How often do you have hip pain and think, quite naturally, that the hip is the source of the pain. Not true.
Pelvic rotation is the true cause of most hip pain. In Naprapathy we call this a Classic Rotation, where one side of the pelvis or the innominate bone, has rotated either forward or backward, and the corresponding opposite side must then move in the opposite direction. There is a series of events that are set up when this happen and I will try to illustrate.
First, however, I want to mention that there is no way of determining just HOW this all came about. It could be from how you sleep, how you get up out of your bed, or how you get out of your car. It could be because you sit too long or drive too long at one time. Perhaps you fell down as a child, or perhaps you were carried inside your mother’s womb in an odd position that set up this chain of events. It really is not important HOW we got this way. What matters is how we correct the rotation and can we get out of it and stay balanced.
Posterior Hip Rotation
This is a condition that is usually evaluated by your Naprapathic Doctor when you come in for an examination and treatment. The doctor will have you stand first, and check to see if your pelvis is even by looking at the spine from behind. He or She will place her hands on the top of each ilium and compare their height together. One side is usually higher. This could mean several things: either the Psoas muscle on that side is tight and therefore you are experiencing a hike of the leg up on that side, or the pelvis has rotated posteriorly on that side and the leg is also going to be short.
Next you will lie down and the same findings are looked at to verify if that hip is still high on the same side. Then the Deerfield Motion Reflex orthopedic test is performed, which will tell the doctor if this is indeed a Pelvic Pathology or if it is perhaps a Lumbar Pathology. In a Classic Rotation, it is Pelvic Pathology. So there is the beginning diagnosis and we proceed with this assumption based upon our findings. The Pelvis will look like this: The side of posteriority is going to be elevated, and that leg is going to be brought up and the heel will appear superior or higher than the other leg, and that leg will be considered the short leg. In DMR the doctor will look at the heels together while the patient is prone on the exam table. He will then bend the knees together and observe what occurs when the knees are bent. If the leg that was short, indeed stays short when the legs are bent, then this verifies the initial finding of a posteriorly rotated pelvis.
There is a corresponding anterior rotation of the opposite side of the pelvis, but that’s not all; the sacrum is also moving… closer to the side that is posterior. This is due to the pull of muscles, such as the piriformis muscle that attaches on the sacrum and on the leg bone. It also has a connection to the sciatic nerve which runs through it or near it, and therefore can cause nerve impingement on the sciatic nerve and pain. The pulling of the sacrum away from the other side of the hip will also cause pain at the sacroiliac joint, which is where most people get confused. The source of the pain is not the SI joint itself, that is just where the pain is felt. The pulling away of the sacrum causes the space to be compromised where the sacrum sits next to the hip bone and the nerves are being pulled. Nerves do not stretch and this triggers a pain fiber to fire and let you know there is something about to damage the neuron there.
All the muscles in the hip are involved. On the posterior side of the hip the hamstrings are shortened, tight and excessively strong, but also weak. Their shortened length takes away from the contractile filaments and makes the muscle easy to tear. Correspondingly on the front the quads are longer, but also trying to work harder so they are long and weak as well. The first exercise I would give patients is NOT to stretch the hamstrings that are short, but exercise the quads and make them stronger. This will begin the process of balancing out the length as well as the strength of these two opposing muscle groups. I would also include psoas stretches to help lengthen this very strong hip flexor that attaches from the lumbar spine to the leg bone.
The Psoas muscle may be the prime culprit in this entire scenario. Many things can cause the psoas muscle, a major hip flexor, to become tight and develop trigger points. Often diet can affect the nutrition to the muscle as with someone who drinks too many sodas in one day. Too much sugar will eventually get lodged into the muscle fiber causing it to fire without control. Usually it is posture related as with someone who sits in a car for long periods of time, or at a desk. I once had a patient who was knitting for hours and did not stand up. When she tried to stand up, not only did the muscle spasm, but it caused her sacroiliac joint to move out of its’ place and the pain was terrible.
The sacroiliac joint is affected because of several biomechanical faults happening at the same time. First the psoas muscle gets tight and shortens. Sherrington’s law states that a muscle will grow to its’ use. So by sitting for extended periods the muscle is used in a shortened state and does not lengthen to its’ full capacity any longer. The shortened psoas muscle causes the leg to be drawn up on that side and the hip also elevates. The psoas attaches to the lumbar spine along the anterior of each of the spinous processes of the lumbar vertebrae. It then travels down and attaches to the medial or inside part of the upper femur, not the pelvis. The pelvic bone on that side will rotate posteriorily due to the mechanics of this pull on the leg upward. In addition there is more space at the SI joint so the sacrum moves underneath the pelvic bone; thus pulling on the opposite side SI joint which is where the pain is felt and ultimately fibers tear. The piriformis muscle also gets shortened; it normally runs from the sacrum, from its anterior side to a downward angle and attaches onto the femur at the trochanter — the part of the hip that out to the side of our bodies. But with the leg drawn up this muscle will take a more horizontal plane which makes it shorter. With this muscle being shorter it is also very tight, and the sciatic nerve travels through it or under it, so you get nerve pain. We call this pain the “silver dollar sign” because it encompasses an area about the size of a silver dollar under the gluteus maximus muscle.
Muscles of the legs are affected as well. The posterior ilium causes the hamstrings to become short and weak, while the opposite side rectus femoris muscle is working hard to gain balance and it becomes weaker. The simple way to correct this, once the trigger points are removed from the psoas of course, is to exercise the quadratus muscles of the anterior thigh. This will in turn inhibit the hamstring muscles and they will lengthen, and balance is restored. However, deep massage of the psoas and deep hip stretches are required to lengthen the psoas on a daily basis holding the stretches for long periods.
On the side of pelvic anteriority the rectus femoris has become shorter and tight, but weak. The hamstrings on the back of the thigh are waging a battle against the quadratus muscles and they are now weak as well. To remedy this, have the patient work the hamstring group which will in turn inhibit the quadratus muscles and bring things back into balance.
I usually recommend some lumbar rolls to help the piriformis muscle and the iliacus muscle to lengthen, which will allow the sacrum to move back into the proper position of being the keystone of the pelvis.
On rare occasions you may have a lumbar disc bulging into the muscles of the low back which can be determined by an orthopedic test for that region. Several scenarios arise in the lumbar spine with a pelvic rotation. The L4 vertebrae could be rotated to one side, causing the ilium to rise and muscles in the low back will become tight and spasm. Or another lumbar vertebrae could be rotated to the opposite side but still causing the ilium to elevate and pain is felt across the entire waistline. When the piriformis muscle tightens down on the sciatic nerve pain could be felt down the back of the leg, but often it could be felt rising up to the low back. The site of pain is variable because the nerve fibers know to share the load lest they get damaged.
Any time numbness travels down into the leg, or the front of the lower leg, it is an indication of a disc bulge that is located in the low back. When the disc bulge is in the lower thoracic it will cause the belly button to deviate to one side due to nerve impingement. I have seen stomach muscles wiggle due to the muscle spasm caused by a nerve root impingement at thoracic spine eleven. We applied electric stimulation to the muscle known as Russian Stim and treated the back with Soft Tissue Work and the problem resolved. We literally exercised the muscle until it fatigued in order to break the spasm syndrome. Electric Stimulation is excellent for relaxing nerves.
I recommend a balanced action that is achieved with yoga postures. There is always a backward action to a forward bend, or one side and then the other in every pose. I use yoga as a therapeutic tool and give each patient no more than three poses at their first visit. These are the exact poses in a specific direction to help alleviate their pain. I enjoy teaching yoga, but these one on one sessions offer a great deal of long term relief to patients and keep their pain from returning.
It is generally a long battle to regain balance once the Psoas muscle has developed trigger points; it could take weeks, months or longer. Classical rotations are easier to treat especially if the pathology is isolated to the pelvic region, where lumbar pathologies are difficult but not impossible. These re determined through orthopedic tests we call Deerfield Motion Reflex. More on that at another time.
Remember, don’t sit for too long a time whether at the computer on in a car. Try not to slip and fall on the ice either. Stretch every day for at least 20 minutes, even in intervals, to keep all your muscles at their normal balanced length. You can quote me on this: “A lengthened muscle is a strengthened muscle.” And than Sherrington for helping us figure out this dilemma!
Yours in Health,