Lower back pain is the single most common musculoskeletal complaint in the world. Up to 85% of the population will complain of low back pain at some stage in their lives. It is also the 3rd most common reason people will visit a GP.
Lower back pain can be broken into 2 broad types.
Central Low Back Pain – pain that does not dominate one side and is experienced generally across the entire lower back region.
Unilateral Low Back Pain – pain that is experienced on one side only.
It is this second that we are going to talk about.
Whilst there are other possible causes of unilateral low back pain, the most common cause we see is actually the hip. The reason is that when we load the lower limbs in tasks such as getting out of a chair, walking, running, climbing stairs, this load is transferred from the ankle, through the knee, then to the hip and then finally the lower back. If the hip is not functioning optimally, this load will bypass the hip and be transferred straight into the lower back on the same side.
Because the hip has significant movement in all 3 planes (forwards, backwards, side to side and rotation) it plays a much more complex role than the ankle and knee which move predominantly in 2 and 1 planes respectively. Back pain on one side can also be attributed to the ankle or knee but these are less common causes.
What does the evidence say?
Sadeghisani and colleagues in 2015 conducted a review of all the published literature of hip range of motion and its relationship to low back pain. They concluded that hip range of motion testing, particularly hip internal rotation, should be a standard, routine part of an examination for patients with low back pain.
Eyvazov and colleagues in 2016 conducted a study on 28 patients booked in for a hip replacement found that their concomitant lower back pain was reduced by 50% after their surgery.
A study earlier this year by Prather and colleagues on 101 patients with low back pain found that those with positive hip examination findings (predominantly reduced hip flexion and internal rotation range of motion), had more pain and poorer function compared to those with normal hip findings.
Sorenson and collegues (2016) found that asymetrical performance of hip abduction (moving the leg out to the side) was a significant risk factor for people that get low back pain when standing.
How do we find out if your hip is the problem?
There are 2 parts to the assessment.
Assessment of your lumbar movements in positions that you have reported to be a problem. For example if you get your pain during or after running, then we’ll get you on the treadmill to have a look at what happens around the hip when you run. If you get the pain simply getting out of a chair, then we’ll examine that movement. We will often find that due to reduced hip function, there are abnormal compensatory movements that occur in the lumber spine.
Assessment of hip strength and range of motion on the same side. Often if the pain is related to the hip, there will be deficits in either strength or range of motion or both, on the same side as your pain. Studies show that the 2 most important movements to assess are hip flexion and hip internal rotation.
If you are suffering from lower back pain one one side then don’t be afraid to get in touch with us to have your hip checked out.
Ellison JB, Rose SJ, Sahrmann SA. Patterns of hip rotation range of motion: a comparison between healthy subjects and patients with low back pain. Phys Ther. 1990; 70(9): 537-541.
Chesworth BM, Padfield BJ, Helewa A, et al. A comparison of hip mobility in patients with low back pain and matched healthy subjects. Physiotherapy Canada. 1994; 46: 267-74.
Eyvazov K, Eyvazov B, Basar S, Nasto LA, Kanatli U. Effects of total hip arthroplasty on spinal sagittal alignment and static balance: a prospective study on 28 patients.Spine J. 2016 Nov;25(11):3615-3621. Epub 2016 Jul 15.
Prather H, Cheng A, Steger-May K, Maheshwari V, Van Dillen L. Hip and Lumbar Spine Physical Examination Findings in People Presenting With Low Back Pain, With or Without Lower Extremity Pain.Orthop Sports Phys Ther. 2017 Mar;47(3):163-172. doi: 10.2519/jospt.2017.6567. Epub 2017 Feb 3.
Sorensen CJ, Johnson MB, Norton BJ, Callaghan JP, Van Dillen LR. Asymmetry of lumbopelvic movement patterns during active hip abduction is a risk factor for low back pain development during standing.Mov Sci. 2016 Dec;50:38-46. doi: 10.1016/j.humov.2016.10.003. Epub 2016 Oct 13.
Sadeghisani M, Manshadi FD, Kalantari KK, Rahimi A, Namnik N, Karimi MT, Oskouei AE. Correlation between Hip Rotation Range-of-Motion Impairment and Low Back Pain. A Literature Review.Traumatol Rehabil. 2015 Oct;17(5):455-62. doi: 10.5604/15093492.1186813.
These are some simple progressions that can help for those who have difficulty going up stairs. Start with option that is best suited to your ability level and then progress through each of the exercises until you are ready for stairs!
Here are a few different exercises that can be used to strengthen the core at home – no equipment required!
The exercises range in their difficulty so find an exercise that you can do quite comfortably and then progress onto harder variations.
Remember, core strength is NOT associated with reduced risk of lower back pain. In fact, many people with lower back have an OVER active core, not an underactive core.
If you find these exercises exacerbate your back pain, stop and choose an exercise that doesn’t. If you’re still getting pain, discuss with your physiotherapist and they will be able to tailor exercises that will help improve the problem.
Hip bursitis or “trochanteric bursitis” has historically been used to describe pain on the outside of the hip. Recent research has found that only 20% of individuals presenting with pain on the outside of the hip have bursal thickening on ultrasound (Grimaldi & Fearon, 2015).
Whereas changes in the gluteus Medius and gluteus minimums tendons are much more commonly observed on scans. Bursal changes are now known to be an incidental finding, with bursal swelling occurring as a protective mechanism to reduce damage to the tendons. As such, hip bursitis is now referred to as gluteal tendinopathy and is recognised as the primary cause of pain and tenderness on the outside of the hip that may extend down the outside of the thigh.
Who gets it?
Gluteal tendinopathy affects 10-25% of the population and is experienced by one in four women aged over 50 years (Mellor et al., 2018).
Females tend to be at the highest risk of developing the condition, with a 4:1 ratio compared to males. Clinically, it is also commonly seen in runners and those with prior hip injuries or hip surgery.
Why does it occur?
Gluteal tendinopathy occurs as a result of repetitive compression of the tendons against the greater trochanter (the bone you can feel on the outside of your hip). Repetitive loading of the gluteus Medius and gluteus minimums can overload these tendons, as they are unable to adequately withstand the demands placed upon them.
Continually applying excessive load to the tendons progressively worsens the condition, as small micro tears occur in the tendons causing inflammation, pain and dysfunction.
Typical activities causing compression and irritation of the gluteal tendons include running, walking upstairs, crossing the legs or sleeping on the affected side at night.
How do I know if I’ve got Gluteal Tendinopathy?
Gluteal tendinopathy is characterised by pain on the outside of the hip and outer thigh. Typically people with gluteal tendinopathy experience at least one or more of the following symptoms –
Pain sitting with crossed legs
Pain going from sitting to standing
Pain with prolonged standing or pain standing on the affected leg
Pain going up stairs
Pain with walking/running
Difficulty lying on the sore side at night
Hip Bursitis causes and exercises
How did I get it?
Gluteal tendinopathy can develop due to a number of contributing factors such as –
Muscular weakness (glutes)
Commencing a new activity e.g. gym, vigorous walking
A recent increase in training load
Biomechanical abnormalities e.g. over striding
How do I fix it?
The first stage in managing gluteal tendinopathy is to control pain by minimising the compression on the greater trochanter and managing load on the tendons. Depending on the severity of the condition, this may involve temporarily limiting aggravating activities such as running and stairs, to enable healing and allow time for symptoms to settle.
Once symptoms are better controlled, overwhelming research evidence supports commencing strength training of the gluteal muscles. Studies have shown significant strength deficits of the hip abductors (glute med & glute min) in individuals with gluteal tendinopathy, with those who had gluteal tendinopathy being 32% weaker on the painful side and 23% weaker on the non-painful side (Allison et al., 2016).
Tailored strength programs targeting these muscles can effectively improve pain and restore function, by increasing the capacity of the tendons to cope with the demands of everyday activities.
The good news is the majority of individuals who undergo a progressive strengthening program will recover from gluteal tendinopathy within 3 months.
Two Best Exercises for Hip Pain
What to avoid?
To prevent further irritation, it is necessary to reduce compression of the tendons. This can be achieved through the following management strategies –
Reducing time with legs crossed
Not ‘hanging’ on one hip in standing
Reducing stride length when walking
Using a rail to climb stairs and placing feet wider when walking up stairs
Avoiding stretching of the glutes
Placing a pillow between the knees when sleeping on the side
Should I get an Injection for my hip bursitis?
Corticosteroid injections have traditionally been used to treat help manage pain in gluteal tendinopathy, however recent evidence suggests they may actually prolong recovery.
A 2018 Australian study comparing individuals with gluteal tendinopathy who received corticosteroid injections to those who underwent strengthening exercise, found exercise to be superior both in the short and longer-term. While both groups had similar reductions in pain at both 8 and 52 week follow-up, the exercise group reported a significantly better global improvement in function than corticosteroid injection use (Mellor et al., 2018). Thus, exercise is considered the current cornerstone treatment for non-surgical management of gluteal tendinopathy.
Take home messages:
Gluteal tendinopathy (previously hip bursitis) is an overload problem related to activity
It is reversible and can be improved with non-surgical management
Corticosteroid injections may prolong recovery
STRENGTH training is best!
Allison, K., Vicenzino, B., Wrigley, T. V., Grimaldi, A., Hodges, P. W., & Bennell, K. L. (2016). Hip Abductor Muscle Weakness in Individuals with Gluteal Tendinopathy. Med Sci Sports Exerc, 48(3), 346-352. doi:10.1249/MSS.0000000000000781
Grimaldi, A., & Fearon, A. (2015). Gluteal Tendinopathy: Integrating Pathomechanics and Clinical Features in Its Management. J Orthop Sports Phys Ther, 45(11), 910-922. doi:10.2519/jospt.2015.5829
Mellor, R., Bennell, K., Grimaldi, A., Nicolson, P., Kasza, J., Hodges, P., . . . Vicenzino, B. (2018). Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: prospective, single blinded, randomised clinical trial. Br J Sports Med, 52(22), 1464-1472. doi:10.1136/bjsports-2018-k1662rep