Treating Low Back Pain Through the Hip

As DC's, treating low back pain is our staple. Obviously, we treat much more than low back pain, but many people come to us for this complaint. A recent JAMA study found that low back and neck pain had the highest amount of health care spending, with an estimated $134.5 billion. The second leading cost was other musculoskeletal disorders, followed by diabetes.⁽¹⁾ Interestingly enough, another JAMA study broke down the expenditures even further and found that even though only 1.2% of patients received surgery, they accounted for 29.3% of total 12-month costs. Furthermore, this study also found early imaging led to greater expenditures as well. ⁽²⁾

LBP has many potential pain generators, causes, and history, but ultimately most LBP is the end result of dysfunction above and below the lumbar spine. This paper focuses on how the hips play a crucial role in helping patients with low back pain.

The lumbar spine has many potential pain generators, including the muscles, the facets, the ligaments, and the disc and nerve roots. Your initial assessment should be aimed at determining the pain generator and whether it can be alleviated. For example, if extension movements increase the person's LBP, then stressing the facets should be part of the exam to make a logical conclusion and treatment plan around decreasing pressure on the facets, which would be loaded in extension movements. In this example, your treatment would want to include distractive manipulations to open the facets and not extension based manipulation. Home care could consist of spine safe flexion based movements. However, if repetitive extension based end-range loading decreases peripheral symptoms and flexion movements or flexion based provocation movements increased peripheral symptoms, you would avoid symptom inducing flexion movements and add extension based active care into your plan.

However, many lumbar spine issues are the result of poor function above and below that area, and the hips are a big player in lumbar spine dysfunction. The assessments mentioned above are critical and should not be downplayed, but it should also be pointed out that this is mostly initial treatment while function is restored above and below the problem area (based on the assessment), which is the focus of treatment. The efficiency of the musculoskeletal system is shared motion throughout our joint system while allowing for maximal movement with the least amount of energy expended. In a nutshell, this means getting motion from our transitional areas (thoracolumbar spine, hips, foot/ankle, cervicothoracic junction) while stabilizing those core areas or areas in between (lumbar spine, mid-cervical spine, knee, shoulder).

An essential part of treating low back pain lies in our assessment of the hip. Here are 5 tests that may help you more effectively treat low back pain.

1. The Modified Thomas test:
   1. Sit the patient at the very end of the table. Have the table raised enough so the feet won't touch the floor. Ask them to hold the opposite knee to the chest and lie back on the table. The results:
      1. Knee and leg off the table with no external deviation – psoas muscle is hypertonic
      2. Leg is up and externally rotated slightly- tensor fascia lata/Iliotibial band is hypertonic
      3. Lower leg/knee is extended - Rectus femoris is hypertonic
2. Passive hip flexion test
   1. Lie the patient supine. Have them relax and guide the leg toward the patient's head. Keep them relaxed. Use a contact at the heel and just follow the natural path of the leg.
      1. If the leg/femur moves inward at any time, adductor hypertonicity is likely a compensatorymuscle (usually due to poor pelvic floor or lumbar spine stability).
   2. FABERE and Impingement tests:
      1. FABERE: With the patient, supine cross the involved-side foot over the opposite knee. Brace the opposite ASIS lightly and let the knee fall toward the floor (full ABDUCTION).
         1. Pain in the femoral-acetabular joint- Think hip labrum pathology
         2. Pain in the back -Think SIJ pain generator (probably more specific for SIJ than hip)
      2. Impingement test: With the patient, supine cross the involved foot over the other knee and ADDUCT the leg across while stabilizing the involved-side ASIS.
         1. Positive for impingement or DJD with increased or immediate groin pain
3. Internal hip rotation test.
   1. With the patient prone, block the lumbar spine/sacrum, bend the knee to 90 degrees and allow the leg to fall out (internally rotate)
      1. NORMAL = 40 degrees of IR
      2. Less than 40 degrees with a SOFT end feel = SIJ and hip external rotator tightness
      3. Less than 40 degrees with a HARD end feel (usually <10 degrees)
         1. Under 50 with no history of trauma -> retroversion of the hip
         2. Over 50 or a history of trauma -> DJD of the hip
      4. 65-80 degrees of internal hip rotation
         1. Anteversion of the hip -> Instability of the hip
4. Hip Extension test.
   1. With the patient prone, ask the patient to raise one leg at a time and see where extension occurs immediately. The higher the leg goes, the less information you will get from this test. Ask the patient to only raise the leg an inch or 2 off the table.
      1. Look for erector activation. It is common to see one side dominate the activation regardless of the leg that is raised. This is likely the dominant compensation vertical chain.
      2. Look for immediate lumbar spine extension and where it occurs.
         1. This is the most unstable area and the most likely to develop spondylolisthesis or pars defects.

Along with these tests, you should also palpate the iliofemoral joints and thoracolumbar area for restrictions. Lumbar spine issues are almost always due to a lack of shared motion in the thoracolumbar spine and dysfunction (hyper or hypomobility) in the hips. The lack of shared motion and the compensatory activation of compressive muscles (erector spinae, posterior fibers of the quadratus lumborum, psoas, etc.) leads to excessive and repeated forces being fed into the lumbar spine. This leads to breakdown of the discs and compressive loading of the facets.

Based on these tests, you will be better able to formulate a treatment plan that incorporates more manipulation and soft tissue release (decreased internal rotation, modified Thomas test) or more stabilization/functional rehabilitation.

Corey Campbell, DC
MPI Vice President

1. JAMA 2020 Mar 3;323(9):863-884. doi: 10.1001/jama.2020.0734. US Health Care Spending by Payer and Health Condition 1996-2016.; Dieleman, Cao et al.
2. JAMA Netw Open. 2019;2(5):e193676. doi:10.1001/jamanetworkopen.2019.3676; Expenditures and Health Care Utilization Among Adults with Newly Diagnosed Low Back and Lower Extremity Pain.; Kim; Vail; et al.