Almost everyone, nowadays, you meet will say “I have tight hamstrings” and when you ask them to bend forward and touch their toes they’ll say “I’ve never been able to do that”. Many of these people will concurrently experience some form of low back pain – it may not be severely debilitating, but if it’s achy or intermittent, it’s still low back pain. In PT school, we were taught to always check directly above and below the affected target zone because it could be coming from elsewhere. Now, in my clinical practice I take it much further than just above and below 1 joint, but the idea is still the same – always find the source, don’t perseverate on the location of the pain!

lbp.jpg

I understand that in school and throughout the orthopedic world there are different classifications of LBP (i.e. extension/flexion based exercises, lateral shift, traction/manipulation etc…) but this post is meant to give a general insight into back pain and how hamstrings being tight might be playing a role.

Now, back to the topic at hand. Since we’re talking about tight hamstrings in this topic series, we’re going to work backwards and discuss how having these supposedly “tight” hamstrings can contribute to common ailments such as low back pain or hip pain (most notable FAI – which you can read about in the most recent topic series here).

Low Back Pain

I am about to explain one scenario in which low back pain exists, there are many findings and ways to develop LBP – this is not an end all be all.

The lumbar spine is connected directly to the sacrum, which is wedged between the two innominate bones on either side. So logically, there would exist a direct relationship between the L spine and the Pelvis. In fact, PTs talk about lumbopelvic rhythm, lumbopelvic stability, lumbopelvic ROM etc… By grouping them together many PTs would consider, and treat, this area as one area, which may cause some to miss the subtle influences that the pelvis may have on the L spine.

In the previous post, we discussed anatomical relationships of the hamstrings, internal/external obliques, and transversus abdominis. Addtional muscles that need to be added to the mix are the psoas, iliacus, adductor magnus, rectus femoris, and TFL.

 

The Psoas and iliacus muscles are often grouped together as the iliopsoas, but they are separate until their insertion. The psoas originate from the from of the vertebral bodies of T12-L5, and the iliacus covers the majority of the medial side of the iliac foss and joins the psoas on the lesser trochanter assisting in hip flexion and medial rotation. The adductor magnus is one that many tend to forget, it has an extension component because it starts on the ischial tuberosity and inserts into the linea aspera as well as the adductor tubercle. The TFL and rectus femoris assist in hip flexion due to their origin on the iliac crest and ASIS respectively.

As humans, many of us spend the majority of our days sitting at a desk leading to tight hip flexors (our nervous system adapts and overtime will allow us to assume this posture efficiently by effectively shortening certain muscles and lengthening others) and poor core engagement (how many people actually engage their core while sitting after 10 hours?). Take a minute and review the anatomy of the core muscles we discussed in the previous post and visualize how an anterior tilt can put these muscles on stretch and at a poor length-tension relationship.

With increased tightness (read: overactive, or increased neural activation of…) developing in your hip flexors pulling your pelvis into an anterior tilt, the glutes stop being as effective (or can also be overworked inefficiently trying to overcome the activation of hip flexors anteriorly) and the erectors posteriorly begin overworking for the lack of hip extension – effectively shortening and resulting in increased lumbar lordosis. This definitely makes sense visually and Smith et al (2016) found that there was increased activation of erector spinae during walking activities in those who were asymptomatic but had a history of LBP. They also found reduced endurance of the deep fibers of multifidus. The posterior wall of your core is not able to sustain a contraction for as long when you start having low back pain – this one piece should cue you into that the overall functional of an individual’s core is altered if htey have a history of LBP or are currently experiencing LBP.

What does this have to do with the hamstrings being tight? Remember that the hamstrings attach to the ischial tuberosity – an anterior tilt will result in the hamstrings on stretch while at rest. It also puts the hamstrings outside of their optimal length-tension (I warned you that this was a very important principle) for contracting and holding the pelvis in a neutral position. As a result, the hip flexors and erector spinae will dominate and result in a non-neutral spine; increasing the compressive forces through the spine, thus low back pain. The hamstrings are not the only muscles affected, the adductor magnus also attaches at the ischial tuberosity, so the extension AND adduction fibers are also affected.

Hip pain

After the previous discussion on low back pain – you may notice that many of the muscles mentioned have an attachment at the hip, and so you can imagine that there would be a direct relationship between low back pain and hip pain.

An anteriorly rotated pelvis (think the tight hamstrings we discussed just above) will disrupt the relationship between the femur and acetabulum. We will now skip to a tangent principle that is just as important as the length tension relationship mentioned in the previous post. It’s called Wolff’s Law. It essentially states that our body is constantly taking up and laying down new bone in accordance with where stress is. It’s our body’s way of adapting to the daily stresses we put our body through. As a result, if one side of a joint is consistently under more stress than the other, that particular side of the joint may become thicker overtime due to this principle. This can lead to potential problems over time however.

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Picture this: A soccer player with tight hamstrings presents with groin pain. You find that they have an anteriorly rotated pelvis with excessive lordosis. The anteriorly rotated pelvis disrupts the relationship of the acetabulum and femur, and with the repetitive nature of soccer (running and forced/explosive hip flexion while shooting), the superior/anterior portion of the femur will bump into the acetabulum. Overtime, the body will adapt and the irritated part of the femur will become thicker with increased bone lay down. Now the femoral head is no longer spherical and the shear forces between the femoral head and acetabulum begin to wear away the cartilage – the athlete now has a Cam impingement and potentially the development of hip arthritis.

Many may argue that this post is focused on being able to achieve neutral, but life does not occur in a neutral spine or hip. I completely agree with that statement. However, because life is so dynamic, we must be able to achieve neutral before we can become dynamic. Otherwise we are perpetuating the dysfunction through inefficient movement. Life is about being able to move into and out of neutral, thus creating the dynamic nature of movement we see.

The third part of this series will focus on basic movement dills to help your athlete achieve neutral and then progress them into more dynamic exercises.

References:

Smith, J. A. PT, PhD, Kornelia, K. PT, PhD Altered multifidus recruitment during walking in young asymptomatic individuals with a history of low back pain. JOSPT 46(5) 365-374; 2016

Harris-Hayes, M. PT, DPT, MSCI, OCS et al. Persons with chronic hip joint pain exhibit reduced hip muscle strength. JOSPT 44(11) 890-898; 2014

Prather, H. DO et al. Hip and lumbar spine physical examination findings in people presenting with low back pain, with or without lower extremity pain. JOSPT 47(3) 163-172; 2017

Megan Sions, J. DPT, PhD et al. Trunk muscle characteristics of the multifidi, erector spinae, psoas, and quadratus lumborum in older adults with and without chronic low back pain. JOSPT 47(3) 173-179; 2017

Ishizuka, T. et al  Instantaneous changes in respiratory function induced by passive pelvic suspension in the supine position in relation to increased diaphragm excursion. J phys ther sci. Mar;29(3):432-437; 2017

Workman, J. C. et al. Influence of pelvis position on the activation of abdominal and hip flexor muscles. J strength cond res. Sep;22(5):1563-9; 2008.

Teichtal, A. J. et al. Wolff’s Law in action: a mechanism for early knee osteoarthritis. Arthritis Res. Ther. Sept;17(207); 2015

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