Back pain on one side? It could be coming from your hip.

by | Sep 2, 2021 | Back Pain, Hip, Low Back Pain

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.

  1. Central Low Back Pain – pain that does not dominate one side and is experienced generally across the entire lower back region.
  2. 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.

  1. 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.
  2. 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.

Book online at clinicalphysio.com.au

Or alternatively send us an email here and ask us a question.

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.

 

Ankle dorsiflexion knee to wall measure for squat

How to Treat and Manage Stiff Ankles

If your ankle mobility isn’t up to par, the next steps depend on the source of the restriction. Generally, if the limitation is felt at the front of the ankle, it may be due to joint-related issues.

  • Banded Ankle Mobilizations: This technique involves using a resistance band tied to a stable surface while performing ankle flexing exercises on a step. Check out this quick helpful video for guidance.

Conversely, if the tightness is located in the back of your ankle around the Achilles tendon region, consider:

  • Contract/Relax Stretches: A simple exercise like the bent-knee calf raise can effectively relieve restrictions in this region.

Lastly, for an immediate solution, consider using a wedge or support under your heels during a squat. Two papers from The Journal of Strength and Conditioning Research have shown that wedges can enhance squat depth without negatively impacting biomechanics. While some may see this as a “cheat,” the science supports it. If you struggle to achieve that 12 cm in the knee-to-wall test and find it challenging to squat low, use that wedge!

Hip Range of Motion

How Much Flexibility Do I Need and How Do I Test It?

For effective squatting, studies have determined that achieving 125 degrees of hip flexion is necessary—this is 35 degrees beyond a right angle. To test your hip mobility, you can use an inclinometer available on your iPhone. Simply follow these steps:

  1. Lie down on your back with your legs extended.
  2. Place the inclinometer length-ways on your thigh,
  3. Gently lift your knee towards your chest to measure the maximum angle, without moving the opposite leg.

     

    measuring hip flexion

    How to Treat and Manage Stiff Hips

    The hip joint is mostly passive during a squat, so if you’re experiencing limitations, it’s most likely due to an issue with the hip joint itself. There is up to 20% of the population that may be limited by the shape of their hip joint and the way it developed during childhood and adolescence. If that is the case, it makes if very difficult to improve the range of motion. Things like acetabular retroversion or a lower femoral head/neck offset ratio cannot be changed.

    For the rest of the population, here are some effective strategies for improving hip mobility:

    • Banded Hip Mobilisations: These exercises can help increase the range of motion in your hips by stretching and mobilizing the joint. Look for a demonstration in this video.
    • Inner Range Hip Flexor Strengthening: Strengthening your hip flexors can counteract tightness and enhance your ability to squat lower.
    • Like with ankle mobility, adding a heel wedge can help. By elevating your heels, you may experience a reduction in trunk forward bend, minimizing the hip flexion required and facilitating a more comfortable squat position.

    Conclusion

    Mastering a deep squat requires more than just strength; it hinges on sufficient ankle and hip range of motion. The studies from 2015 and 2022 have made it clear: flexibility in these joints is paramount for optimal performance.

    By regularly assessing your mobility and implementing these targeted exercises and techniques, you can improve your squat depth, enhance your overall strength training, and reduce the risk of injury. Remember, every body is unique, so listen to yours and adjust your approach accordingly. Happy squatting!