Strong Hips, Less Pain: Connecting Hip Strength to Chronic Low Back Issues

Low back pain is something that affects up to 80% of the adult population. It is the second most common reason for medical consults. Most low back pain will fall into the category of non-specific low back pain (85-95%), which is when anatomical or neurological causes are not identified. Pain can start from daily tasks, pathologies, weaknesses, genetic causes, or muscular imbalances. Low back pain can be triggered by other structures that are affected, such as stabilizing muscles, joints, discs, nerves, and other dysfunctions. Low back pain can be divided into five categories: mechanics (80-90%), neurogenic (5-15%), non-mechanical (1-2%), referred visceral (1-2%), and other (2-4%) (2).

When someone is experiencing low back pain, it can be a mentally, emotionally, and physically isolating experience. According to the World Association for the Study of Pain (IASP), pain is considered “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” (1). Most patients experiencing chronic low back pain developed it in one specific moment, or it developed over time due to work and life activities. When seeking help with low back pain, providers often tell patients they are told they need to rest, strengthen their core, and avoid movement. The core is typically defined as the front midsection of the abdominal muscles and deep core. However, when evaluating low back pain, the entire torso as well as strength and movement of the lumbopelvic hip complex must be included when developing a treatment plan.

To help gain a better understanding of the lumbopelvic hip complex, let’s look at the specific anatomy. This complex consists of the lumbar spine, pelvis and hip. The lumbar vertebrae are on top of the sacrum, which attaches to the ileum forming the sacro-illiac joint. The pelvis consists of the ileum, ischium, and pubis bones. The femur sits in the acetabulum of the pelvis forming the hip joint. There is a lot of musculature that either originates or inserts into this complex, assisting with the various ranges of motions that are produced from the lumbar spine and hip complex. Some main muscles involved in the hip complex include the rectus femoris, hamstrings, psoas, and glute maximus. This is not an all encompassing list, but maintaining the strength of muscles that originate from the lumbar spine and insert into the hip or muscles that originate in the hip complex is important. Low back pain may not originate from the lumbar spine directly, but can be caused by muscle tightness and weakness originating from the hip complex.

When it comes to improving movement quality and health of the hip complex, flexibility, mobility, and strength all need to be considered. There needs to be joint mobility to be able to go into all ranges of motion, the flexibility of the muscles to handle ranges of motion, and the strength to control movement in and out of those ranges of motion. Ranges assessed in the lumbar spine are flexion, extension, lateral flexion, and rotation, while in the hip complex there is flexion, extension, abduction, adduction, internal and external rotation.

To assess your own joint mobility, you can do the lumbar ranges of motion to see where you may feel tightness or limitations, as well as trying hip 90/90 rotations to assess internal and external hip rotation. Some ways to assess your flexibility are by doing hamstring stretches laying on your back, quadriceps, and hip flexor stretches. Ways to test your hip strength is by doing single leg exercises. With a single leg squat, squat as low as you are able to for five repetitions. While doing this, watch yourself in a mirror and see if you are sinking into your hip, dropping your chest, or your knee is caving in. For a single leg RDL, you want to look at if you are rotating your hips open, keeping the back leg and torso in a straight line, and if you are dropping your chest.

Working on all aspects of flexibility, mobility, and strength of the lumbopelvic hip complex can significantly help decrease chronic low back pain and improve daily life function. Having each individually is important, but improving all three is where a decrease in pain and an increase in movement quality will be seen.

With back pain, one may have developed an avoidance of movement patterns, specifically squat and hinge. However, both squat and hinge movements are shown to be beneficial patterns to help decrease low back pain and improve overall movement quality, when done properly and programmed appropriately. It is very important to follow a proper exercise progression to avoid further injury. Squat and hinge patterns both involve major muscle groups that have an attachment to the hip and pelvis complex. “Therapeutic exercise in low back pain would relieve pain, improve functionality, and reduce the risk of recurrence. It is necessary to consider the entire spectrum of different exercise therapies, including motor control exercises, balance, aerobic training, stretching, and muscle strengthening.” (1).

The body is made to move and wants to move. Movement is key when helping recover from injuries, there are times where rest is appropriate, but it should not be a long term solution. To build strength we start small, and with progressive overload are able to increase our strength and bodies’ resiliency to outside forces.

Hip and Low Back Joint Mobilizations:

• Cat/cow
• Thread the needle
• 3 way child’s pose
• Banded hip mobilizations-3 way
• Hip 90/90 rotations
• World’s greatest stretch

Soft tissue mobilization and Stretches:

• Foam roll: glutes, hamstrings, quadriceps, adductors, IT band, back
• Lacrosse ball: piriformis, glute medius, psoas, hip flexor
• Banded hamstring stretch or sciatic nerve glides
• ½ kneeling hip flexor stretch or couch stretch
• Adductor rockbacks
• Thomas stretch
• Figure 4 stretch or pigeon pose

Exercises to Strengthen hips:

• Clams/rev clams
• 4 way hip
• Lateral heel taps
• Glute bridge variations
• Banded hip flexor marches
• Kickstand RDL
• Monster walks
• Lunge variations
• Dead bugs
• Pallof press
• Bear crawl holds
• Hip airplanes
• Single leg balance
• Single leg squats
• Single leg RDL
• Squat variations
• Deadlift variations
• Cardiovascular activity: walk, bike, jog

References:

1. Santamaría, G., Rodríguez, I., Rodríguez-Pérez, V., Cobreros-Mielgo, R., Lantarón-Caeiro, E., Seco-Casares, M., & Fernández-Lázaro, D. (2023). Effect of hip muscle strengthening exercises on pain and disability in patients with non-specific low back pain—A systematic review. Sports, 11(9), 167. https://doi.org/10.3390/sports11090167

2. Aparecido Magalhães, R., Gabriel Bertoletti, J., Luísa Morais Amancio, A., Borges da Cruz, G., Delbim, L., & Martelli, A. (2024). Effects of strength training program in the treatment of chronic non-specific low back pain. International Seven Journal of Health Research, 3(1), 34–48. https://doi.org/10.56238/isevjhv3n1-006

3. de Sousa, C. S., de Jesus, F. L. A., Machado, M. B., Ferreira, G., Ayres, I. G. T., de Aquino, L. M., Fukuda, T. Y., & Gomes-Neto, M. (2019). Lower limb muscle strength in patients with low back pain: A systematic review and meta-analysis. Journal of Musculoskeletal & Neuronal Interactions, 19(1), 69–78. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6454257/

4. Natoli, A., Jones, M. D., Long, V., Mouatt, B., Walker, E. D., & Gibbs, M. T. (2024). How do people with chronic low back pain perceive specific and general exercise? A mixed methods survey. Pain Practice, 24, 739–748. https://doi.org/10.1111/papr.13354

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