Back Pain – Understanding The Role Of The Hip

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Welcome to the Back Pain Solutions Podcast – Back Pain. Understanding the Role Of The Hip

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Introducing Back Pain – Understanding The Role Of The Hip

Movement should not take place through the spine but from the hip. The hip is a powerful, and very stable joint, which we must use to our advantage when performing any activity, whether that be walking to the shops, or training in the gym. If utilised effectively it should provide us with a very stable platform for movement.

In this episode we introduce the hip joint and discuss why it is important that we consider this joint when looking at spine health.

Lower back pain exercises and movements

The hip is a very stable joint, a very powerful joint, which is surrounded by some large muscles and is designed for movement. With the increasingly sedentary nature of our lives we’re seeing less movement through the hips. The result is a greater emphasis being placed on the anterior muscles of the hip joint, and deactivation of the posterior muscles such as the gluts, which is increasing the risk of injury. There is also evidence that some key muscles surrounding the hip can become deactivated during episodes of back pain, which can exacerbate the problems that people experience.

When the muscles in the front of the hip become tight, and weak at the back in our gluts, we find that people will start to move more through the back when walking. Rather than experiencing effective extension at the hips the body rotates, and the legs are ‘flung’ forward. This movement, over time, will start to damage the soft tissues of the back and cause back pain.

Often there is a lack of awareness about the impact of movement at the hip so just being in tune with this will help when walking particularly. We advise to open up the hips, and emphasise extension, when walking, so you start to stretch out the muscles at the front and engage the muscles at the back. Sometimes people will need some help with other exercises that help to ‘activate’ the posterior muscles such as the gluts.

Show Highlights Back Pain – Understanding The Role of The Hip

People need to be patient, understand the fundamentals, and learn to re-activate the muscles around the hip so they can use them effectively and take advantage of this powerful joint. It is from this joint that we want to see much more movement occurring, as we try to limit motion at the spine. At a basic level people must begin by understanding the hip hinge, which is a basic exercise that trains us to move through this joint whilst keeping the spine itself in neutral.

Interview Transcription for Back Pain – Understanding The Role Of The Hip

Ben James 0:00
When we’re young, we move with freedom and confidence with a great resilience to injury. Somewhere along the line, we’ve developed poor habits and become more vulnerable to back pain, smart, strong features, evidence based and practical advice to help you take back control of your health and get back to the activities you love. This is your guide to better health. So join us as we demystify some of the commonly held beliefs about back pain and build your confidence to a stronger back the smart way.

Okay, welcome back to smart strong everybody. I’m back again. This is your host Ben James on with my colleague and good friend again, Jacob stay morning, Jacob. So we’ve talked a lot, so far around the back and around back and out to me talked a lot about the muscles. Today we’re talking hip, and we’re talking about why the hip replaced such a fundamental role in back health and in resisting back health. We’re going to talk a little bit about the anatomy as we’ve done with previous episodes on the back. And then again, as always talking around some of the exercises We can be looking at to increase mobility, because the hip is where we want to see more movement. And previously we’ve been talking about resisting movement. So listen in as we talk and we visit the hip and give you some advice about how to manage the hip and and focus on the hip when you’re looking at your back health, so Jacob, why don’t we start with a little bit of anatomy around the hips, some of the key fundamental some of the key muscles. Obviously, we don’t need to go into too much depth, but there’s some important things that we want to we want to cover and emphasize to the listeners.

Jacob Steyn 1:36
Sure we probably have to look at which muscles actually crosses the hip joint. Actual back at the back we have the posterior chain, the main muscles, there are the big buttock muscle, the glute max, and then we have the glute meat, which is the smaller part of muscle running a little bit to the side. Also crossing the hip joint and then we hamstrings, also causing the hip joint. And then we go to the front. And if we look at the front, we have a very big hip flexor which comes from the low back over the hip joint into the upper leg. And that’s the PSOAS or the iliopsoas, actually. And rec fem also crosses the front of the hip joint. Those are the quadriceps, the big upper leg, front of the upper leg muscles. We haven’t we have a few smaller, deeper muscles that we don’t really want to speak about that actually cross the hip joint. We will mention them but they don’t have such a big relevance to the actual movement, more, more of a stabilizing effect.

Ben James 2:46
Yeah, no, absolutely. And when you say stabilization, I think that’s one of the key things that we we kind of try and educate people on is the joint in itself is a highly stable joint and is that that ball and socket joint, but the socket is really quite a deep socket. So the stability there at the hip is is significant,

Jacob Steyn 3:09
Especially compared to the shoulder.

Ben James 3:11
Yes.

Jacob Steyn 3:12
So yeah, a very, very, very stable joint, a deep ball soccer joint, as you mentioned, but it also has consequences. And we’re going to speak about that a little bit more.

Ben James 3:24
Yeah, so I think one of the things that maybe it’s a good place to start with, with the hip as we say it’s, it’s a very stable joint, there’s some key muscles crossing that joint and some, some very large muscles. So clearly, it’s designed for movement and it’s designed for for powerful movement. So that’s one thing that we want to talk around around how a lot of people aren’t getting much movement or much activity around that joint. I think as well. There’s some important muscles there that you’ve touched on the we find, kind of deactivate almost with pain, so From from back pain, there’s evidence there that has an influence on stability. And as well, back to this sedentary lifestyle that we lead, sitting in a car, sitting at a desk all day, what we’re finding is those anterior muscles the anterior chain are becoming quite tight, and the muscles at the back of becoming weaker, which again, is making is unbalanced and having an impact on on back pain.

Jacob Steyn 4:26
Well, that’s it when you when you sit a lot, you basically turn off the posterior chain, the buttocks and hamstrings and low back becomes weaker because the communication from the brain to these muscles become less. And besides the pressure that you have at the hip joint, from sitting long periods, the front of the anterior group muscles, especially the the SOS, across the hip joint, as muscle become shortened and tight. And that’s the feeling that you have when you get out of a chair. You always feel like oh, I need To stretch the front of my head. Yeah. And if we do that, for longer periods, daily, then it’s just self explanatory that we get tied to the front of hips and we get, we get the back of the hips.

Ben James 5:16
Yeah, and actually touching on that will will have a video at some stage on the website with a with a stretch for the video service which is which is quite effective, because you often find with a lot of people, and they’ve got back pain, it’s always in it one of those areas that should be investigated, it should be tested in patients just to see what actually is that tightness in that that muscle around the hip because, again, as you say, where we’re really finding that muscle is becoming tighter from from a lot of the sort of entry work that we’re doing and therefore what is the impact of that on back pain? Is it being investigated? Is it being tested by the clinician or are they just focusing in on specifically where Ttaht area of pain is and not looking holistically at the patient.

Jacob Steyn 6:04
So that brings us back to actually investigating the movement. Looking at what you mentioned before, whether we actually fixed the pelvis fixed the low back and asked the movement to come from the hip joint. When when we’re pretty tight at the front, and we are weak, or we’ve been we’ve become weak at the back, the glutes, and the idea of actually fixing the pelvis to a big extent and actually asking the movement to come from the hip doesn’t happen. So we end up working more with our quads with our legs in front of us, or we walk with swiveling through the low back so we actually get this movement through the low back instead of the very good extension that we after.

Ben James 6:51
And do you think it’s, again, is it a lack of awareness from from a lot of people because you do often see you know, when you’re when you’re in the kind of professional Off the background we have your often, you know, it’s it’s interesting to observe people, because observation is obviously such a key part of what we do and in terms of management of patients. But you do see this poor movement through the hip, like you say, kind of quad dominant. So they’re walking almost from the knees as it were, which, for some of the listeners is going to be a little bit confusing, but you almost see that there’s, there’s a bit of flexion at the hip, and there’s really not much drive through that hip, and yet, it’s such a big powerful joint and the muscles are so big. Why is that movement not overriding these poor movements? How do you think patients are getting to this stage? Is it just simply poor habits? Or is that sitting, just deactivating these muscles? And

Jacob Steyn 7:44
I think it’s an awareness. I think people aren’t really aware of this. And I think making it just just knowing that when you get out of a chair, you got to try and stop walking with pushing through the hip.

Ben James 7:57
Yeah.

Jacob Steyn 7:58
Knowing that okay. Being aware of what I’m doing with my core. Am I just just walking with being unaware of actually pushing through the hip and fixing my core? Or I’m actually I wouldn’t say you you’d have to brace we’d like to have happening by or happening. we’d like it to happen naturally. But if you if you’re aware that okay, if I keep my core still I can actually just push through a little bit the first few steps and open up the front of my hip joint.

Ben James 8:26
Yeah,

Jacob Steyn 8:26
Then you’re already doing a big job.

Ben James 8:30
Yeah, and I was gonna say it’s a which is it’s good that you came in there with that we’ve talked about how walking can be such a healthy activity for for patients suffering from back pain, and like you say, a simple exercise here from a from a hip specific point of view. You know, again, is is walking and like you’re saying, just not not ridiculous he overemphasize it if you like, but when you’re walking, just be aware. of that hip extending and stretching at the front, because so many people and you see it so often my patients with back pain, there’s very little extension of that hip, and it’s the contracting that glute muscle and being aware of it. And as you’re pushing through, try and squeeze that muscle a little bit, because gradually, you’ll notice that you get an increase range of motion, which is a specific game, what we’re looking for with the hip.

Jacob Steyn 9:28
That’s it. I think, for a lot of people, you can already fix a big part of the problem just by this awareness. And I think then there’s a big group of people that would have to actually get help from a professional where somebody will help them to activate the posterior chain, glutes and hamstrings and help them to learn to understand to fix the core, so we limit the movement coming through the spine. And I think that some people will need that professional help from somebody who knows more about this topic. Yeah. Yeah. Because they don’t have that awareness and you know, some people are better at being aware of this and other people are not so good at that. So

Ben James 10:11
Yeah, and again, as always, they’ll be they’ll be some exercises related to this episode on the on the show notes on the website and, you know, things like look out for things like the glute bridge, for example. And, and the clams where we’re looking to activate the some of these muscles as well, because I think some of it is, is is again, back to not just training the muscle and looking at building endurance or strength, it’s, it’s first of all, being able to be aware of it and understand what movements activate some of these muscles so that you can become aware of exactly how you move them. And again, it’s back to that education and understanding of how the some of these muscles work and the impact they have.

Jacob Steyn 10:52
Yeah, and often you you know, like you say, first you want to activate them. I think people think that when you go to A gym where you have to do rehab, you have to. And that’s what a lot of ladies and gents do is they just jump in there with heavy weights and yeah, but quite often the muscles they want to use aren’t actually even activated that well. Yeah. First you start with with low intensity, more reps, very focused on technique approach, and you activate those muscles and then you, you slowly build it up to greater intensity and fewer reps and more complex movements. Because let’s face it, the amount of exercises there are and to use to build up glute and posterior strengthes. There’s there’s just dozens.

Ben James 11:40
Yeah, no, absolutely. And if you jump into too quickly, you see it again. So often, and we’ve mentioned it before, some of these poor lifting techniques in the gym and not really going through the hip at all or going through the lower back and actually, that’s exactly what we don’t want to do. So you’re therefore not even, you’re not training the muscles around the hip effectively and then you put a lot of pressure on the back. So It is starting smallest, starting with the fundamentals of understanding that movement and back to things like the hip hinge which we’ve talked about previously. Because that’s really going to get you those motor patterns that neurology ingrained so that you are moving through the hips, rather than through the back, that back stays in neutral. Again, back to the bracing of the muscles, and tear abdominal wall, etc, etc. And that in itself will will start to make you move through the hips because otherwise, you know, you’re not going to be able to move at all if you’re if you’re not moving through the backing, you’re not moving through the hips properly, then you’re not moving. So I think you know it like you say it’s, it’s trying to, it’s trying to be patient on this journey. And even if you don’t have back pain, it’s it’s telling yourself to understand the fundamentals and build up and be patient with with that fitness goal that you may have. Rather than just jumping in saying well I’m going to the gym, right? I’m going to start doing deadlifts. You know because Exercise, but horrendous if you if your techniques Not, not what it needs to be, you know?

Jacob Steyn 13:06
Exactly and just talking about a deadlift or any complex movement for that matter. You have to start with knowing what am I doing with my core and my using my glutes, or am I giving the work to my quads for example, if I’m lifting, doing a deadlift, I think creating the awareness is the very first step. And that starts with small movements. Then slowly increasing the, the, the technicality of the exercises and how many people I’ve seen doing a hip hinge? Well, from the start, but almost zero.

Ben James 13:48
Yeah, yeah.

Jacob Steyn 13:50
I mean having the understanding to actually do the hip hinge and going into giving the work to the hamstrings, with a neutral spine. I mean let’s face it, that’s a very small percentage. So great, you know, awareness is actually key.

Ben James 14:05
Yeah. And that and that’s not just in people that may be sedentary that you know, that’s how athletic people as well, you know that, that there, you’ll, you’ll say move through the hips and they move through the low back. And you know, when you’ve got the knowledge and you’ve been doing it for a long while it it seems so, so simple and so natural to do and yet it’s so difficult for so many because the habits have been built up for so long and breaking those habits takes time it takes patience and it takes consistency and dedication really because it is but it again It can’t be like with any task, you know, if you want to improve you got to put in the time but it is so important because frustratingly, you see a lot of patients have been seen by so many different people. And again, some of these basics are just so simple, and yet they’re not being they’re not being adopted as they should be or they are they sadly haven’t even had the advice. So the Get some treatment, they’ll feel a bit better and they leave the office and bang, they’re back to moving through their back again and, and the cycle continues. So, all are focusing specifically now a little bit on the on the glute meat because we we mentioned in the intro how some of these muscles can can switch off following an incidence of back pain and glute means one of those muscles list. There’s a lot of evidence there now that says if you’ve got back pain and sometimes that that glute Meade muscle isn’t even active activating firing or functioning as it should be. You want to talk a little bit about specifically the glute meat or gluteus medius. We should call it by its proper name.

Jacob Steyn 15:41
Yeah, sure. The the gluteus medius it’s basically it’s a very important muscle because of acts in quite a few things that you do when you use the hip for x And it contributes a lot to lobeck stability. Because of the glute need on the left is weak, then if you stand on the left leg, the right hip will drop down. And that already causes moving through the low back through the spine. And that’s not what we want. We want to be able to fix the, the, the lower part of the spine with the pelvis and then obviously give the movement to the hip. So the, the glute med does that it provides stability when you’re on one leg, so in the walking phase, from one leg to the other leg, it ensures that the hips, the pelvis stays horizontal for the biggest part is always this element of the gyroscopic movement that develops but the the main stability or a lot of the stability, together with quadratus lumborum for this pelvic pelvic movement, lateral movement, I would say comes from the glute med and the second very important function that has actually causing this external rotation at the hip so pulls the knee out outwards. But it doesn’t only pull the knee outwards it, it stabilizes the hip. And I’d like you to think of the whole leg as an extension of the hip. So if the, if the hip is not stable, the whole leg is actually compromised the knee the foot, you know, if the if the glute meat is not pulling the knee out, the knee will drop inwards, and the foot will also flatten so you look at a sort of flat foot best plainness effect. And you’ll look at unwanted pressure through the knee. And yeah, so just to finish that, if you if you basically have a stronger glute meat pulls the knee out, it causes the full arch into a good position and you imagine having that stability then running shouldn’t be a problem.

Ben James 18:04
Yeah, no, absolutely. And and, you know, just drawing back on what you’ve said there, it just goes to show, you know the the impact that these things can have an exacerbate and, and the other problems that can be caused because when you talk about the the resistance of rotation or internal rotation at the hip, which which is an activity that the glute Meade provides or supports. There’s evidence to say that, you know, that movement in itself or resistance of external rotation, that hip can increase risk of cruciate ligament injuries, for example. We see that a lot. And that that, that movement is, is classically linked with cruciate ligament injury. So we’re maybe being a little bit catastrophic here, but if you imagine you’ve got back pain, glute meat, not firing as they should be, and then your Going out and trying to do exercise or particularly something like football, then are you putting yourself at risk of further injuries? And the evidence suggests that we are now Are there many studies that say, well back pain increases risk of cruciate ligament injury, probably not. And, you know, it’s probably not something that you should be worried about, but it just to show how important that muscle is anatomically, to, to activities in the in the lower limb as well, which again, if all you’re doing is focusing on the area of pain, then you’re missing the whole picture, as it were. So I think, you know, certainly you want to be it’s a consideration you want to have and there’s a simple exercise that is often prescribed for activation of the glut med which is which is the clamp so we talked about that, that a little bit will have again, video on the website just for reference because as always, it’s easier to have visual aids with with exercises, but it’s worth just touching on because it’s such an important muscle.

Yeah, glute clams, they are the exercises. There’s actually a group of them. There’s the one, that it’s where you lie on your side and you have your classic examples where you lie on your side and you have a nice pulled up and you keep your ankles where your heels touching each other. And you keep your pelvis still so you don’t rock backwards. Rely on your side. You keep the pelvis still and you raise the knee. And so you can, you can hold a knee there for a couple of seconds and bring it back to touch the other knee and then you raise it again. And it’s an isolated movement for the glute med.

Yeah,

Jacob Steyn 20:42
And it feels like a very silly exercise, because you just got to repeat this knee raising. But if you do it properly, and I find with patients that it depends quite often with with their hypnotic pelvis anatomy because there’s such a variation in hip joint socket and hip socket, positioning the direction in which it faces that sometimes you have to tweak it a little bit, you have to pull the knees up a little bit, or you have to, you have to tweak it a little bit until until they really find that they’re really using the glued meat. But if you get that, then you can actually just isolate the glut med movement, and that’s how we get communication going from the brain to this muscle.

Ben James 21:31
Yeah, and when you say, you know, it feels like a silly exercise, I think it is because a lot of people think, well, I’m lying here doing this exercise and I’m not feeling anything. And it’s and you know, it’s important to emphasize that it’s not an exercise to build strength and size and bulk in a muscle you know, like with what a lot of people are doing at the gym to to get stronger, etc. This is a activity to get that muscle fire and again and get that communication going. That’s the important first step.

Jacob Steyn 22:00
Exactly. And it’s like we said earlier, it’s building the base. It’s low intensity, many reps, building the communication, neurologically. And then from there, we’ll take the next step.

Ben James 22:11
Exactly. So I think, you know, the take home so far is that the hip plays a fundamental role in our movement, and particularly in our resistance and rehabilitation to back back pain, you know, if we’re going to keep that spine in neutral, as we’ve been talking about for, for the last half, however, many episodes, and we’re going to brace, then our movement has to start going through the hip. We’ve talked about the hip hinge before, and it really can’t be overemphasized just how important that is. So looking at the exercise would be a good one to get that muscle firing. Whether you’ve been tested or not, you’re not going to do any damage by by focusing on that and getting a better understanding of of how that muscle works and get that communication going. And then the other element that you can start to do from today is focus more on your walking Focusing on extending that hit properly and contracting those muscles in the in the buttocks, as you’re pushing that leg backwards and through, so that you can just start to be more aware of the hip, more aware of the movement and the movement potential. So that we’re looking at that range of motion. Because this is what we say, where we want to see more movement, not less. So around the spine, we were looking at those muscles to resist movement and in the hip, we want to increase movement, that’s where we want to see the movement coming from because not only is it going to spare your spine, but actually if we’re looking at sporting activity, then the muscles around the hip are so powerful. That’s where you’re going to get a lot of your speed and power from and you’re going to be a lot more efficient and a lot more effective. Effective when you’re doing athletic activities. And just coming back to that point athletic activities and some of the people that are going to be going to the gym and doing deadlifts and things Often what we see is everyone’s trying to do a deadlift from the ground. And I think this is something that is important to touch on. And we learned this and we discussed this at depth at the at the McGill seminar we did out in Holland. That hip screen is so important, because not everyone has the anatomical potential to do a really deep squat. And there is genetics and history that will affect that. And we talked about how people of Polish descent, as a rule, have the ability to squat very deep, their their hip joints allow it, whereas those with Celtic descent have less range. So if you’re trying to squat right to the floor, you’re going to find it some people are going to find it very difficult to keep that back straight and do that exercise. And therefore we’ve got to start thinking about lifting that bar off the floor and that’s something that I think it’s important to touch on for the going to the gym already?

Jacob Steyn 25:03
Yes, I think especially because we’re talking about the hip. And I think it’s, it’s another part of the awareness, being aware of what your own anatomy and your own body is capable of. And like you mentioned, there’s this this big variation between the goal the Eastern European hip and the Celtic, Scottish hip. And the Polish being a very good example of Eastern European hip where they have a lot of range of motion because of the shallowness of the hip joint socket. And quite often the direction in which it points or points more towards the front of the person, you know, anteriorly and quite often more to the side. So you have this disadvantage of actually making a deep squat with a neutral spine and if Like, like Ben mentioned, if you have somebody screening the hip range of motion that you have as an individual, it gives you this awareness of what is the range that I can work with. If I do a deep squat? How deep Can I squat? Potentially, if my muscles and my nervous system supports me to make this, this is as deep as I can go without breaking a neutral spine, for example, you know, or a protected spine position. And I think that’s where a lot of people see a video of a professional weightlifter and I think wow, you know, this this Russian Dude, you can really touch the ground with his bum when he’s got 200 kilograms over his head like, block off. But you have to be realistic. If you if you’re, for example, Dutch. We have I think from my testing so far, testing patients, I’ve tested dozens over here. Over here, at least in the west of Europe, we have more of a generally more of a Celtic Scottish hip position. So what we have at our gym for example is I’ve made blocks of people don’t actually pull from the ground. But so we can stack these blocks up and intensive centimeter heights. So they actually pull off the blocks. And this is very, very, very important. Because what, coming back to what we’re saying what Ben said a lot in the beginning is actually limiting the movement through the spine with getting into the hip. And if you’re not pulling from a high enough position, doing your deadlift or any other complex weight, then you’re going to have to compromise the position of your low back you’re going to move through the low back.

Ben James 27:50
Exactly. Yeah. So I think that’s that’s takeaway message number three really is just be aware of, of that hip mobility. When you You are doing a deadlift if you are doing deadlifts. And as we say, you know, we’re not we’re not avoiding those activities. Clearly we are if you’re you’re currently suffering from back pain because we’ve got a, we’re not at the stage to do deadlifts. But if, if you’re training for athletic endeavors, and and you’re listening in out of interest rather than because of a suffering from back pain at this moment in time, just be aware of that because, like you say, Jacob, you know, it is fundamentally important because if you don’t have that anatomical ability, you have to compromise your spine, if you are all going to try and do the deadlift from the floor, it is just impossible for the whole of the population to do so it is an important point that that we need to make. So a relatively short episode today, just focusing in on some of the key fundamentals of the hip, and just being aware of how important that is from a stability point of view and also from a generating power point of view. And there’s some key things that we can be looking at and take over. messages that you can be focusing on from today which are, get that glute meet, fire it. Start walking and being aware of your walking stride and extending through the hip and feeling those buttock muscles contract as you’re walking, really focusing on that, because it will make a big difference in it. Over time, you will notice an increase range of motion, particularly if you’re an office worker, this is really important, just to get that movement through the hip and improving that. And then if you are going to the gym, if you are doing exercises, step lift. Be aware of that anatomical capability in the hip to show that you know that you’re lifting from a position of safety, and you’re not compromising that lower back because the hip will certainly help on your road to recovery with back pain. So as always, head on over to the website and look at some of the other resources that will give you some visual aids. To help with some of those exercises and some of the things we’ve discussed. Next time we’re going to be talking about The shoulder. The hit plays a key role, but also the shoulder because activities within the upper body for not moving right through the shoulders again, as you probably going to know what I’m going to say is going to compromise your low back. So, thanks again, Jacob. And we’ll speak again next time on we’re going to focus on the shoulder.

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