The Hip Flexors
Today we dive into the world of hip flexor muscles. More specifically, the psoas muscle. Why? Because the hip flexors are one of the top 2 culprits of muscular low back pain.
Worldwide, 577 million people are experiencing low back pain at any given time.* Some studies have estimated that 80% of Americans will experience low back pain in their lifetime.* It’s a pervasive problem, but I believe it doesn’t have to be. We just need better knowledge of how to take care of our backs.
Many sufferers of low back pain walk through my clinic doors with classic muscular imbalances. Even those who have structural spinal changes (e.g. scoliosis) can have the added layer of muscular imbalance, which further exacerbates their structural condition.
As a novice therapist, I remember my mentor being acutely annoyed that another novice therapist in our clinic didn’t check the hip flexor length of her patient before she transferred the patient to his care for further evaluation. Now, as an experienced therapist, I totally get his frustration. Tight hip flexors are low hanging fruit in the world of low back pain. Unfortunately, I still see therapists failing to check the hip flexor length in patients with low back pain, even when it’s quite obvious by the patient’s posture.
Why are the hip flexors ignored, or at best, forgotten? Possibly because their anatomy is slightly abstract, especially to patients, new therapists, or those who lack formal anatomical training. Many of my patients ask, “How can a muscle in the front of my hip be causing my low back pain?”
The answer lies in the anatomy. We feel the hip flexors stretching in the front of the hip, but the psoas, the main hip flexor, dives deep and attaches directly into the low back. It attaches not only to the vertebra but also the DISCS of T12-L5. Can you imagine how it feels for a tight psoas to be yanking on your L4 disc?! Not good, especially if you currently have or have had any type of disc injury.
Anatomy of the Psoas
What are the implications of tight hip flexors, you may ask, besides low back pain? MUSCLE IMBALANCE. As the hip flexors tighten, and over time, shorten, the abdominals and the glutes can no longer function correctly. We end up with what’s called Lower Crossed Syndrome, a classic muscular imbalance. Weak core, weak glutes, and tight hip flexors and tight lumbar extensors.
Lower Crossed Syndrome
How can we better identify this problem? First, assess your posture. Are you someone who has “excessive lumbar lordosis”, i.e. very back-bent in your low back, with your butt and chest sticking out? You likely have tight hip flexors. Second, check the length of your hip flexors: lie on your back, legs straight. Bring one knee to your chest, and as you do, pay attention to the leg still on the floor. Does that leg lift further away from the floor, possibly dragging the heel toward you and bending that knee? Tight hip flexors, and possibly quadriceps as well. If you still aren’t sure, pay a visit to your friendly physical therapist and ask them to perform a Thomas Test.
Self Thomas Test
How do we remedy this problem? We begin a regular stretching and strengthening program. We stretch the hip flexors, and we strengthen the core and the glutes. Again, very low hanging fruit in the world of physical therapy, but unfortunately missed quite a bit.
Those who have structural changes in the spine, such as scoliosis, kyphosis, etc., can greatly benefit from this simple treatment program. However, it’s important to note that this won’t be the only treatment prescribed, as we also need to re-align the muscles and skeleton in the other 2 planes of motion (i.e. frontal and transverse) - remember, we are 3-dimensional beings. The Schroth Method is so successful because it addresses impairments in all 3 dimensions.
Tight hip flexors, and subsequent lower crossed syndrome, is present in countless cases of low back pain. It happens to those with and without scoliosis, with and without hyperkyphosis, and with and without leg length discrepancy. It is a muscular imbalance, which means there is a muscular solution. My goal is to collectively improve the assessment and treatment of this straightforward problem.