and if your ever so lucky foam rolling (which feels like getting hit by a steel pipe as you roll the side of the leg). This myth has been dispelled under advanced imaging and shows that this friction syndrome is actually a compression syndrome. The appearance of the band moving back and forth is an “optical illusion” and really changes in the tension between anterior and posterior distal band because of activation times of the gluteus maximus and Tensor Fascia Latae. What is usually the cause is the inability to maintain a level pelvis when standing on one leg. The muscles on the stance leg (leg in contact with the ground), namely the gluteus medius and minimus (along with others) work to prevent the oppsite side of the pelvis to drop. In the case of ITB, when this pelvis drops it pulls on the band causing compression which ultimately yields inflammation and pain on the side of the knee. A simple test would be to stand with your hands on your hips and stand on one leg. If you feel the opposite hip drop slightly, you are at risk to develop some etiology of knee pain if not ITB syndrome. Simply, in these conditions strengthening of the hip girdle to provide pelvic stability and and lateral core strengthening will often significantly reduce symptoms associated with this condition.
Have flat or “pronated” feet? While this may be a structural issue requiring orthotic intervention, this is not always the case. Do your knees cave in with jumping or squatting? More often times than not, it is an issue arising from above in the kinetic chain. Can you guess where? The glutes (shocker)! Strengthening of the deep lateral rotators and hip abductors along with working the foot muscles (as simple as doing barefoot single leg exercises) can in turn restore adequate arch height and decrease risk or severity of many knee and ankle pathologies.
The hips are one area that cannot be overlooked as the culprit in many conditions where the victim (pain problem) might be elsewhere in the body. Frankly, there are not too many conditions that I don’t see involvement of the hip girdle including most every hip, knee, ankle and foot pain problems. I even analyze hip function in shoulder patients and often find compensations present!
Science has shown that the best force producers make the best athletes. The muscles responsible for the peak force generation usually come from the powerhouse in your rear. Big butts aren’t just good to look at, they’re functional as well. Whether you’re an athlete, weekend warrior, or just ordinary Steve, the hips are the key and often the missing link in your rehabilitation or performance program. They constitute part of the pillar/core and sit in the middle of your body for good reason. Don’t neglect them!
If you are already experiencing pain, avoid any aggravating factors and seek a qualified clinician who can perform a comprehensive evaluation (a good choice is always Performance Spine and Sports MedicineJ)
Best In Health,
Jim Tholany, PT, DPT
NEXT ISSUE, PROPER LIFTING AND THEN
EXERCISE PROGRAM PART 3!!!
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