One of the most common scenarios we see as clinicians is when clients come to see us to help them with their “back pain”, when under close examination it is clearly an issue with their hip.
Why do the two often get confused when they are quite different parts of the body?
Both hip pain and back pain can cause very similar symptoms
When we hear the “story” of the client’s pain, back and hip problems (in particular femero-acetabular impingement) both areas can cause very similar symptoms. Both can cause pain when sitting. In the case of the lower back, sitting can put more pressure on the discs of the lower back, which is a common cause of lower back pain, however in regards to the hip, sitting “jams the hip up”, causing irritation of the hip joint. Hip joint pain, although often present at the front of the hip, is commonly felt in the buttock and area, mimicking back pain.
Other movements that cause both back pain and hip pain include:
• Standing from a sitting position
• Standing after a while
• Walking for a while
• Turning in bed
Finally, both back and hip problems can occur suddenly, with a specific movement (such as bending forward, irritating the discs of the lower back or loading up the muscles around the hip beyond their capabilities to take load) or gradually over time, with no specific incident triggering the issue. Surprisingly, hip arthritis can develop over years without pain, but it’s not until a particular trigger or event that it actually becomes symptomatic.
The muscles that support both the back and the hips are the same
Although the core stability muscles (multifidus and transversus abdominus) directly control the stability of the vertebrae of the lower back, the “power” and ability to resist load in the lower back is the role of the gluteal muscle groups around the hips and pelvis.
Therefore, when you lift something heavy off the ground or go running uphill, although the basic control is maintained by the core stabilisers, the strength to perform the movement comes the gluteal muscle groups.
The gluteal muscle groups are also the stabilisers and power muscles around the hips. Weakness of these muscles not only makes the lower back vulnerable to load and injury but also increases the load and makes the hip more vulnerable to injury.
A major part of the rehabilitation process of both the back and hips is improving both the stability of the lower back and improving the strength and control of the gluteal muscle groups around the hips and pelvis
It can be hip, back or usually both!!!!
A thorough examination of both the back and hip is needed to really determine the main reason for your pain or injury. However, it is not unusual for these injuries to occur concurrently.
A common scenario is that over time, there has been more and more degenerative changes in the hip. As a result, the muscles around the area become weaker and this leads to more load on the lower back, eventually causing injury in the lower back as well.
When we examine the lower back, if there is an injury, we usually expect to see either a change in movement pattern with repeated movement (when you bend forward in general with a disc issue in the lower back, the movement gets worse with repeated movement) and/or particular aspects of pain with movement (with facet joint irritation, bringing you backwards and over to that side will jam up these joints and replicate these symptoms). If the movement patterns are the same with repeat movement and there are no obvious signs that the facet joints in the lower back are being irritated, it is unlikely to be a direct back issue, even if it feels like the pain is coming from around the area.
Hip joint irritation is likely to be from two main sources:
• Impingement of the hip (femero-acetabular impingement) – When the hip is brought into a “quadrant” position (forwards, inwards and rotated), this can jam up the hip joint where the ball of the hip joint presses against the rim of the socket, causing pain. The aim of treatment in this scenario is to improve the glide of the hip joint to minimise this jamming occurring.
• Greater Trochanter Impingement Syndrome (GTPS) – As the tendon of the gluteus medius and minimus muscles travels over the bony ridge it attaches to (the greater trochanter), if it is weak, it can get irritated/torn or can irritate the bursa underneath it (this bursa, of small sac of fluid, present to minimise the irritation of this tendon on the bone, can get irritated itself and cause pain). This is due more directly to weakness of the gluteus medius muscle and causes pain when needing to perform exercises for a longer period of time that require stability of the hip, such as walking, running and walking up and down stairs. On examination, these muscles are usually directly painful on touch, painful and weak on contraction. This is often the classic scenario when it hurts to sleep at night on either the painful side or the other side (both positions compress and put the muscle on stretch, causing pain). The main aim of managing this issue is strengthening this muscle group to be able to take the load required for everyday tasks and your individual needs.
Where do you start?
It is the clinician’s job to work out whether your main issue is coming from your hip or your back (or both) and direct your program in the right direction. This may involve additional testing (x-ray examination of the hip is common to visualise the current state of the hip and see any basic degenerative changes) or more sophisticated examinations such as MRI to look directly for disc or facet joint issues in the lower back or tears in either the muscles around the hip (gluteus medius and minimus) or in the rim around the hip joint (labral tear).
Depending on the findings and suspicion of the primary cause of your pain, this will direct the most appropriate management of the issue (back, hip or both) for pain relief and functional outcome you desire.
Do you have any questions?
Call us on (03) 9857 0644 or (07) 3505 1494 (Paddington)Email us at admin@mdhealth.com.auCheck out our other blog posts hereOur clinical staff would be happy to have chat if you have any questions.
