By Debbie Rockett, PT
Jacksonville Orthopeadic Institute
Stretch Winter 2013
THE BACK HIP AND KNEE CONNECTION IN ORTHOPEDIC PROBLEMS
Did you ever think your hip could hurt because of your back or knee?
In the human body, we are connected by muscles, ligaments, nerves and bones acting as the building blocks. How these components work together determines how our joints feel. Ligament stability, muscle strength, joint mobility and the ability of the nerves to operate without irritation or blockage are key to normal function.
The lower back area, known as the lumbar spine, is made up of bones called vertebral bodies, discs that act as “shock absorbers” between the bones and ligaments that help, along with muscles, support these structures. Inside this “column” of structures houses the spinal cord. At each vertebral level, spinal nerves exit from the spinal cord on either side. In the lumbar spine, these nerves supply both lower extremities. Back problems that involve nerve irritation or compression can lead to hip and knee pain depending on the levels involved. Certain muscles of the low back also attach to the hip. Issues here can lead to pain in the hip or restrictions that lead to problems of normal hip movement and pain is the manifesting result.
Have you ever been diagnosed with bursitis of the hip? There are several diagnoses that involve pain on the outside of the hip; however, pain will alter how you walk. Weakness of the muscles in the area reduces support to the pevic area and resulting back pain can occur. In addition, increased internal rotation of the femur can lead to knee pain as changes in the movement of the knee cap change as a result. The iliotibial band is a structure that runs from the outside of the hip to the side of the knee. Tightness here can cause irritation the bursa on the side of the hip and the pain results. Restrictions in hip joint mobility can not only cause hip pain, but also effect the back and knee by changing the mechanics of how they move. Tightness of the hip flexors located at the front of the hip can affect the position of the low back and sacroiliac joints and how they function in relation to each other.
In reference to the iliotibial band once more, this structure attaches to the fibula head. This is located on the side of the knee, just below the knee joint. Tightness of this band can not only manifest as hip problems as described, but cause pain also on the outside of the knee. This band also attaches to the outside of the patella (knee cap). Tightness can cause the patella to track to the outside of the knee and cause pain. The rectus femoris muscle is one of four muscles located at the front of the thigh. These muscles are responsible for straightening the knee. The rectus femoris muscle starts above the hip at the front (the pelvic bone) and also crosses the knee to join the other three muscles as they attach below the knee. The patella movement and position are partly controlled by these muscles. Tightness here can cause both hip and knee problems. Foot problems can lead to issues from the feet to the knees, hip and low back. A Physical Therapy evaluation is essential for your therapist to assess how all these factors interrelate and to address the problem effectively. Discussed in this article are just some of those factors to illustrate this.
THE INFULENCE OF COMORBIDITES ON RECOVERY FROM BACK SURGERY
Over 70% of the US population experiences low back pain at some point in their life. In most cases, the patient recovers in 2-3 days; others recover with the use of physical therapy and medications. About 1% of those who suffer with back pain have a medical condition that requires surgery. Nevertheless, over 25,000 back surgeries occur each year. Although there are so many people who choose back surgery as an option, there is a wide range of satisfactory relief, 16-95%. With such a wide range of satisfaction, research has recently looked at factors which may influence failure rates in low back surgeries.
Perhaps the greatest influence on the success of back surgeries, spinal fusion, in particular, is smoking. Studies show that patients who smoke have advanced degenerative changes in the low back compared to non smokers, and are more likely to have disk herniation. Such conditions may be resolved via a spinal fusion. During a fusion, the doctor places small pieces of bone along the front or back of the spine to encourage the bones to grow together in order to fuse that section of the spine. With patients who smoke, the nicotine influences the amount of blood reaching the bone graft, therefore affecting healing. Over 54% of smokers require multiple back surgeries compared to less than 50% of non-smokers. Research suggests that those who quit smoking for longer than 6 months post operatively, not only have a significant improvement in healing following spinal fusions, but also are 40% more likely to return to full work duty compared to those who do not quit.
There are multiple other factors that have an influence on the success of back surgeries including depression, anxiety, and family stress. Those with such psychological concerns tend to have low threshold for pain and focus on negative events. If you are a patient impacted by such psychological concerns, it is optimal to seek counseling prior to surgery and also to focus on small successes. Have your family reward good behavior and positive achievements in order to help you see the improvement toward your ultimate goal.
Obesity is another factor to consider when having any type of back surgery. Surgical risks such as blood clots, UTIs, and failure of the hardware increase with obesity. It is important to understand these risks and to get moving early. Talk to your Physical Therapists about ways in which you can reduce your risk of complications through your home exercise plan. Your Therapist will have many, easy and convenient ways of staying moving to reduce your overall risk.
BACK CARE 101
Yes, another article on back care. It seems like there is a lot of information out there regarding how to take care of your spine. Some of it seems good, and some of it not so good. I am here to tell you, keep it simple. By understanding structure, function, and body mechanics, you may be able to resolve or prevent low back pain.
To begin with the spine is made up of numerous cylinder shaped bones called vertebrae. These bones stack together forming what is known as the spinal column. They are connected together by facets joints, discs, muscles, and ligaments. The spine is generally thought of as being divided into 4 regions:
- Cervical (neck) consists of 7 vertebrae and provides lots of movement
- Thoracic (torso) consists of 12 vertebrae, less movement, connection for ribs
- Lumbar (lower back) consists of 5 large vertebrae, provides lots of movement
- Sacrum/Coccyx(tailbone) 8 fused vertebrae that connect to pelvis bones
The main function of the spine is to protect the spinal cord. It also allows for trunk mobility and support, as well as shock absorption via the disc and it numerous curves. The muscles that run along the front (abdominals) and back side of the spine act as a corset to help brace and protect it.
Because there are so many structures that make up the spine, you can see why it can be difficult to figure out the origin of back pain. Typically there are a few common factors. They generally fall into the following areas:1- weak core muscles (abdominals and lumbar erectors) 2- poor flexibility in the hips, hamstrings, and lumbar area 3- poor postural habits (sitting, standing, and sleeping) and 4-poor body mechanics with lifting, pushing, pulling, and carrying.
Back problems usually present as localized symptoms in the lumbar region but sometimes these symptoms can radiate down the leg as well. Localized pain is often the result of muscle guarding from such things as sprains/strains, arthritis, joint stiffness, and/or disc injury. Radiating symptoms are usually related to pressure or irritation to a nerve or nerve root. The source of irritation or pressure could be from entrapment due to decreased disc height, disc protrusion, muscle entrapment, and/or arthritic changes.
Treatment for these different conditions can vary based on the origin of the problem. Typically, treatment is focused on decreasing muscle guarding via massage, ultrasound, heat, ice and electrical stimulation. When symptoms have decreased enough, light stretching and gentle joint mobilizations may be beneficial. As things improve core strengthening exercises are initiated to help protect your spine for the performance of daily activities. Learning and using proper body mechanics and posture will help ensure that your back is not exposed to further trauma. For help with your back problems or prevention of future problems, consider speaking to one of the Therapist’s at JOI.