Is Hip Weakness Contributing to Your Back Pain?

The hips and low back are closely linked by multiple shared muscles.  Contraction of these shared muscles will affect motion at the spine, pelvis, and hips.  Poor movement at one of these areas can create compensatory movement at the others because of the common muscle attachments.  Often, rehabilitation exercises targeting the abdominal and low back muscles result in only partial resolution of low back pain.  The missing piece may be addressing weakness of the hip muscles.

Research Shows a Link between Hip Weakness and Back Pain

Weakness or poor endurance of the gluteus maximus has been associated with low back pain in athletes and non-athletes.  Women with longstanding low back pain have smaller gluteus maximus muscles compared to those without low back pain.  Female athletes with low back pain show side to side differences in hip strength which may predispose them to compensatory movements.  Chronic back pain in men is associated with weakness of the gluteus medius muscle, elevated body weight, and tenderness in the low back region.   Weakness of the gluteus medius is often present in those who are limited in their ability to stand because of low back pain.

It is unclear if hip muscle weakness is the result of disuse or a cause of low back pain.  In either case, exercise targeting the hips is required to restore strength and proper movement patterns.  Many people with weakness of their hip muscles overuse their low back muscles.  Overactive low back muscles leads to fatigue, pain, and abnormal movement.  This results in a viscous cycle where abnormal movement results in more pain; and more pain worsens the compensatory movements.

A 2015 study in the Journal of Physical Therapy Science compared the effectiveness of low back and hip strengthening exercise to low back exercise only.  The group of people who exercised both the low back and hip muscles showed significantly greater improvements in back strength, balance, disability, and pain.  Another study in the Journal of Back and Musculoskeletal Rehabilitation also showed better outcomes in people who performed exercises for both the low back and hip muscles.  The following 5 exercises were included in the study.   Try these to get you started.

Clamshell

The clamshell strengthens the gluteus medius muscle.  Begin by lying on one side with the hips flexed to approximately 45 degrees.  The knees are flexed and the feet kept together.  A resistance band can be placed around the thighs just above the knees.   Start the exercise by rotating the top hip to bring the knees apart.  Hold this position for 2 seconds and then return to the start position slowly.  Be sure to remain lying completely on the side with one hip stacked on top of the other.  Allowing the pelvis to roll backwards during the movement is the most common mistake.   The clamshell is a great exercise to start with because it requires minimal activity of low back muscles.

Side-Lying Hip Abduction

Hip abduction strengthens both the gluteus medius and maximus.  Begin by lying on one side with the bottom hip and knee bent.  The top knee remains straight.  The top hip is maintained in neutral or slight hip extension with the toes pointed forward.  The toes are pointed forward to orient the hip in slight internal rotation.  This increases gluteus medius activity.  Initiate the movement by lifting the top leg about 30 degrees.  Hold this position for a count of 2 seconds and then slowly lower the leg to the start position.  Ankle weights can be added for resistance once 15 proper repetitions can be performed.

This exercise activates the gluteus medius to a greater level than the clamshell.  However, it is also more challenging to perform correctly.  Similar to the clamshell, it is important to remain completely on the side with one hip stacked on top of the other.  Allowing the pelvis to roll backwards during the movement is the most common mistake with this exercise.   Also, as the muscle tires, the leg will drift forward into hip flexion.  It is important to maintain the leg lined up or slightly behind the trunk and upper body.

Quadruped Hip Extension with Knee Flexion

Begin on the hands and knees.  The shoulders are positioned directly over the hands.  The hips are positioned directly over the knees.  The spine is maintained in a neutral position throughout the exercise.  Initiate the movement by flexing one knee to 90 degrees.  Next, lift the heel up towards the ceiling keeping the knee flexed.  Hold this position for 2 seconds then return to the starting position.  Lower the leg back down before repeating another repetition on the same side.  It is important to avoid arching through the low back.  Complete the desired number of repetitions on one side before beginning with the other leg.

Cook Hip Lift

Begin by lying on the back with your hips flexed and feet lined up with the shoulders.   Flex the hip by holding one knee to the chest.  It is helpful to place a small towel roll or ball in the crease of your hip.  Lift your toes off the floor and perform a bridge from one leg.  A common mistake is to excessively arch the low back.  Be sure to achieve the bridge position by extending through the hips.   Hold this position for 2 seconds then return to the starting position.  Lower the body back down before repeating another repetition on the same side.  Complete the desired number of repetitions on one side before beginning with the other leg.

The positioning of the hips during this exercise facilitates a neutral pelvis and low back position.  This is helpful for people with a history of low back pain.  However, this also increases the challenge to the gluteus muscles compared to a standard bridge.   Raising the toes makes you press your heel into the ground as you lift your hips. This facilitates the glutes and hamstrings.

Lateral Step Down

The step down exercise begins with the hands on the hips standing with one leg on the side of a step or 8-inch high box.  Maintain balance on 1 leg and slowly squat to lower the heel of the other leg toward floor.  Gently tap the heel and return to the start position.  Throughout the exercise the trunk is maintained in an upright position.  Avoid leaning the trunk to the side or waving the arms.  The knee should not move forward past the toes.  Also, the knee should remain over the toes so it does not cave inwards into valgus.  Perform 8 to 10 slow and controlled repetitions before switching sides to the other leg.

Closing Thoughts

It is important to exercise the abdominal, low back, and hip muscles to fully recover from an episode of low back pain.  These muscles do not function in isolation.  Not addressing muscles imbalances often leads to recurrent episodes of pain.  These 5 exercises address common hip muscle imbalances in people with low back pain.   In most cases, exercises should be individually prescribed based on a physical therapist’s examination of movement and strength.   Additional individualized exercises integrating multiple muscles with functional movement patterns are often beneficial to help people achieve their goals.