Lower Back Pain Referring To The Hip; Hip Pain & Buttock Pain & Hip Exercises

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Lower Back Pain Referring To The Hip; Hip Pain & Buttock Pain & Hip Exercises

Many sufferers of back pain will report experiencing pain in areas away from the low back itself, which is known as referred pain. Referred pain is the result of the extensive nervous system which supplies sensory nerves to many tissues in the low back, pelvis and thigh. As a result, an injury to any of these structures can cause pain to radiate to any of the other tissues. The brain is unable to determine the specific source of the pain and therefore the primary source of injury isn’t always obvious. Hip pain is a common source of pain in those suffering from low back injury so a thorough history, and careful examination, are required in order to distinguish the site of injury and direct effective treatment.

In this episode we talk about the differences between hip and low back pain. We discuss the anatomy and where you should expect to feel pain in a true hip injury. We also discuss the reasons why true hip pain is uncommon and how we can take advantage of this joint to support our low back due to the stability, as well as the power, of this joint. Furthermore, we describe the importance of conditioning the muscles around the hip which reduce stresses on the low back by removing reliance on the lower back extensors during movement. 

Some of the things you’ll discover…

• Why you shouldn’t get distracted by hip pain and that often people suffering from lower back pain will experience discomfort into this area
• Differentiating between true hip pain and pain radiating from the lower back
• Why you should expect to get an anatomy lesson as part of your treatment!
• Why many patients experience referred pain when they’re suffering from a low back injury
• Why true hip pain, and injury, is rare particularly amongst younger patients
• Some of the clinical tests that you should expect to experience when being examined for hip pain
• Some of the exercises that help to stimulate, and train, the muscles of the buttock which provide support to the lower back

Show Highlights

The hip joints provide a powerful platform for supporting the low back and due to the stability of the joints are rarely injured in isolation. Often the discomfort patients experience in the hip joint are a result of referred pain from the low back, so it is important that we do not focus in on the symptoms alone when trying to manage pain of this nature. Be sure to challenge any healthcare professional that ignores the lower back when your primary complaint is discomfort in the hip or groin. This holistic approach to examination is important to direct an effective treatment plan for the underlying issue.

Interview Transcription

Unknown Speaker 0:00
When we’re young, we move with freedom and confidence with a great resilience to injury. But somewhere along the line we develop poor habits and become more vulnerable to back pain. Back Pain solutions 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 back health through movement. 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.

Ben James 0:27
Okay, welcome back to the back pain solutions podcast Everybody with me, Ben James. And as always my co host Jacob stain, today we’re talking hip pain, or is it hip pain? Is it back pain? Is the hip pain being referred from the back or vice versa? This is often a question that we get asked by patients or certainly a symptom that we see from patients experiencing back troubles that they experienced some hip pain as well. This specific episode, we decided to create because of a listeners comments and email to us. Derrick from the US. Thank you for the feedback. Thank you for the review. And thank you for posing the question because it is an interesting topic for discussion. So as always, before we start, take advantage of our ebook, get on over to our website, w w w dot smart, strong co.uk. Download the ebook, start taking back control of your back health and your back pain today so you can get back to the activities that you love. So Jacob, hip pain, this is often a bit of a confusion, a bit of a confusing topic for patients because sometimes they will kind of focus on that hip pain or they come in with hip pain and if we’re just been symptom based, then we can get led down a track of focusing on the hip and undiscounted in the lower back and that often seems to be how some patients come in to see us. They’ll have seen other practitioners that are focused on the hip, but actually the problems the problems in the low back. Do you see the same things?

Jacob Steyn 2:01
Yeah, exactly. And I think that’s where a lot of people because you know, a lot of people have the idea that the hip is the hip joint itself sits on the side of the body, you know, on the side of the upper leg here, next to the glute muscles. And I think a lot of the confusion is, be it’s easy to solve the confusion by understanding the anatomy. And that’s what I usually do with my patients, I, I first go into telling them exactly where they can find the hip joint, and that hip joint pain would actually present very different to what they’re feeling pointing to the side of the hip, you know, on the side of the glute, and so, just like you said, then they become then you have this big confusion or what is it exactly because, you know, it’s not a sharp pain. It’s not a it’s not a pain that comes specifically by using my hips, other than when you would have a hip pain or hip problem or real hip injury. But it would be maybe from walking long distances or sitting for a long time. And so then you should become a little bit suspicious to what isn’t it? What is the actual cause?

Ben James 3:23
Yes, yeah. No, it’s it’s a good point. I think it’s, it’s that kind of pattern recognition, isn’t it? But also, I think, quite often people kind of misunderstand where that pain actually is. And when they describe hip pain, it’s not it’s not necessarily their hip at all. So that’s a bit of an educational piece as well as always, that we, we discuss about the importance of the educational element from our side as practitioners and informing patients about about their anatomy and about their their health in general. And this is certainly one good example of that where that hip pain actually is more buttock pain. And it’s not not a deep kind of joint pain that you would expect from a true hip injury or a hip issue.

Jacob Steyn 4:09
Exactly. And so, you got to ask yourself, why do I feel it on the side of my buttock, side of my hip? And two, so we as as practitioners, we we look at pain in different ways. It could either be a local, locally cause pain, or it could be a refer referred pain. And yeah, and what you see often with this is it would be a low back injury that refers to the side of the buttock. You know, and it can also refer even more to the front wall to the side of the hip, but more to the front side of the hip. And that’s where we often get the confusion of hip pain instead of…

Ben James 4:55
Yeah, that kind of growing, growing discomfort is often communicated by patients?

Jacob Steyn 5:00
Exactly.

Ben James 5:02
And without going into too much depth, a lot of that is is down to the kind of neurology and whether the nerves exiting the spine and the tissues, whether it be the skin or other structures where they where they innovate where they supply that neural neurology. That’s where the body kind of gets confused. And that’s how this kind of referred pain works to in simple terms. So would you say Jacob, there’s a percentage of patients that you see that have got a back pain that have got hip pain as well? Or does it does it vary? Do you find?

Jacob Steyn 5:36
If we talk about true hip pain then I think I have seen people with real back injury and true hip joint pain, but they are very minimal. You know, it’s very seldom that I find a patient who has that and it’s either a real sports injury, very unusual, or you know, it’s someone on the On the side where they’ve got some arthritis, some degeneration at the hip, and now they’ve got low back issues as well.

Ben James 6:07
Yeah, I was gonna mention I was going to mention age because you know, with the hip is a hugely powerful stable joint. So if you if you are young and you haven’t had any significant injury, then yes, there are one or two more conditions that that directly affect the hip. But actually, if you haven’t had an injury then the likelihood of that pain being to true hip pain is is quite low, I would suggest

Jacob Steyn 6:36
Exactly. It’s a deep ball and socket joint very strong capsule, very strong joint and you know, this this joint can take a lot from from running long distances to squatting heavyweights. Of course, there’s a limit to it, you know, if you would make a repetitive deep squats and you start impinging the joint Too often, then you can have some problems. I’ve seen that as well. But in general, I think, you know, if we look at the biomechanics, we quite often have this typical pattern recognition as you mentioned Ben or a dysfunction that presents and that would be where we, we sit a lot, we don’t use our glutes or buttocks well enough and our hamstrings, the posterior chain, that suffers then becomes weak. And so now we go for a long walk, and we start getting or these muscles start, they start to want to protect the area, but they’re not used to the conditioning. And so they cramp up and so we have a cramped up buttock area. And so we don’t use the hip properly, and then we started giving more work to the low back and that just creates the dysfunction that we don’t want, you know, more work at the low back less at the hip. And, and that just gets worse.

Ben James 7:54
Yeah, so and, and on that note, we’re those that are suffering from back pain. There has been research to show reflex inhibition of some of those muscles in the buttocks particularly glute glute Meade, which is important stabilizer, you know when we’re walking when we’re doing key activities. So if you’re suffering from back pain, and then you’re going out for a long walk and those muscles aren’t firing on firing effectively, and there’s no insurance there already, then that cycle of kind of vicious cycle of compounding that problem becomes a problem because then you’re starting to use like you say, your lower back a little bit more in terms of a power generator for walking, which we definitely don’t want. The flip side is for those people that are sitting alone, or generally, our movements are very flexion based so that posterior chain is generally weak deconditioned in most of the population that are not focused on it or athletic or or training those, those particular muscles. And as a result of that, that can then lead to, to back issues. So weakness around the hip Then cause your lower back problems. So it is fundamentally a hugely important platform for one of a better term in terms of being the power generator. We’ve discussed this before in terms of movement patterns to keep the back in neutral and moving from the hip. But certainly, hip pain is often a symptom described by sufferers of low back issues, rather than it being like you say, Jacob, true, hip, problem, discomfort. So, on that note, what are some of the things that we could suggest to the listeners in terms of identifying hip pain versus lower back pain? Really, do we need some of those? Do we need some of those clinical tests? Can people self perform some of these tests at home just to try and understand or identify if it is actually coming from the hip or the low back?

Jacob Steyn 9:51
So the first thing I think that somebody has to do is to they’ve got a Realize that either the or they gotta do something to they’ve got to try to figure out whether it’s a back problem or a hip problem and it’s just all off. It’s very easy. You You just assess your back when you get up in the morning. So you do a slide, forward bending or backward bending or to the sides. Quite often at that time of the day, you’ll see that if you make those movements, you’ll get this like referral to either the buttock or to the front of the hip. That’s the first thing. The second thing you could pay attention to is to Is there any groin pain? You know, do you experience groin pain at some times real deep groin ache, sometimes it refers to the knee and this would indicate a real hip joint injury. I have patients as well. They go to across a gym, for example, and sometimes when they squat, they will actually feel pain in there. groin and this is very significant of a real hip joint injury. I think other than that, if you go to a therapist or clinician, then I suggest you have your glute Meade strength checked. So the clinician therapist can test the strength of your glutes and they should do some basic testing to see how it’s going with your back.

Ben James 11:24
Yeah, absolutely. I think that would be the key point, you know, don’t be if you are suffering from some hip discomfort and it is specifically the hip that you you feel is causing your pain then don’t go to a practitioner and and just accept them looking at that, that hip in isolation, you know, question, could it be coming from my low back could could have back problem cause that hip discomfort in it, and expect them to look at it holistically and to do the clinical tests to rule that out because i think that’s that’s good. To get you to where you want to be far, far quicker, far more efficiently if we’re looking at this holistically, looking at this as a, as a whole, and we would always do a hip screen as part of a low back examination and vice versa to in order to rule in rule out, hip pathology of any kind, so, be sure be certain Be confident to ask those questions and challenge your, your therapist your practitioner on that, on that area, because it is it is important and quite often, the hip discomfort is being referred from the lower back particularly if you’re feeling more buttock type of pain and often, that can be that can be a back issue groin is a little bit more difficult because because groin pain is often what people experienced with with true hip issues. But again, that can often be referred from from low back problems as well. So that becomes a little bit more difficult to identify. But again, clinical tests and a good history should elicit that information So be be confident to challenge your therapist and ask those questions and make sure that they are looking at your low back. And in terms of proactively doing things for, for the hips, whether you’ve got pain already, or you are trying to avoid discomfort or strengthen your lower back and strengthen your body as a whole. Some good exercises to start with Jacob you know, a very good one very low impact safe, keeps the back in neutral, but really starts to help people re engage with those, those glutes, typically, glute medius is the clamshell very simple, low impact exercise that’s very much focused on getting that muscle firing. Again, I think that’s something that everybody could do daily just to start challenging that muscle and get it, get it active and start to get that area function and property again, because as we say is such an important platform for sporting activities, endeavors but daily activities as well and protect Can you low back. So any other exercise other than the clamshell that would be a good one too just for people listening to start focusing on those buttocks focusing on the area to start to build that strength build that endurance.

Jacob Steyn 14:12
Two exercises I can think of the first one is the glute bridge. But I have to say, most people when I get them to do the glid, Glute Bridge straight off, tends to pull their low back hollow. So, you know, then I usually have to correct that. And so I, I want to what do you mean by that just just for people listening to you, are we talking arching the back egg overall? Exactly. So they arch that bully. In this case, we don’t want them to arch the back at all. Because any arching of the low back when you push your hips up and the glute bridge exercise, means that you’re, you’re using your lower back muscles instead of hinging at the hips using the glutes.

Ben James 14:55
Yes. So as always, we’re keeping that back in neutral. That’s that’s a mantra that we We’ll probably exhaust forevermore, but keeping that back in new driveline, and employing that brace of the of the abdominal muscles, as always is is a start to this exercise.

Jacob Steyn 15:12
But then I have to say for a lot of people, it’s going to feel like they’re twisting the hips forward. And in fact, they might be working very hard to twist the hips forward to maintain that neutral spine. In other words, not arching the low back. And so don’t be afraid of twisting your hips forward. And when you get to the top, not, not over arching the hip or not over, shooting with the hips. You want to really squeeze the buttocks and maybe hold it there for five seconds. That’s a great way to get the activation and the brain communicating to these muscles going.

Ben James 15:47
Yeah, and another little tip as well, for for people that attempt this, this exercise often, if your glutes aren’t firing effectively, maybe you’re a little bit more hamstring dominant which we want to avoid in terms of executing this exercise effectively, you can try and if you’re on a firm floor, just make sure you try and try and push those feet away from you a little bit. As you start this exercise that helps to switch off the hamstrings a little bit helps you to target those glutes, so that when you are pushing up, it’s coming from the glutes and less so from the from the hamstrings. I think that’s another important little tip that that helps people out with this with this exercise, particularly, and for people listening, how much would you in terms of sets in terms of repetitions in terms of holds, if they’re new to this exercise? We’re not going to hold too long?

Jacob Steyn 16:40
Three seconds. When that goes, Well, you go to five seconds, three sets of five repetitions on a daily basis. I think if you’re consistent with it, that’s where you really build up this communication to the muscle groups that you need.

Ben James 16:54
Yeah, and I think that I think that’s a key point. Again, you know, we’ve mentioned this before, but the repetition is important, don’t worry so much about, you know, just how many you’re doing on a daily basis or lifting heavy or all those things that that often we focus on when we’re when we’re in the gym or people focus on when they’re in the gym, they, they start to do these things and then kind of go too heavy go to extreme, you’ve got to be patient with these things. So being persistent and consistent is is the key. So focusing on doing the clamshells everyday line on your left hand side, and just lifting that, that right hip up, repeating that maybe 10 times during the left side, repeating a few times, then doing something like the glute bridges, as Jake has just described, try holding it for three seconds. First of all, as you’ve executed that efficiently find that easier, then increase that, that length of time that you hold it, but do it every single day because doing it every single day is what’s going to get those muscles firing effectively. And as you do that, then you can start to add more challenging exercises and over time Your your group create great strengthen those muscles, which is which is usually supported for the lower back, as we’ve said before. So, Jacob some of the clinical tests that people might experience as part of an examination just so they can be confident that that they are being viewed holistically by a practitioner. So can you describe some of the tests that you use maybe and we’ll just talk about that a little bit. So people have a bit of a sense of, of what they should be looking for when, when they go to see a therapist just to give them some idea.

Jacob Steyn 18:35
Sure. Somebody comes in to my practice, and they point to the hip, saying they’ve got this diffuse, spread out hip pain, then I have a big suspicion and I’m almost hundred percent sure that it’s not coming from the hip, but it’s actually referral from the low back. And so I want to show to them first of all, that it’s not a hip problem, because quite often they have a strong opinion that it’s coming from the hip Maybe they’ve been to a therapist before, telling them that it’s a hip problem and they’ve been treated for the hip and it just didn’t get better, for obvious reasons. And so, then I would do a hip scouring to see what is their hip range of motion is there any limited range of motion, and then I would apply a little bit of pressure with internal rotation of the hip and external rotation, some axial load and maybe some adduction compression so

Ben James 19:33
So just to describe that to listeners, what we’re saying here is you you’re going to be lying on your your back, and then generally they’re going to flex your your knees or bend your knee, and then we can take the side of the big bone in your in your upper leg and apply pressure in different directions in that joint. So 360 seconds. Look at it like a clock face. And we’re going to move that, that bone around the clock face and applying pressure and putting some tension in that joint just to identify if there is any signs of any hip pathology, something like maybe impingement, if you’re pushing, let’s say, Your, your right hip, across your body and applying some pressure there may be you’re starting to get that pain in the hip. If you’ve got something like impingement within that, that hip joint that may then start to suggest, well, it could be a hip problem. But if that scarring doesn’t identify or recreate any of that pain, then we’re starting to think that pains more likely coming from somewhere else such as the lower back.

Jacob Steyn 20:45
Exactly, right. So that’s the thing we we rule out first that there’s nothing going on at the hip and usually the hip is doing perfectly fine. So then we go to the low back and then we we will assess the low back, and I would Generally, if I think of referred pain, it’s quite often flexion based in other words, and that means that if someone’s flexing forward, they’re reaching towards the floor or they’re reaching to get something, they will feel something in the low back. So I’ll put them on a chair or on my bench, seated, have them slouched, really bad, apply bit of pressure, move their upper body to the left and right, a little bit diagonally forward, left and right. And see if there’s any referral going down to the buttocks or to the to the hamstrings, and then I will play a little bit further with some nerve tension straightening the leg or flexing the neck, you know, apply. So, getting the nerves to stretch a bit more from their exit points in the low back.

Ben James 21:49
Yes, yeah, we’re going to try to aggravate those structures a little bit in this scenario just to see if we cause that reaction and cause that that pain in into the hip. So all of these kind of clinical tests, in isolation on always very, very strong. But collectively, they should start to build up a nice pattern of where that structure is, is damaged or where that that problem is occurring. And really the point in it that the take home here is make sure that if you’re seeking out some support, and you seek out some help, that that practitioner is looking at not just your hip directly, but is looking at your lower back because if you are younger, if you had no significant injury, sporting or otherwise, then the chances are that it’s coming from somewhere else rather than the hip joint itself. But we should always rule out that hip pathology always see a clear history taken from the practitioner. So I always say be confident enough to challenge them to look at your lower back as well. If they’re just taking In a very much focused approach on on your hip in isolation, because that is that is under estimating the potential problem. And it’s it’s not the holistic approach we want to look for. But I think from a proactive point of view, focus on doing some of those exercises for for hip function for firing those muscles, because in today’s society, they, they’re just so so weak, so underestimated. And without a focus, you can be increasing your risk of, of issues. So, Jacob, anything else really, to add there? I think it’s it’s a fairly straightforward episode in terms of, you know, is it hip pain? Is it back pain, but I think we both agree, the majority of cases that we see that, that would describe hip pain are actually suffering back pain, rather than it being true hip pathology. So don’t be distracted by that. And make sure you get in a full picture of the issue going on.

Jacob Steyn 23:56
Yeah, so what I want to add then is that you know, When we talk about referral from the low back into the Buttocks, we, what I’ve seen is two different types of referrals. There’s the very strong referral and that might be a trapped or impinged nerve or irritated nerve and the lower back because of inflammation acutely already chronic and that would be something you can call up by creating nerve tension and you’ll see it refer refer to the to the buttock or maybe even further down to the hamstrings or even further down towards the foot. But we also have this spread out, achy referred referral into the lateral side of the hip area and into the buttock, which could have different regions than a impinged nerve. And the big test for me often I mean, I I really have a good idea when I see people like this and I see a lot of them that presents like this. The big test is after one week when they come back and we’ve fixed their movement, we’ve looked and made sure that they, they limiting the movement through the low back so we can give an opportunity to heal. And we said, okay, we’re going to move more through the hips. We’ve done some relaxation exercises, specifically for the low back for the discs. And we’ve started with light glute activation, but also especially light core activation exercises. And the the thing that I see is when they come back a week or maybe two weeks later is that you know, generally it’s gone. So that that referral down maybe they still have a little bit of low back ache, now that they’re also aware of it. But the reality is that usually it’s a lot better or it’s almost gone. And that surprises them a lot then but then also understanding that they know what actually is going on. Now from there, we can build better patterns and better understanding And, you know, then they’re motivated to do something about it.

Ben James 26:03
Yeah. And again, I know I’ve mentioned it already, but they’re, they’re more kind of bought in to doing those exercises to build the strength building insurance to build the, ultimately the resilience to problems down the line because, unfortunately, the lives that we lead in the desks, desk jobs and the sitting and probably more sitting now people, a lot of people are working from home, it’s still it’s August 2020, as we record this episode, so a lot of people still working from home as a result of the COVID. So a lot of these people are just not using those those muscles as effectively as they should be. And that’s a really big problem. So if you’re listening and you haven’t been suffering, any significant issues then definitely worth proactively looking at some of these exercises, to start to build that resilience and start to train your body To work much more effectively, because if everyone was doing that, then we would be seeing Far, far lower rates of back pain and lower back problems. So, Jacob, thanks as always, guys, thanks for listening. Thanks. As always, for the reviews were that we’re getting, it’s all helping to improve the show give us a focus for the content that we create and share. As always, we really appreciate the podcast ratings that we’re getting over on iTunes. So please head over there, look up the back pain solutions podcast. If you’re listening to it on a different platform at the moment, give us a rating give us a review. It all helps. And as always, head on over to the website. You can contact us there with any queries, any questions, we can maybe answer those directly or answer them on the show, as we have done today, hopefully so thanks as always for listening and we shall speak to you again on the next show.

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