Thursday, April 17, 2014

It's all in the Hips

Part 1 of the Hip
Today's installment is about the hips. We hear a lot about back & knee pain, but many times it's the hips that cause and contribute to pain in those areas.  Here's what the National Institute of Neurological Disorders has to say about back pain; "Americans spend at least $50 billion each year on low back pain, the most common cause of job-related disability and a leading contributor to missed work. Back pain is the second most common neurological ailment in the United States — only headache is more common. Fortunately, most occurrences of low back pain go away within a few days. Others take much longer to resolve or lead to more serious conditions." 
The Hips are the linchpin of the lower half of our bodies, they help us move, dance, perform sporting activities and allow us to do daily living activities like bend over and pick up items. If we view our bodies as a moving chain, you could see how lack of movement in one area is sure to cause a increase in movement in an area close by. Therein lies the conundrum of modern life, for thousands of years our ancestors moved all day, seeking food, preparing shelter and defending those close to them. Fast forward to where we are today; where many of us travel hours for work, then spend the day siting at a workstation-- many of those who exercise do so in a seated position on cable driven machines--and to top it off we go home and rest, once again in a seated position.

We Live in a flexion based society.
Many of the problems we see in the clinical setting today have a element of muscle imbalance caused or contributed to by the summation of our daily activities. Our bodies are learning machines, they quickly adapt to whatever we expose them to, and in the case of the hip, if we leave it in a flexed position long enough (i.e. sitting) they tend to stay that way. When the hips can't move the compensation typically is the low back moving too much. This quickly overwhelms the low back which is designed for stability.

Exercise can actually worsen the problem.
Faulty movement patterns(secondary to imbalances) can actually feed the postural imbalances. For those who strength train, there's a tendency to focus developing the muscles we see in the mirror. Those muscles are situated in the front of the body, the same bad influence we get from sitting is accentuated in many of our work out routines.  To add fuel to the fire, running-a constant state of falling forward-contributes to muscle imbalances of the hip. 
Ask me how many runners I treat for knee pain...

What do we do now?
There's a renaissance occurring in rehabilitation, as clinicians we are looking for the weak link as opposed to to simply treating the source of pain. Marvelous movement screens have been developed to detect these postural disturbances.  I use this type of analysis more than orthopedic testing with miraculous results. None of my patients with low back or knee pain leave without corrective exercise strategies to address "the hidden problem".  What I try and get across to them, and hopefully you, is that these problems are a culmination of everything we do.  If lasting relief of an injury or pain is expected, modification of lifestyle AND activity need to be addressed on a semi regular basis. 
Tune in next time for some of my favorite strategies and corrective exercise moves, from the leaders of this renaissance movement. These activities have become a game changer in my personal and professional life.  
^^Now, don't be this guy. ^^
Consider what you can do to make a difference in how you move today-a simple idea such as replacing your office chair with a standing station or kneeling chair, but more of that in our next post. 

PART II of "It's all in the hips"
The body is a mobile object
The body needs to move in every direction to accommodate our daily living activities, as well as any other activities we put it through. Each portion of our body contributes to the overall movement , as each instrument plays it's part in an orchestra. The body will steal from adjacent joint to accommodate the movement. In rehab, we call this "substitution". It's a normal event that occurs all day every day with each of us, whether we are "in shape" or not so much. When substitution occurs, the hips refuse to move causing the lower back to move too much to accommodate it, the hips become what is essentially a "bad neighbor".

Everything in moderation is all right
We all need to sit, but altering the position needs to become a priority. Substitution in excess will lead to poor biomechanics, so it's important we do what we can to avoid letting the hips get stuck in that seated position. In my last entry we discussed hip mobility and the effects static positions have on the hips. Any body part left in the same position for too long will soon loose it's ability to move, because of neurologic motor control principles.  An extreme example is where a joint is cast/immobilized for weeks and the patient has little to no movement when it's finally removed.

Ergonomics; fitting the individual to the workstation
No two people are the same, each individual has unique needs and characteristics that must to be taken into consideration when dispensing ergonomic advice. In general terms, we can look at what ergonomic help we can get to lessen the effects of prolonged postures.

In a kneeling chair or in a perched position (sitting at the edge of your chair) we improve not only is the hip angle, but also restore the natural and beneficial low back curve. Another beneficial effect is the glutes will "turn on" in this position, as sitting typically turns the glutes off forcing other muscles to overwork in a majority of the lower back pain syndromes.  Other chair substitutes in the past have included sitting on a physioball, however a recent study showed no improvement in posture and an increase in discomfort.(1).  As we stated earlier, changing positions has been shown to decrease physical stress and improve pain patterns.  There are some wonderful apps you can use as a reminder to take a "micro break", 30 seconds to a minute to perform some yoga like restorative stretches. For those who are confined to a car; the seat back should be altered often to alleviate the stress being placed on the hips. 

Get up stand up
In a similar vein, standing work stations are now being offered for some when your doctor recommends them to your HR department. The newest of these stations are actually adjustable putting the user at an optimal position in either the standing, perched or seated position. OSHA provides these guidelines to standing work stations, in this example it's for food handlers but it applies to any type of work. (2).  
Next post we will be discussing active sparing strategies and corrective exercises of the hips and lower back. 

1.Stability ball versus office chair: comparison of muscle activation and lumbar spine posture during prolonged sitting.

Gregory DE1, Dunk NM, Callaghan JP.

PART III of "It's all in the hips" 
A Body in Motion Tends to Stay in Motion
In the last post we discussed what can be done to lessen the effects of postural strain and the resultant muscle imbalance that is silently causing or contributing to the back and knee syndromes.  We also need ACTIVE strategies to move well.  
The active strategies are called corrective exercises, they can be performed for just a minute (micro-break), as part of your "dynamic" warm-up, or in the cool down phase of your workout. The moment and duration you would perform these depends on individual needs, but it's hard to overdo these. Ask your qualified health/fitness pro for clarification or call upon us for specifics. These may look familiar for those of you with a regular work out routine, however why you're doing them may have been a mystery.
The Leg Lowering Progression
Here's a great exercise from Gray Cook, found in his book "Movement" (1), it promotes the amount one hip can move in relation to another. One may wonder why that's important, until we consider some sporting activities. Start with a supported (wall or partner) straight leg raise. The athlete should be pressing hard into the floor with the hands to lock in the trunk throughout the movement. Knees should remain straight, ankles dorsiflexed, hips neutral (watch for external rotation), and trunk is rigid.
The tall half kneel
This position is an essential step in our rehab progressions, and it's also a great way to strengthen with core integration, but it's use in this discussion is to promote hip extension. Hip extension is so critical to us all, it's especially absent in so many of my runner patients, so here's the fix. In performing the tall half kneel, form is everything, the upside knee and the downside knee are both at 90 degrees and the posture is lengthened (thus the tall). While maintaining the tall posture lean in to the front knee. 5 second pulses with a second break will restore some much-needed movement.  This courtesy of , an excellent resource for anyone that wants to perform better.

Tim Lincecum, a pitcher for the San Francisco Giants displays incredible hip "dissociation" which allows him to generate speed from his core, not his shoulder.

While we're not all MLB pitchers, the same principles that make these guys great in their movements help us be proficient at the activities we love.  The opposite is also true, if we lack this movement, it's part of the overall problem that leads to dysfunction and injury. Hiking, surfing, soccer, racket/club sports and many other activities rely on this essential movement to generate power from the core, without it we develop energy leaks and other parts that are related but not always close break down. 

The Dynamic Warm up
The latest research on warming up before your work out supports moving stretches done briskly and briefly. These new stretches are called dynamic warm ups. The general rule is 10 to 20 paces, moving in a range that is only slightly challenging. We're not looking for the deep burn you may experience in Yoga, this gets the ligaments, tendons and joints ready for activity. The warm up you choose should mimic the target activity.
These two activities are literally the tip of the corrective exercise iceberg, I don't want to overwhelm you, just provide a deeper understanding of the many options that are becoming popular in the world of rehab and sports science. Contact us with any questions and consider getting some instruction on activities such as these.

1-Cook, Gray. Movement: Functional Movement Systems ; Screening, Assessment and Corrective Strategies. Santa Cruz, Calif: On Target Publications, 2010. Print.

 Thanks so much for reading and if you think someone you know can benefit from this post, please share!
Dr. Gene Serafim

Dr. Serafim is a Rehabilitation and a Strength and Conditioning Specialist. He lives and works in the Exton PA area and has devoted himself to furthering his understanding of movement related disorders. He teaches continuing education and operates a private practice. More information can be found at and feel free to like us at our facebook page.

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