The Hip bone's connected to the back bone...
You’ve likely heard this kids song before, simply guiding you through the body parts and how they are connected to each other. And guess what? It’s true! All of these body parts are connected. The knee bone’s connected to the, the thigh bone’s connected to the Hip bone, the hip bone’s connected to the back bone and so on… This post takes a look at how important the hips in relation to the lower back and how reliant the back is on the hips mobility and stability to create a strong centre in the body.
First comes the anatomy
The hip joint is made up of the femur bone which is the upper leg bone connecting into the pelvis which becomes the hip socket.
The major muscles of the hips are the Glutes which are made up of Gluteus Maximus, Gluteus Medius and Gluteus Minimus, the deep lateral rotators including Piriformis, superior/inferior Gemelli, Quadratus Femoris, Obturator Internus/Externus, Tensor Fascia Latae, Iliacus, Psoas Major/minor, Rectus Femoris and Sartorius. Wow that’s a lot of muscles.
Functions
Gluteus Maximus: Extends and externally rotates the hip.
Gluteus Medius: The gluteus medius is a bit of an over achiever as in it tries to do everything. The posterior fibres externally rotate and extend the hip, the lateral fibres abduct the hip and the anterior fibres internally rotate and flex the hip. The Gluteus medius also help to stabilise the hip when walking or running.
Gluteus Minimus: Abduct and medially rotate the hip
Piriformis: External rotation of the femur at the hip joint. When the thigh is flexed beyond 60° piriformis becomes an abductor and internal rotator of the femur.
Superior/Inferior Gemelli: External rotation, adduction and extension of the hip.
Obturator Externus: Lateral rotation of the hip joint; helps abduct a flexed thigh.
Obturator Internus: Lateral rotation of the hip joint; helps abduct a flexed thigh.
Tensor Fascia Latae: Flexes, medially rotates and abducts the hip.
Iliacus: With the pelvis fixed: Flexes the hip With femur fixed: Flexes trunk towards the thigh & tilts pelvis anteriorly.
Psoas Major/Minor: With hip fixed: flexes & may laterally rotate the femur. With femur fixed: Flexes the trunk towards the thigh and tilts the pelvis anteriorly. Unilaterally may assist in lateral flexion of the spine.
Rectus Femoris: Extends the knee and flexes the hip.
Sartorius: Flexion, lateral rotation and abduction of the femur at the hip. Flexion and medial rotation of the leg at the knee.
Hamstrings: Extend the hip and flex and rotate the knee.
Adductor longus: Adduction, medial rotation and flexion of the femur at the hip. Anteriorly tilts the pelvis at the hip joint.
Adductor Magnus: Adducts, medially rotates and Posterior fibres extend the thigh at the hip joint. Posteriorly tilts the hip joint.
Pectineus: Adducts and flexes the thigh at the hip joint. Anteriorly tilts the pelvis at the hip joint.
Gracilis: Flexes, medially rotates, adducts, flexes the thigh and anteriorly tilts the pelvis at the hip joint.
The trigger points in the muscles of the hip can also mimic back pain and even cause pain down the leg as in sciatica.
The hips don't lie
Who knew that Shakira was into biomechanics when she penned the hit song “the hips don’t lie”. The hips play a pivotal role in both back and knee stability, health and injury.
What happens if the hips are tight?
If the hip muscles are tight and/or the hip joints are restricted then the next joint will have to provide that movement. The next joint above the hips is the lower back and the next joints below the hips are the knees.
If the hip joints won't rotate then when you go to rotate your body more rotation will come from the lower back and this can then lead to back pain.
If the hips won't extend and flex then when you are walking or running you will find that extension and flexion will have to come from the lower back. Repetitive over extension on the lower back can end up degenerating the joints of the spine whilst repetitive flexion of the spine can result in damage and degeneration of the intervertebral discs leading to disc bulges or herniations.
What happens if the hips are unstable?
If the hips are unstable this means that the joints above and below will end up moving more than they should and can cause muscle imbalances, pain, joint degeneration and movement issues.
As in the picture, if the hips are unstable they will often drop out to the side when you walk, run, lunge or squat.
Trendelenberg gait
A trendelenberg gait means that when you lift on leg the pelvis drops down on that side and the pelvis shifts to the side of the leg that is on the ground. This is a sign that the Gluteus Medius on the side of the loaded leg is weak. This is one reason why it is important to strengthen the glutes.
If you have back pain check the hips
One over looked area when it comes to lower back pain is the hips. If your back is sore, often it is because it is being asked to do something it can't do and is now being overloaded or asked to move more than it should. The muscles of the back may become tight and overused if they are asked to lift more weight than they should, when the hips should be pulling their weight and taking more of the load.
Often when someone has lower back pain you will find a tightness or restricted range of motion in the external or internal rotation of the hips. As mentioned earlier, if the hips won't rotate then this rotation will have to come from the lower back or knees. Often releasing the hips will take a lot of pressure off the lower back.
Pelvic tilt
If your pelvis is tilting either anteriorly, lick a ducks bum or tucking under, like a flat back then this will put pressure on the spinal joints including the sacroiliac joint.
Anterior pelvic tilt will likely put more pressure on the lumbar spinal facet joints and sacroiliac joints.
Posterior pelvic tilt will put more pressure onto the discs.
Regional Interdependance
Regional interdependance is the relationship that one region of the body has on another, just like the hip bone’s connected to the back bone. Joints generally alternate between stable joints and mobile joints. The foot is stable, while the next joint above it is the ankle and it is mobile, then the knee is stable and so on. If the ankle is stiff and not mobile then it can cause issues with either the foot or the knee. We have another article just on that topic. You can click here to read it…
So what can you do?
A lot! Especially if you aren’t doing very much for your hips and have back pain. If have back pain and your hips are either tight or weak/unstable then getting them mobile, strong and stable will likely lead to a decrease in lower back, hip and knee issues.
Stretches and mobility
If your hips are tight a great mobility exercise is the active 90/90. This moves the hip joints through most hip movements so is a great daily hip exercise to keep the hips mobile. Some other stretches are the figure 4 stretch or the pigeon as well as glute stretches, internal rotator stretches, adductor stretches and hip flexor stretches.
Active 90/90
The 90/90 or active 90/90 is a great hip opener and warm up that gets the hip moving in most directions. Start sitting on the ground with right leg out in front with the knee bent to 90º have the left leg behind you also bent to 90º at the knee. Then rotate the left legs out and up and the the right leg up and out so you are sitting with your knees up and feet on the ground. Then drop the knees back down. Use your core to hold you up. Repeat 10 times then do on the other side with the Left leg dropping down.
Figure 4
This is one of the most common hip stretches and is known for stretching the piriformis muscle as the piriformis muscle becomes and internal rotator as it comes over 60º of hip flexion. This is how this stretch can stretch the piriformis, which is also an external rotator in the neutral position. Cross the right leg over the left knee. Thread the hands through the gap in the right leg and latch onto the left back of thigh. Pull knee towards chest. Hold for at least a minute. Pulling the left leg higher with each out breath.
Pigeon
Have the right leg bent to 90º in the front of the body with the right foot around the outside of the left hip. Have the left leg behind you straight on the ground. Press the hips towards the floor and breath deeply. As you relax with the out breath feel as though you can sink further into the stretch. If your back and hips are flexible enough you can lie over the front leg, getting a very strong stretch through the right hip. Hold for at least a mixture and up to 5. Using the breath to relax. Repeat on the other leg.
Hip flexors
Chair/couch stretch
Place right top of right foot on the edge of a chair or couch. place hand on hips or do it next to a wall if you need to hold on for balance. Lunge forward with the left leg whilst bending the right knee. You should feel a stretch in the front of the right leg. Tuck the pelvis under (posteriorly tilt) to increase the stretch at the front of the hip.
Psoas stretch
Get into a lunge stretch. With right leg back. Lunge far enough forward that your left knee is over the left heel. Take right arm up and over and tilt over to the left. You can also add some rotation to the right to open up the psoas more. Remember as always when stretching the hip flexors, you need to tuck the pelvis under into posterior tilt.
Adductors - Reverse Warrior
Stand with feet wider than hip width. Turn the right foot out 90º so it is pointing out to the right. Lunge out to the right keeping the right knee over the right ankle. Then slide left hand down left thigh lifting the right up back over your head. Hold for up to a minute and then repeat on the other side.
Internal rotators
Lie own your back with your knees bent to around 90º. Keeping the hips on the ground, drop the left knee inward and take the right heel outward. Try to drop the knee ads close the ground as you can. You should feel the stretch in the outside hip. You can place the Right foot on the left knee to help pull it over further. Hold for up to a minute using your full diaphragmatic breathing to help release further. Repeat on the other side.
Foam roller and massage balls
Target the lateral hip (outside) and also the glutes, hamstrings, quads, hip-flexors, ITB and calves.
Instability
If your hips are unstable then working on exercises that help to stabilise the hips is important. Exercises like the Monster walk for hip stability as well as lunges and step ups.
Monster walk
Place the band either around the knees or ankles or for a real challenge try both. Full legs apart to hip width, you should feel tension on the band at this point. Then step the right leg forward and out, then the left leg forward and to meet the right, hip width apart. Then step the left leg to the left and then the right to meed it hip width apart. Then step the right leg bak and out, then the left left to meet it. Then step the left leg back and out to the left and then the right leg to meet it keeping hip width apart. This is one rep. Perform 10 with control. Your Glute med and quads will be burning at the end of this.
Banded Lunge
Tie band onto a song fixed surface. Place around the thigh, just above the knee. Make sure the line of the band is in alignment with the knee. Pull far enough away that the band starts to pull the knee inwards. Use the outside glute( (remember good ole Glute medius) then lunge as normal keeping the knee from drifting inwards. Repeat 10 times on both sides and perform with control. You should feel this burn the glute medius and the quads.
Step ups
Find an appropriate height step or bench that is stable enough to take your weight and won't topple over.
Lift one leg and step up onto step, then pressing down with heel lift your body weight onto this leg trying to engage the glutei on the step and step up, lifting the other leg into a high knee. Hold for 2 seconds and then take the leg back down slowly and with control, try not to wobble too much. Repeat 10 times and then 10 times on the other leg.
Treatment
Massage therapy and dry needling to the hips is a great way to release them. The hips are notorious for having trigger points in them so having a practitioner assess and treat the hips will be essential to getting you out of pain. And then the exercises can begin to get you strong and stable.
So there you have it, if you are having back or back pain then you really need to check the hips to see if they are mobile and stable. As always, let us know what you think of this article and get in touch if you need help with any back pain or hip dysfunction.
