Research Review: Low Back Pain and Its Relation to the Hip and Foot

By Amy Martinez DPT, PT

Edited by Brent Brookbush DPT, PT, COMT, MS, PES, CES, CSCS, ACSM H/FS

Original Citation: Cibulka, M. T. (1999). Low back pain and its relation to the hip and foot. Journal of Orthopaedic & Sports Physical Therapy, 29(10), 595-601. - ARTICLE

Introduction: Research has demonstrated a correlation between a loss of hip rotation range of motion (ROM) and low back pain (1-3). An asymmetrical loss of hip external ROM has been correlated with sacroiliac joint dysfunction (SIJD) (4-7). SIJD has been shown to increase the likelihood of other asymmetries, such as subtalar joint pronation (8-9). This 1999 case study by an American researcher demonstrates a relationship between SIJD , asymmetrical hip rotation ROM and subtalar joint pronation in an individual with unilateral LBP. This study may suggest that ankle, hip and SIJ dysfunction should be assessed and addressed in those with low back pain.

Caption: Dr. Brookbush cues an athlete through the "Integration Exercise", Resisted Walking

Resisted Walking - Example of a lower extremity "Integration Exercise"

Study Summary

Study Design	Case study
Level of Evidence	III Evidence from non-experimental descriptive studies, such as comparative studies, correlation studies and case-control studies
Participant Characteristics	Demographics Age: 35 yrs Gender: male Number of participants: 1 Participant was referred to physical therapy for recurrent unilateral low back pain with insidious onset Inclusion Criteria: Recurrent unilateral low back pain Asymmetry in hip rotation range of motion (ROM) between the right and left sides Exclusion Criteria: N/A
Methodology	Participant described his low back pain by completing a pain drawing, a pain scale rating and the Oswestry low back pain disability questionnaire An initial physical examination was performed by the researcher, including: Visual postural inspection, muscle tone observation and assessment of trunk active range of motion (AROM) Palpation of pelvic landmarks while standing, sitting and forward bending Manual muscle testing (MMT): Hip flexor and knee extensor muscles were assessed while sitting Hip extensor, knee flexor and hip medial and lateral rotator muscles were assessed while prone Straight leg raise, Faber and Thomas tests while supine Leg length assessed while supine, long-sitting and prone Manual compression and distraction of the sacroiliac joints Passive range of motion (PROM) assessment of hip ROM Sacral and lumbar spinous process spring tests while prone Based on the results of the examination, the participant was instructed to perform manual right hip medial rotation stretches and standing, weighted hip abduction strengthening exercises At the following intervals the participant returned for follow-up and in each session completed the Oswestry low back pain disability questionnaire and was re-evaluated; treatment was altered as needed: 2 weeks 1 month 3 months Re-assessment included bilateral feet AROM, PROM, MMT and Navicular drop test Change in treatment approach included use of "off the shelf" medial longitudinal arch supports 3 months and 10 days 1 year
Data Collection and Analysis	The Oswestry low back pain disability questionnaire was used to report the patient's perceived level of disability
Outcome Measures	Low back pain Oswestry low back pain disability questionnaire Pain rating scale of 0-10 Medial and lateral hip rotation ROM Subtalar joint range of motion Navicular drop test
Results	On initial evaluation, the participant was found to have a sacroiliac joint dysfunction A posteriorly tilted right innominate and anteriorly tilted left innominate were noted At 1 year follow-up, visual examination found both posterior and anterior superior iliac spines were horizontally level The Oswestry low back pain disability scores: Initial: moderate perceived disability of 38% 2 weeks: minimal perceived disability of 10% 1 month: no perceived disability 3 months: moderate perceived disability of 32% 3 months and 10 days: no perceived disability 1 year: not noted Hip PROM (reported as medial/lateral rotation in degrees): Left hip: 45/45 at all testing intervals Right hip: Initial: 20/70 2 weeks: 35/55 1 month: 35/55 3 months: 40/50 1 year: 45/50
Our Conclusions	This case study describes relationships similar to those described in Lumbo Pelvic Hip Complex Dysfunction (LPHCD), Sacroiliac Joint Dysfunction (SIJD) and Lower Extermity Dysfunction (LED). Further, the participant's unilateral pronation demonstrates the importance of a dynamic postural assessment, such as the overhead squat assessment, to determine the full extent of asymmetries and compensation patterns in those exhibiting signs of LBP and/or SIJD.
Researchers' Conclusions	In this case study, the participant exhibited low back pain and asymmetry in hip rotation ROM. Sacroiliac joint dysfunction with unilateral excessive hip lateral rotation and unilateral excessive subtalar joint pronation were demonstrated on the same side. These findings suggest a correlation between low back symptoms, hip and lower extremity dysfunction.

Overhead Squat Assessment demonstration of the sign "Feet Flatten". Dr. Brookbush demonstrates the excessive motion noted at the foot/ankle complex with his hands. Break down of the short and long muscles on the white board behind him.

Caption: Overhead Squat Assessment demonstration of the sign "Feet Flatten". Dr. Brookbush demonstrates the excessive motion noted at the foot/ankle complex with his hands. Break down of the short and long muscles on the white board behind him.

Overhead Squat Assessment - demonstrating feet flattening (pronation). (Image: Courtesy of www.BrentBrookbush.com)

How this study contributes to the body of research:

This case study on an individual with unilateral low back pain (LBP) examined hip rotation range of motion (ROM), signs of sacroiliac joint dysfunction (SIJD ) and subtalar joint position. Previous studies demonstrated correlation between low back pain (LBP) and SIJD , SIJD and asymmetry in hip external rotation ROM (4-7), SIJD and subtalar joint pronation (8-9), or LBP and excessive hip lateral rotation (8,10). Unique to this study, the researcher demonstrated that an individual with unilateral low back pain may exhibit all of these impairments. These findings may imply a correlations between LBP, SIJD , asymmetry in hip rotation ROM (specifically excessive hip external rotation) and subtalar pronation, or perhaps a compensation pattern that includes these signs and additional maladaptive changes in motion.

How the Findings Apply to Practice:

The findings of this case study imply that there may be an association between sacroiliac joint dysfunction (SIJD ), asymmetry in hip external rotation range of motion (ROM) and unilateral subtalar pronation. This suggests that individuals with unilateral low back pain (LBP) should be assessed for SIJD , asymmetries in hip ROM, and subtalar position/motion. Further, human movement professionals should be prepared (have a repertoire of techniques) to address any dysfunction noted at these three joints, despite the hip and subtalar joints being distal from the area of patient complaint.

The study had many methodological strengths, including:

The researcher used the Oswestry low back pain disability questionnaire as a functional outcome measure, enhancing the validity of the results.
The participant was observed for one year, providing both short-term and long-term results of the intervention plan.
The SIJD special test methods were common special tests and were clearly described; enhancing replicability of the study and clinical applicability.

Weaknesses that should be noted prior to clinical integration of the findings include:

A ‘gold standard’ for detecting movement dysfunction of the sacroiliac joint does not exist. SIJD movement assessment are heavily reliant on palpation, which may reduce reliability.
The researcher visually assessed trunk range of motion; an objective, reliable continuous interval measure (example, bubble goniometry) may have increased reliability.
This study was a single-subject case study; this is a weaker form of evidence that is likely best considered a potential finding that should be verified by larger studies.

How the study relates to Brookbush Institute Content

The Brookbush Institute (BI) has developed predictive models of postural dysfunction based on evidence of common tissue changes (muscle, joint, fascia and nerve) to aid human movement professionals in selecting optimal assessments, manual interventions and exercise. This case study describes relationships similar to those described in Lumbo Pelvic Hip Complex Dysfunction (LPHCD) , Sacroiliac Joint Dysfunction (SIJD) and Lower Extermity Dysfunction (LED) . Further, this study demonstrates the importance of a whole body dynamic postural assessment, such as the overhead squat assessment , to determine the full extent of asymmetries and compensation patterns in those exhibiting signs of LBP and/or SIJD.

The following videos illustrate common assessment techniques for the LPHCD and SIJD :

Overhead Squat Assessment: Sign Clusters – Lumbo Pelvic Hip Complex Dysfunction

Overhead Squat Assessment: Sign Clusters – Feet Flat Breakdown

Goniometry: Hip external rotation in prone

Goniometry: Hip internal rotaiton in prone

Stork Test: Special Test for SIJ Motion

Bibliography:

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Cibulka, M. T., Sinacore, D. R., Cromer, G. S., & Delitto, A. (1998). Unilateral hip rotation range of motion asymmetry in patients with sacroiliac joint regional pain. Spine, 23(9), 1009-1015.
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Rothbart, B. A., & Estabrook, L. (1988). Excessive pronation: a major biomechanical determinant in the development of chondromalacia and pelvic lists. J Manipulative Physiol Ther, 11(5), 373-9.
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Questions, comments, and criticisms are welcomed and encouraged.

Low Back Pain and Its Relation to the Hip and Foot