Part II: Correcting the Lower Back and Hips
A few weeks ago my good friend and author of Day by Day: The Personal Trainer’s Blueprint to Achieving Ultimate Success, Kevin Mullins, wrote an introduction of sorts to the state of “corrective exercise” in the fitness industry.
To summate: Stop it. Just stop. People still need to train in order to get better.
He followed that up with a treatise on the shoulders. Today, he’s back to cover the lumbar spine and hips.
Grab a cup of coffee.
This is good.
Part II: Correcting the Lower Back and Hips
In the last article – HERE – we looked at how we would address the issues that occur at the shoulders and thoracic spine. We discovered that optimal shoulder function comes from a healthy scapulohumeral rhythm, a mobile thoracic spine and humerus, and strong scapula and core muscles. In the end we identified common problems and proposed unique exercise solutions that can not only correct issues when they arise, but also strengthen the capacity of the joint altogether.
That followed my opening article in which I discussed my stance on the current state of our industry and how we’ve gone overkill in regard to corrective exercises. You can read that HERE.
Which brings us here to the next installment of the series – a similar dive into the lower back and hip joint, an anatomically different, but physiologically similar region of the body.
You’ll discover how lower back pain isn’t simply the lower back, how hip dysfunction or immobility requires more than flexibility and blood flow, and that integrated three-dimensional movements are the key to unlocking the hips and core.
As Shakira sings, “hips don’t lie”.
We are going to dive into the anatomy of the region, the physiology of the segments, and biomechanical implications that must be considered by any professional worth their salt.
We are going to unlock our, and our client’s, potential by adding another five great exercises to the equation too. But first, I want to take a moment to clear the air and amend a point I made in my previous post.
An Amendment on the FMS
In my last article I made a bit of a blunder when I described an issue that I have with the Functional Movement Screen. In my efforts to write a short, and interesting, piece of literature that covers a complex topic I did not effectively communicate my viewpoint on the matter. My claim that “the FMS puts the fear of God into trainers” isn’t quite accurate.
Brett Jones of FMS and I had a call on the matter and enjoyed an outstanding conversation on the FMS, how trainers are using it, and my specific area of concern.
Brett Jones (Note From TG: NEVER make Brett angry. Ever. Just kidding. Brett’s as professional as they come and one of THE best presenters I have ever had the pleasure of learning from. But seriously, don’t feed him past midnight.
He drew to my attention that the FMS, when taught properly and used properly, especially after the level 2 certification, provides trainers a lot of tools to correct and address issues that are present in the screens.
And he is spot on.
In my experience with the Functional Movement Screen, and the literature it publishes, I’ve found tremendous success in identifying, addressing, and correcting flawed patterns. The tools are present for a trainer to succeed.
So, to that end – the FMS itself is not an issue, and in fact, the certifications and resources that Gray (Cook) and Lee (Burton) provide are high on my list of recommended education for trainers. Simply put, much of the responsibility lays on the trainer performing the assessment to ensure they understand what they are screen, why they are doing it, and what it all means regarding the client’s exercise program.
And so, my point is really this:
“The FMS can put the fear of God in trainers who haven’t invested enough time to understand its purpose and nuance. This can be avoided by investing in your education and diving head first into new information.”
Basic Hip and Lower Back Anatomy – Skeletal
When looking at the skeletal anatomy of the spine and hip we find that it is quite simple. There are four major considerations:
- The thoracic spine – capable of flexion, extension, and rotation. In an ideal world the thoracic spine handles the bulk or rotation and extension of the spine.
- The lumbar spine – capable of flexion, extension, and rotation. In an ideal world the lumbar spine serves more as a stable base for movement that allows the pelvis to move underneath, and the thoracic spine to move above.
- The pelvis – capable of anterior tilting (pouring water out of our belly button), posterior tilting (pouring water out of our back) and lateral tilts to either side (pouring water out of our sides).
- The femurs – capable of internal and external rotation, flexion and extension, as well as abduction and adduction. Each of these movements are necessary to generate the variety of locomotion patterns we execute daily and for the specific movements we perform in training.
The ankle and foot are also capable of impacting health of the hips too, especially in the running community. Issues in these lower joints can cause negative effects to move upwards in the kinetic chain and begin causing negative adaptations in the hip joint or lumbar spine. We will address these correctives in the final part of this series, Hip-Knee-Ankle-Foot, so stay tuned.
For now, simply acknowledging their role in the process is enough.
Under the same principles, the shoulders can also impact the function of the hips. A dysfunction in the shoulders, such as upper cross syndrome, impacts the T-spine, which disrupts the lumbar spine and pelvis. Improving the health of the shoulder joint can help alleviate the poor postures that stress the lumbar spine and allow for a better functioning pelvis that experiences the ranges of tilt patterns because the lack of tightness in the lower spine. The scapula specifically should be considered (and will be in our correctives).
Basic Anatomy of Spine and Hips – Muscular
There are muscles that could be mentioned in this section that run very deep in the body and have very specific function.
The multifidus for example is a muscle that runs along the spine and has an important function; yet, our training practices aren’t exactly targeting it.
It is always good to know these types of muscles, such as the quadratus lumborum, obterus group, gemelli1 , and the aforementioned multifidus. Still though, this article is meant for our day-to-day efforts and most trainers simply don’t need to consider these things
There are some major players that you need to know though:
- The abdominal wall, specifically the transverse abdominus, rectus abdominus, internal and external obliques, and psoas muscles. These muscles flex, extend, and rotate the spine and some act on the hip as flexors.
- The gluteus maximum, minimus, and medius. These muscles act on the hip as external rotators and hip extensors.
- The four muscles of the quadriceps, three muscles of the hamstrings, the tensor fascia latae as well as your abductors and adductors all act on the hip and knee joint. These muscles drive motion of the femur in the hip socket in a variety of ways that are unique to each pattern. In the next section we’ll isolate the specific motions and what muscles are involved for bookkeeping purposes.
The erector spinae, the quadratus lumborum, lattisimus dorsi, and lower trapezius muscles function on the thoracic and lumbar spine from the posterior of the body. These muscles are critical for putting the T-spine in the right place and stabilizing the L-spine during movement.
Basic Movement Physiology
Knowing what is in play is only half of the battle.
Note From TG: Goddamit Kevin. Rule #239 of being a nerd is that whenever the phrase “only half the battle” is used it must always be followed with GOOOO, Joe.
In fact, knowing the structures and muscles involved is irrelevant if we don’t understand how they create movement in the body. To avoid blowing this article out into a thirty-thousand-word book on physiology we are going to have a down and dirty list of functions and the muscles that do the work.
I implore you to read and learn more about the muscular physiology that drives these movements from other resources. Play with things at the gym and try to “feel” what you can. I felt obligated to include this information in an honest effort to create the best free guide to hip correctives you’ll find. What you do with your education from there now rests in your hands.
- Spinal Flexion – rectus abdominus, psoas major
- Spinal Extension – quadratus lumborum, erector spinae, latissimus dorsi,
- Spinal Rotation or Lateral Flexion – Any of the core muscles mentioned above when functioning unilaterally. If one side of the rectus abdominus fires, then you’ll see lateral flexion and some rotation. Other rotators include the internal and external obliques and serratus anterior.
- Spinal Stability – transverse abdominus, multifidi, all muscles above fired isometrically
- Hip Flexion – psoas major, iliacus, rectus femoris, sartorius, tensor fasciae latae, adductor longus and brevis, gracilis, pectineus. Some fibers of the glute minimus and medius engage here.
- Hip Extension – glute maximus, biceps femoris, semitendinosus, semimembranosus. Some fibers of the glute medius engage too.
- Hip Abduction – the glute maximus, minimus, and medius as well as the tensor fasciae latae. The piriformis functions when the hip is at 90 degrees.
- Hip Adduction – adductor longus, brevis, magnus, pectinius and gracilis
- Hip Internal Rotation – tensor fasciae latae, adductor longus, brevis, and magnus, pectineus, sections of glute medius and minimus
- Hip External Rotation – piriformis, gemellus superior and inferior, obturator internus and externus, glute maximus, minimus, medius, psoas major, sartorius, quadratus femori
Now, I realize that this list reads like the appendix of a textbook, but don’t get lost in the noise. Notice the tremendous amount of overlap. You’ll see that the glutes have multiple functions as do the adductors and the TFL.
This sort of information at least shows us what the major players are going to be.
The Fascial Integration
We must also give attention to the intricate layers of fascia that are found in the core, hip, and thigh. Whether we address it through myofascial release or integrated non-linear movements, we must give it attention.
As noted in the previous edition, fascia is a highly communicative tissue that can arrange our body and its structures at a speed that is closer to the speed of light or sound than it is the speed of our cognition.
Fascia adapts, positively or negatively, to the stress placed upon it. Sit in a chair all day? Well, your fascia is likely bound up and dehydrated. Exist in a world where yoga, integrated movements, and sports are a major focus? Chances are you have healthy fascia.
The utilization of non-linear movements is one of the best ways of to improve fascia.
The Major Issues
The issues that occur at the spine and hips are almost always interconnected. A client could deal with just one or all of them.
Chances are that you’ll deal with all of these issues in some point in your career.
It is important to read and learn each of these as their own issue while also understanding that a client could show up to you with a Royal Flush of dysfunction. Luckily, the correctives we’ll discuss at the end are Swiss army knives – they are great for everyone.
1) Desk Posture
Once again, our lovely desk posture makes an appearance on the list. It is important to acknowledge the impact that upper cross syndrome (UCS) can have on core function, and thus hip function. If someone is slouched over with internally rotated shoulders, a kyphotic thoracic spine, and weak abdominal muscles, then we can very likely ascertain that their hips aren’t going to function optimally.
The lack of thoracic extension, poor function of the core muscles, and the overextension of the erector spinae and trapezius muscles dramatically impact the way someone can function up and down the length of their spine.
Ironically, many of these same flaws are also present in lower cross syndrome (LCS), which involves the muscles of the lumbar spine, abdominal wall, and the hips. Dysfunction caused from sitting all day can make the muscles involved weak (glutes and abdominals) or tight (muscles of the lower back and the hip flexors).
When a client presents these issues, especially together, it can be hard to prescribe any challenging exercises because their entire torso is locked from neck to butt. It is important to spot these issues early and begin implementing a corrective strategy that gets that client on the right path.
Thankfully, we’ll have some exercises below that will be great for both UCS and LCS issues.
2) Excess Anterior Tilt
When the pelvis is stuck in its “tipped forward” position for too long there are issues that can present themselves at rest and during exercise. In fact, continuing to exercise, especially with exercises that promote even more tilt, can cause damage to the vertebral discs.
In this position the erector spinae and QL are pulled tight while the anterior core is left in a lengthened and overstretched state. This sort of weakness in the abdominal wall makes optimal hip function harder to achieve and can lead to injuries at the spine.
Another unfortunate consequence is the overextension of the spine, or flaring of the rib cage, which can create the appearance of a midsection that is holding excess bodyfat. This bulge is simply a result of poor posture and would disappear once the pelvis is set back to neutral.
It should be noted that though that the pelvis should be able to anterior tilt through a full range of motion – it just shouldn’t be stuck that way.
3) Excess Posterior Tilt
The exact opposite of anterior tilt is the posterior version, which is when the pelvis is tilted back too far. This “belt-buckle to nose” condition is often found in individuals with lower cross issues since their abdominal walls are weak and their hip flexors overactive.
Image Credit: precisionmovement.com
This position pulls the glutes completely in line with the body and flattens out the lumbar spine by ridding of the natural curvature of that region. This is not only “less attractive” due to the appearance of having no ass, but it also dangerous to load someone who can not achieve even low levels of hip extension and hip flexion. When someone is stuck here – they effectively have no idea of how to move their hips.
The corrective strategy here requires specific interventions that improve the awareness of the client as well as the strength of the glutes, hamstrings, abdominal wall, and even latissimus dorsi muscles. Additional efforts can be spent to improve external rotation of the femur and abduction too.
Once again, the hip should be able to posterior tilt during some movements and to help create stability.
4) Sticky Femurs (no, this isn’t technical)
One of my favorite terms for someone lacking the ability to rotate their femurs in their hip sockets (internally or externally) is “sticky femurs.” What I mean by this statement is nothing more than the image of having gum stuck in the joint that prevents optimal movement.
This is a combination of a lack of mobility in the joint due to not experiencing enough movement variation. Very active people could have “sticky” hips if they don’t cross train or experience movements in all three planes. Many “big” lifters struggle with external and internal rotation at the hip.
The other side of the coin is weak external or internal rotators that are incapable of owning the position that we put the femur in with excellent mobility. This is very common in dancers, those who practice yoga, or others who don’t actively strengthen these muscles. Detrained individuals fall into this category too. The mobility is there, but strength at end ranges is not.
5) Poor Coordination
Sometimes the issue is simply getting people to start exercising more and feeling their body move in a variety of ways. Frequent exercise, especially when done with coordination as the end goal, can improve a lot of functions of the hips on its own. It is amazing just how bad things can get when someone is rusty or de-conditioned.
Of course, you’ll need to spend time mobilizing and strengthening the various elements of the hip joint, but you’ll likely see increased output by simply exposing clients to new forms of movement and exercise. Any training program that features unilateral, contralateral, ipsilateral, and bilateral movements in all three planes is ideal.
6) Weak Core
Lastly, poor strength in the core itself can cause serious issues. It can derail any segment of the body since the primary function of the core itself is force transduction – AKA – translate forces from the limbs to each other and to the external environment.
A strong core is capable of remaining stable as the limbs create and accepts force. We must ensure our clients can move through all three planes of motion, with optimal function at the joints, with a variety of loads and challenges, because they possess a strong core. For this reason, most of our programming for the core should emphasize creating, and maintaining, tension.
The Corrective Exercises
Once we dive into the corrective strategies it is important to acknowledge that all these movements can be used to help with each issue. All these movements in some way will impact the ability of the client to succeed in overcoming hip dysfunction.
Each are also excellent in isolation as warmups, isolated correctives, and “fillers” between primary movements (as Tony often discusses). The Sumo deadlift, obviously, is a primary movement that should occur early in a program, especially if we are loading it up.
1. Glute Bridge Pullovers
This simple variation of the traditional glute bridge accomplishes two major things:
- Drives all the major benefits of the traditional glute bridge
- Incorporates lat tension into the glute bridge – a key point for deadlifts and squats
You can strengthen the lats, glutes and abdominals while also addressing coordination issues. This exercise can help with every problem listed above except for “sticky femurs.”
2. Foot Elevated Glute Bridges
Another glute bridge variation that can dramatically improve the strength of the hip muscles (both flexors and extensors). By elevating the feet, you can increase the range of motion you’ll experience and improve your ability to drive into the bridge.
The key is to manage the lumbar spine and avoid overextension. The sort of exercise is great for strengthening the core, improving pelvic tilt issues, addressing coordination, and improving posture.
3. Cossack Squats
A highly advanced variation of a lateral squat – the Cossack squat asks for an incredible amount of external rotation from the femurs. It targets the muscles that drive abduction and hip flexion and extension while moving through the frontal plane.
You can use your arms to help counterweight your body as you go down and find depth. Ease into the motion and look to improve your depth and mobility over time. This is an advanced exercise that can be regressed to holding onto something like a squat rack to help with weight transfer.
4. Copenhagen Side Planks
For some reason we love naming exercises after places – this side plank variation being no different. However, this is one of the most incredible ways of working the adductor grouping without needing to add external load. You’ll also integrate your internal rotators and the muscles of the rotary core. This sort of combo lends itself to improving strength and coordination.
Your goal should be to squeeze the bottom leg towards the bottom of the bench without rolling over and dumping the tension in the side plank.
Drive yourself to maintain an ideal side plank posture the entire time.
5. Loaded Marching Carries
Loaded carries are a movement pattern all their own. Few things can rival the simple effectiveness of grabbing heavy weights and walking around with great posture. This variation though, greatly improves the function of the hips by incorporation intentional hip flexion through the march.
Focus on driving the knees perfectly vertical, play with your speeds, and always emphasize a tight upper back, strong core, and depression of the scapula.
This exercise addresses every single problem mentioned above.
6. Sumo Stance Deadlifts
The validity of a medicine is always in its dose. Sumo stance deadlifts are one of the best corrective exercises you could program assuming:
- You or your client are ready for the stress of loaded hinges
- You choose the appropriate version for where you are in your training routine
- You have earned the right to be here by exercising pain free with less aggressive modalities.
The reason that the sumo stance is so great is that you are literally working all of the muscles of the thigh, hip, core, and upper back at the same time. The external rotation and abduction of the femurs improves the strength of the muscles involved while also helping clients discover new mobility and neuromuscular coordination. This pattern is especially useful for those who spend most of their days sitting.
7. Loaded Beast to World’s Greatest Hip Opener
An interesting cross between a traditional mobility exercise and one of the loading phases in Animal Flow – this is one of my go to exercises for increasing the dynamic ability of my clients.
This version allows you to go fast or slow depending upon skill set while also loading the hips through a full flexion and extension cycle, improving coordination, and integrating the upper body and lower body together in a mobility movement.
You can use this as a “energy system” filler if you so choose (and your client is ready).
8. Hinge Position Face Pull
A lot of clients need help discovering how to hinge. Those same clients also struggle with maintaining tension in their cores and lats too. This exercise combines an active movement of the shoulders (great for shoulder health) with a passive hip hinge to improve core and hip strength.
Add this into any of your programs as a variation of the face pull that challenges your clients do more than just yank on the cable.
Wrapping it Up
Your ability to improve your client’s function around their hips depends on your ability to address the mobility and stability needs of the segment while also ensuring they are getting enough of a training stimulus to cause change. Understanding the nuances of the anatomy and physiology is a critical step in developing progressive programs that correct issues and cause a training effect.
The final part of the series will discuss the relationship of the hip-knee-and ankle.