Hip Spine Syndrome
Patient getting her hip massaged by physiotherapist
The Relationship Between the Spine and Hip
There is a biomechanical relationship between the hip and the low back, sharing multiple muscles that include the psoas, quadratus lumborum, erector spinae, and gluteus maximus among many others (1). Pain distributions reported for low back pain also has overlap with disorders from the pelvic girdle and hip (2). Thus, it is plausible that the hip joint can be the cause of low back pain (LBP). These muscles play an important role in the movements of the lumbar spine, movement in one area will cause compensatory movements at the others due to common attachment sites (1). This notion is termed regional interdependence.
The hip’s influence on low back pain is further supported when examining the 2 clinical prediction rules (CPR) developed for the low back, each containing one hip measurement that can indicate success with lumbar spinal manipulation (SMT)(1). One CPR for acute LBP identified success in patients with internal rotation of the hip of more than 35 degrees in one or both hips had increased likelihood of benefiting from SMT. The other CPR for lumbar-stabilization indicated that an SLR of 91 degrees were more likely to experience reduced disability at 8 week follow up (1).
What Is It?
Hip-Spine Syndrome (HSS) is a concept that described biomechanical influences that a pathological hip has on the lumbar spine through muscle lengths and joint forces (1). It is essentially the coexistence of hip and spine disorders (2). HSS is also considered a spectrum of disorders that can describe the onset of hip disorders prior to the onset of degeneration in the spine and hip (2).
HSS was initially proposed to subdivide patients into 3 groups, namely simple (either hip or spine was the source of pain), complex (hip and spine were both symptomatic and the source of pain), or secondary (dysfunction of one region was interrelated with dysfunction of the other)(2). An example of this is severe hip osteoarthritis leading to abnormal sagittal alignment, leading to LBP (1). This is further supported when examining decrease Oswestry Disability Index scores for LBP following total hip replacement in hip OA patients (1). Additionally, hip-flexion contractures can cause compensatory hyperlordosis in the lumbar spine.
How Does Hip Mobility Affect the Spine?
When examining patients with LBP and patients without, it is evident that those with LBP have asymmetrical hip rotation with internal rotation less than external rotation, and both were more limited compared to controls (1). A research report had found that patients with LBP had limited passive hip flexion and internal rotation compared to their asymptomatic control group (2).
This research report had also identified positive findings in at least 1 of 3 provocative tests for symptoms of pain in the groin, lateral hip, or buttocks (FABER, anterior impingement test, log roll test) suggesting that a hip-spine connection exists (2). Another study found asymmetries within symptomatic LBP professional golfers compared to asymptomatic golfers, noting that they had decreased flexion, abduction, external rotation (FABER), and internal rotation in the lead leg compared to the opposite leg (1). Hip external and internal rotation should be assessed at 90 degrees since this motion is most altered in patients with hip deformities or OA (2).
Evidence supporting the use of treating the hip for LBP is limited to case studies, case series, and 1 RCT. There is evidence that supports LBP is often accompanied with decreases in hip range of motion, hip extensor strength, hip adductor endurance, and hip flexor endurance.
What Are Some Treatment Options?
Physiotherapy and chiropractic are both great options to start with for the treatment of hip spine syndrome. Both types of professionals are musculoskeletal specialists and can help with your injury. A thorough analysis of your movement capacity is used to determine your unique treatment plan. Once diagnosed, the physiotherapist or chiropractor can then decide if myofascial release, spine mobilization or spine manipulation, acupuncture, or exercise is needed for you to reach full recovery. Massage therapy is also a great additional treatment that can be used to loosen up muscle tension that relates to this condition. Osteopathy may also be helpful in determining the relationship between your hip and spine and can be used to target the muscles of the hip and spine. Acupuncture may be used to promote local tissue healing through improved blood circulation and hormone release.
Which Hip Exercises Can Help?
Hip mobility exercises are often used to increase the active control of range of motion of the hip. Mobility differs from strength in their intended goal. Plainly said, strengthening exercises aim to increase the tissue tolerance to load. Mobility exercises on the other hand aim to increase the amount of control you have in a given range of motion and maximizing the amount of motion you have. By improving hip range of motion you may reduce lumbar spine or sacroiliac joint pain. Here are a few hip mobility exercises related to hip spine syndrome:
Banded Hip Scour exercise is used to increase the flexibility of your hip joint capsule. It can increase the range of hip abduction, external rotation and hip flexion all in one smooth motion
Supine Hip Internal Rotation is used to increase your hip internal rotation specifically in a hip flexion position. The floor is used to block the motion of the low back so that you can start to uncouple movement between the two regions
The World’s Greatest Stretch is a best bang for your buck exercise that works on hip extension in the trail leg and hip flexion in the front leg. Additionally it works on increase rotation through the spine in this deep split squat position
References
1. Reiman M, Weisbach P, Glynn P. The Hip's Influence on Low Back Pain: A Distal Link to a Proximal Problem. Journal Of Sport Rehabilitation [serial on the Internet]. (2009, Feb), [cited November 8, 2017]; 18(1): 24-32. Available from: SPORTDiscus with Full Text.
2. 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. Journal Of Orthopaedic & Sports Physical Therapy [serial on the Internet]. (2017, Mar), [cited November 8, 2017]; 47(3): 163-172. Available from: SPORTDiscus with Full Text.