Friday, October 25, 2013

Manage LBA & SIJ pain by Hip intervention

Crucial role of hip in Hip-spine syndrome

Cervical & dorsal spine can produce lumbar spine pain along with lower extremity pain that may mimic sciatica. Similarly muscle imbalances & hip capsular problems may produce SI joint & lumbar spine pain with radiating symptoms in the lower extremity.

In the following article we are trying to focus on hip producing spine & SI joint problems producing radiating & non-radiating symptoms.

Concomitant presence of hip & spine problem named hip-spine syndrome is reported in medical literature but amount of research in this area is scanty. As relates to physiotherapy it becomes difficult to chuck out action plan as every bit of physical intervention must be directed to exact tissue at fault. What causes what, hip gives rise to spine fault or vice versa is yet to be concretely ascertained. Burns SA et al (2) found joint mobilization/manipulation and strengthening exercises directed at the hip alleviates both hip & lumbar spine pain. They have concluded patients with lumbopelvic-hip pain respond favorably to manual therapy and exercise targeting regions adjacent to the lumbar spine and further individuals with a primary complaint of LBP with hip impairments may benefit from interventions to reduce hip impairments.

Many crucial hip joint functions are maintained by pelvifemoral muscles during static & dynamic functions. Hip also has a strong capsule that may suffer from tightness & contracture which may further affect muscle function of hip leading to altered biomechanics of pelvic & lumbar spine producing pain in the mentioned areas. As mentioned above hip mobilization may not only alleviate lumbar spine pain it may also improve muscle function & capsular flexibility. According to Howard M et al (3) use of grade IV non-thrust mobilization improves hip abductor strength immediately post-intervention in healthy individuals assumed to be because of stimulation of mechanoreceptors. In a study by Yerys et al (4) it is revealed that a significant increase in gluteus maximus strength in response to Grade IV P-A mobilizations performed on the anterior hip capsule. Clinicians can utilize these findings in everyday practice to improve muscle strength by integrating manual therapy with therapeutic exercises.

A review of biomechanical prospective of spino-pelvic organization & lumbo-coxa chain in sagital plane:
i. Standing & static posture & lumbar spine curvature to pelvis:  Standing in an erect position is a human property (5). According to Mehta VA et al (8) relation of the pelvis to the spine is overlooked as a contributor to sagittal balance. However, it is now recognized that spinopelvic alignment is important to maintain an energy-efficient posture in normal and disease states. Sagital pelvic alignment is very much dependant on the hip joints. Similarly pelvis anatomy and position, defined by the pelvis incidence, interact with the spinal organization in shape and position to regulate the sagittal balance between both the spine and pelvis. Sagittal balance of the human body may be defined by a setting of different parameters such as (a) pelvic parameters: pelvic incidence (PI), pelvic tilt (PT) and sacral slope (SS); (b) C7 positioning: spino-pelvic angle (SSA) and C7 plumb line; (c) shape of the spine: lumbar lordosis. The genuine shape of the spine is probably one of the main mechanical factors of degenerative evolution. This shape is oriented by a shape pelvis parameter, the pelvis incidence. In case of pathology, this constant parameter is the only signature to determine the original spine shape we have to restore the balance of the patient.

ii. Bending & lifting: Bending and lifting activities are associated with injury to the lumbar discs and ligaments, and cadaveric experiments suggest that this damage is most attributable to a high bending moment (bending stress) acting on the osteoligamentous spine. Dolan P et al (6) examined the hypothesis that people with poor sagittal mobility in the lumbar spine and hips apply higher bending stresses to their spines during everyday lifting activities. They found all subjects flattened or reversed their lumbar lordosis when lifting, and most came close to or exceeded their static in vivo limit of lumbar flexion in many of the activities. The bending moment acting on the lumbosacral junction rose to about 30 Nm, which is about 50% of that required to cause injury in a single lift. Bending moments were significantly lower in subjects who had good sagittal mobility in the lumbar spine. Good hip mobility was similarly associated with a reduction in bending moment, but this reached significance only in subjects who reported a history of low back pain.

iii. Hip Lateral Rotation (HLR) test: Pattern of hip lateral rotation vary in different back pain suffers i.e. they move their hip differently (9). Linda R et al (7) examined whether lumbopelvic motion associated with a clinical test of active hip lateral rotation (HLR) systematically varied between people classified into 1 of 2 low back pain (LBP) subgroups: lumbar rotation (Rot) or lumbar rotation with extension (RotExt). And they further examined whether the timing of hip and lumbopelvic rotation with HLR would be more symmetric, right versus left, in people in the Rot subgroup compared with the RotExt subgroup.

They found People in the Rot and RotExt subgroups displayed systematic differences in how they moved the hip and lumbopelvic region with the clinical test of active HLR. These findings are potentially important because such differences in movement patterns between subgroups of people with LBP suggest different contributing factors and may require different treatments to affect the movement patterns. Here normalizing faulty movement i.e. hip lateral rotation may lead to alleviation of LBA. 

Patterns of hip contracture & it’s genesis: 
 Analysis of patterns in poliomyelitis reveals that fibrosis of gluteus maximus muscle may lead to limited flexion of the hips and various degrees of contracture of the abductor and external rotator muscles (1). In such cases affected hip could not be flexed in the usual sagittal plane, but had to be flexed in abduction. If gluteus maximus tightness & contracture is addressed excellent correction of the other hip contractures are achieved.

Sitting posture: In relaxed sitting posture hip rolls in to abduction & external rotation being flexed. This may lead to contracture of hip external rotators & abductors. That may also lead to tightness of posterior hip capsule.

If hip remains or maintains an abduction, external rotation position then there is compensatory pelvic posture for example iliac out-flare. Hence all of this may lead to altered dynamic sagital balance of the whole lumbopelvocoxa region which may further lead to a degenerative pathogenesis in any of the above.

1.    Patients with lower back or buttock pain that radiates into the posterior or lateral leg are often referred to physical therapy with a diagnosis of sciatica. Often the physical exam does not reveal neurologic findings indicative of radiculopathy. Instead, there is hip abductor muscle pain and weakness. This syndrome involves muscle imbalances that result in overuse strain of the gluteus medius and gluteus minimus muscles, Myofascial trigger points, and trochanteric bursitis. This paper describes hip abductor pain syndrome and provides a rationale for the diagnosis and treatment. Treatment salient points are discussed above (9).
2.    According to a case study by Boyle KL interventions to restore and maintain the optimal position of pelvis and hip (femoral head in the acetabulum) may be beneficial for treating patients with chronic LBP/SIJP. The patient’s pain may be alleviated in just a few days performing exercises to reposition the pelvis and restore posterior hip capsule extensibility and internal rotation (11) anterior interior chain pattern of postural asymmetry.         


1.    YS Hang; J Bone Joint Surg Am, 1979 Jan 01;61(1):52-55. Contracture of the hip secondary to fibrosis of the gluteus maximus muscle.
2.    Burns SA et al Physiother Theory Pract. 2011 Jul;27(5):384-97. doi: 10.3109/09593985.2010.509382. Epub 2010 Aug 26. Clinical decision making in a patient with secondary hip-spine syndrome.
3.    Howard Makofsky et al, J Man Manip Ther. 2007; 15(2): 103–110. Immediate Effect of Grade IV Inferior Hip Joint Mobilization on Hip Abductor Torque: A Pilot Study.
4.    Yerys et al; Journal of Manual & Manipulative Therapy, Volume 10, Number 4, 2002 , pp. 218-224(7). Effect of Mobilization of the Anterior Hip Capsule on Gluteus Maximus Strength.
5.    Roussouly P et al; Eur Spine J. 2011 Sep;20 Suppl 5:609-18. doi: 10.1007/s00586-011-1928-x. Epub 2011 Aug 2. Biomechanical analysis of the spino-pelvic organization and adaptation in pathology.
6.    Dolan P et al; Clinical Biomechanics, Volume 8, Issue 4, July 1993, Pages 185–192. Influence of lumbar and hip mobility on the bending stresses acting on the lumbar spine.
7.    Linda R. Van Dillen et al; Archives of Physical Medicine and Rehabilitation, Volume 88, Issue 3, March 2007, Pages 351–360. Symmetry of Timing of Hip and Lumbopelvic Rotation Motion in 2 Different Subgroups of People With Low Back Pain.
8.    Mehta VA et al; Neurosurgery. 2012 Mar;70(3):707-21. Implications of spinopelvic alignment for the spine surgeon.
9.    Dennis C et al; The Iowa Orthopaedic Journal, Volume 23 57. RATIONALE FOR TREATMENT OF HIP ABDUCTOR PAIN SYNDROME.
10.    Barbee E et al; phys ther.1990,70:537-541. Patters of hip rotation range of motion: A comparison between healthy subjects & patients with low back pain.
11.    Boyle KL. Physiother Can. 2010;preprint. doi:10.3138/ptc.2009-37. Managing a female patient with left low back pain and sacroiliac joint pain with therapeutic exercise: a case report.