Chiropractic Exercise Low Back

and Hip Pain

 ending at the knee. "He said that whenever he lifted anything heavy, symptoms were worse. He also said that he particularly noticed pain in his lower back when he used the stripping machine to scrub floors," Dr. Bronston recounts. At first, these were the only problems the patient reported, but Dr. Bronston probed further, asking what happened when he exercised or moved his legs around. This elicited new information. For about six months, whenever the man rotated both hips or crossed his legs, both hips became painful, and the pain radiated into his buttocks. More and more lately, he added, he was awakening in the morning very stiff and finding it initially difficult to move his legs - or get out of an automobile, abdominal pain, arthritis pain, back exercise, back exercises, back injuries, back injury, back muscle, chiropractic treatment, bone pain, causes of pain, chronic lower back pain, hip arthritis, hip exercises, joint pain, chiropractic, left side pain, nerve pain

Those symptoms, although not part of the patient's initial complaint, prompted Dr. Bronston to consider hip involvement. "The one sign that really gives you a clear indication of hip pathology is pain with range of motion in the hip, particularly extreme abduction or internal rotation," he says. In the clinical exam, among other findings that included hamstring limitation of the straight-leg raise, lower-back pain during the double-leg raise, sciatic notch tenderness bilateral, and intersegmental spinal dysfunction, the patient had loss of hip abduction at 50 percent. "Right away, hip range of motion was a problem, indicating to me he had hip issues," Dr. Bronston says.

An AP pelvis x-ray revealed that although the patient's sacroiliac joints were normal, he had a marked narrowing of the superior joint space of both hips. "In essence, he had moderately advanced degenerative joint disease in both hips, and he also had degenerative disc disease at L4-L5 and L5-S1. The clinical impression was chronic mechanical lower-back pain complicated by degenerative disc disease, but additionally, degenerative joint disease of both hips, with the left side greater than the right." The sciatic-type pain could be considered referred hip or lumbar neurogenic. Dr. Bronston's treatment goal was to decrease the patient's pain levels, increase range of motion in the hip and lower back, and provide him with lifestyle options, such as postural changes, to limit the stress on his back and hips. The years.

After a five-week course of treatment with CMT and electrical stimulation, that proceeded through ultrasound, hip circumduction, and myofascial stretch and release of the involved muscles, the patient was doing well. "His range of motion did improve because we treated the muscle attachments in the lumbar spine, pelvis, and lower back. He made good strides," Dr. Bronston says. "I advised him to take more frequent breaks in his standing position, and to watch his stride so he wasn't overstretching his hip. I also taught him core stabilization, how to assume a neutral spine, and then simple exercises that he could perform at home."

- Common Causes of lower back and hip pain.

In patients like this one -in their sixties and over, with preexisting problems such as knee replacements -hip pain and related problems can often be directly traced to age-related degenerative conditions, particularly osteoarthritis of the hip joint. But osteoarthritis isn't always the culprit-it may actually be the ultimate result of damage done to the hip earlier.

Some of the leading causes of lower back and hip problems that actually originate within and around the hip
include:

-Over-use injuries and repetitive motion or gait problems;

-Acute injuries, such as fractures;

-Avascular necrosis; and

-Infections in the joint or bone near the hip -these are usually accompanied by fever, redness, and/or swelling.

"Most hip problems are due to biomechanical issues. Primarily, that's what we're going to see," says Sharon Jaeger, DC, DACBR, who practices in southern California. "Let's say a patient sprains an ankle or strains a knee, and has knee or ankle problems. That can change the gait and create hip pain. Sometimes, people complain of hip pain after they've changed jobs and are sitting differently. Anything that creates an asymmetry in motion can cause a hip problem."

A thorough history - with probing questions about exercise and movement, like those Dr. Bronston asked his patient - can help point the DC in the right direction. Other questions might yield information that points to fracture or pathology. "You might check to see if they've had a lifestyle or ergonomic change recently that might change the gait. Have they changed jobs, changed the way they sit, taken on a new activity, or recently started driving a long way on a regular basis?" Dr. Jaeger suggests. Another cause of a change in gait includes carrying a baby or small child on the hip. "The whole mechanism is different. That's not an uncommon complaint of young mothers. In fact, anything that you carry often can change the way you bear your weight. If you carry things asymmetrically, that can be a cause of hip problems. Perhaps you have a job on a ladder or are climbing stairs more often, you may become dependent on one side."

The doctor of chiropractic might also ask the patient if he's taken up a new sport recently. While studies haven't shown any specific connection between highimpact exercise like running and degenerative conditions like arthritis (except possibly with extreme long-distance runners), it's possible that the new exerciser or "weekend warrior" favors one side or the other while running.

"In my experience, the hip joint doesn't subluxate very much. It's a very stable joint. What does happen is that patients develop muscle imbalances, incoordination, or gait problems, and then later they develop osteoarthritis," adds John Hyland, DC, DACBR, DABCO, a certified strength and conditioning specialist who practices in the Denver area. "While hip pain certainly is prevalent in aging, it's usually not specifically caused by aging itself, but rather by the accumulated effects of some type of biomechanical problem. Either there's a long-standing imbalance or asymmetry, or a prior injury." People have two hips, Dr. Hyland notes, and usually hip pain isn't evenly distributed between the two. "The other one's just as old, but it doesn't have the arthritis in it. That's when we get the chance to talk about prior injuries to that hip, the person's occupation, and other daily activities that might put additional stress on the hip. Usually the osteoarthritis is the end result of there being some biomechanical problems over a period of time."

Another possible biomechanical cause of hip pain can be a leg-length discrepancy. "Studies have found that even people with small differences in actual leg length have a serious difference in energy expenditure," Dr. Hyland says. Long-standing discrepancies have been shown to lead to hip joint arthritis, and can be treated with a combination of manipulation and, if the discrepancy is anatomical, custom orthotics.

Some possible sources of lower back and hip pain should be immediately referred elsewhere. Because of its anatomy, the hip in particular should be an area of caution for DCs,

Dr. Hyland says. "Unfortunately, the hip is an area of potential malpractice. I do malpractice defense work for doctors of chiropractic, and because the hip is difficult to image and because the joint is so deep, it's not difficult to miss things," he says.

One example is fractures. Yes, it's possible for a patient to come into a DC's office thinking that she just needs manipulation for a sore hip, when in fact, she's fractured her femur. Dr. Bronston once treated an elderly patient who just thought that the fall he'd taken had left him a little sore and unable to get up easily. "The x-ray revealed a femoral neck fracture; the neck of the femur had collapsed into the shaft. Of course, he needed surgery and was taken to the hospital," Dr. Bronston says. "The patient can have a hip fracture and not realize it. He might just think, `Oh, my hip hurts, and I can't walk very well.' If he is already a chiropractic patient, he might be inclined to visit the DC first."

X-rays and other imaging should reveal the presence of any fractures-although some stress fractures can be easy to miss without MRIs- but the patient history may give the doctor of chiropractic an early idea of what to be looking for on the films. Obviously, when dealing with an elderly patient, particularly a woman for whom osteoporosis is a concern, the possibility of a hip fracture should come to mind. In addition to asking about falls and other obvious traumas, it is well to ask if the patient has taken up a new sport, like jogging. "If a patient came off a curb too fast or too hard, they may have landed heavily on one leg and induced a stress fracture," Dr. Jaeger says.

Other things to consider besides trauma include diabetes, alcohol consumption, and the use of steroids, all of which may create avascular necrosis. "In an adult between the ages of 20 and 40 who has hip pain that just doesn't seem to resolve, the DC should watch for avascular necrosis, especially if there's a history of something that might change the blood supply to an area," Dr. Jaeger says. "If the bone density doesn't seem up to par for the age group, or if a lot of vascular calcifications wouldn't be expected for the particular age group, avascular necrosis should be seriously considered." This isn't always an easy diagnosis to make, she adds, and requires a certain deftness in questioning the patient. "People can be on steroidal medications and not think about it when asked. An asthmatic patient, for example, could be on a steroid, like prednisone, and then go hiking and start developing hip pain. If the pain doesn't respond to therapy, it could indicate avascular necrosis," she says. "Other patients might not want to own up to how much alcohol they drink. People don't like "labels," so they don't always give you that information."

If you see signs suggesting a fracture or avascular necrosis, take care to rule them out. "An adjustment is definitely not appropriate to a hip that's been fractured, nor should it be used with avascular necrosis," says Dr. Hyland.
The Importance of Imaging

In most cases, as with Dr. Bronston's janitor patient, x-rays will confirm the diagnostic direction that your history and clinical exam have taken. But imaging the hip isn't as easy as imaging some other joints. "Because of its contour and angle, the hip is difficult to truly visualize well on regular films. Along with many of my colleagues, I find MRI to be much more sensitive," says Dr. Jaeger. "It will show a potential stress fracture or vascular condition much earlier. I'm not saying that you shouldn't start with plain films, but if you have a suggestive history and the patient isn't responding to care, that's when I want an MRI. If the patient has an avascular condition or a stress fracture and you miss it, it could lead to surgery that wouldn't have been necessary otherwise, with potential deformities."

Of course, MRIs are more expensive than standard x-rays, so most DCs won't pursue these as a first option. "Unfortunately, the whole cost factor is a big deal, so usually what happens is that plain films are taken first, and if they're not able to visualize properly what's going on, then the MRI is called for," Dr. Hyland says. "Certainly, for the hip, you really need the two major x-ray views - the straight-on view and then the frog-leg view. Even with those, however, it's sometimes difficult to determine what's happening. There are a number of things that can be going on that don't show up on standard plain films; cases where the MRI is really the only way to see what's going on with the hip." Some hip fractures, he notes, can be tricky to spot on plain films. Even more confounding without an MRI is avascular necrosis, which can occur even in young, healthy people.

For most conditions of the lower back and hip that are amenable to chiropractic treatment, it's usually not the hip itself that needs adjustment. "While mobilization or stretching of a tight hip capsule can be helpful, usually the primary target of adjustment should be the sacroiliac joint because of the altered or asymmetrical gait," Dr. Hyland says. "Usually, that's developed into a sacroiliac joint problem, so the adjustments in my experience are usually to the lumbosacral spine and sacroiliac joints. The hip, on the other hand, needs more focus on strengthening of the muscles."

Because the hip is a large joint and has large muscles around it, adjustments to the area do tend to require more force than elsewhere in the body. This means that added care is also required, especially for elderly patients. He particularly urges caution with adjustments in the case of severely ostoarthritic hips. "Forceful adjustments into an arthritic hip can be very painful -they can flare it up and make it hard to calm it down," he says. "I've been involved in a case where the doctor of chiropractic began adjusting the hip without taking x-rays. Ultimately, it made the condition worse and the patient went on to hip replacement surgery because he had severe osteoarthritis in the hip joint, which wasn't detected, and the adjustments were more aggressive than that arthritic hip could stand."