Injury & & Rehab: hips don’t lie…?
a surprising cause of neck and shoulder pain
By addressing the underlying causes of musculoskeletal dysfunction you can help your clients move better while eliminating recurrent aches and pains.
One in four people suffer from neck and shoulder pain (Leijon, et. al., 2009), which affects their ability to perform everyday activities like lifting their arms to wash their hair or reach a high cupboard. It also limits their ability to participate in athletic activities and dynamic exercises common to personal training programs.
Typically, people with neck and shoulder pain seek help from chiropractors, physiotherapists, doctors and other licensed medical professionals to alleviate their pain. When their symptoms are under control, they often turn to a personal trainer to begin or continue a program of regular exercise. However, once the client begins exercising regularly and engaging in full-body dynamic activities, more often than not their neck and shoulder pain returns. This frustrating situation often causes them to drop out of training (IDEA, 2013).
So why does neck and shoulder pain return so dramatically when clients begin engaging in a program of regular exercise? And what can you do, as a personal trainer, to help identify and remedy one of the most common, yet surprising, causes of neck and shoulder pain?
Progressing from physical therapy to personal training
When progressing from the controlled environment of physiotherapy office/medical facility to a fitness/personal training atmosphere, clients begin performing dynamic exercises that challenge the body through multiple planes of movement. While these types of whole-body activities are necessary to burn calories and stimulate energy producing (and recovery) mechanisms, they also place a large amount of stress on the musculoskeletal system (Price & Bratcher, 2010). If one part of the body is out of alignment when the entire body is being stressed, compensations can occur. Myofascial structures above and below the imbalance must take up the slack to help keep the body balanced as it moves. Over time, these compensations can cause further musculoskeletal imbalances, myofascial restrictions and pain.
How an imbalance of the hips affects the shoulders and neck
The large muscles of the lumbo-pelvic-hip girdle (LPHG) such as the glutes, hip rotators, abdominals, hip flexors and erector spinae group (to name a few), dissipate tremendous forces, namely gravity and ground reaction forces, as they pass through the body (Golding & Golding, 2003).
However, if the bony structures of the pelvis, hips and base of the spine that these muscles attach to are out of alignment, then these muscles cannot perform effectively. This has consequences for both the bony structures and muscles of the upper torso as well as the vestibular system (which helps keep the head aligned over the centre of the pelvis when a person is standing, walking or engaged in other activities) (Schamberger, 2002).
Hence, if the lumbar spine, pelvis and hips are out of alignment due to a structural imbalance, muscular weakness and/or neuromuscular dysfunction, then the neck, head and shoulders must compensate and shift out of their correct positions (see diagram).
Habitual movement patterns of the neck and shoulders that develop to compensate for a misaligned LPHG can result in long term recurring neck and shoulder pain. This pain is often greatly exacerbated when a person engages in full-body movements.
Are the hips to blame for neck and shoulder pain?
You might think this type of musculoskeletal imbalance is uncommon, but the regular practice of performing the assessment below highlights the fact that many clients have misalignment issues with their LPHG. Performing this assessment with clients prior to exercise will help you determine whether an imbalance of the LPHG is contributing to the recurrence of neck and shoulder pain.
Dowel rod on hips assessment
Stand behind your client as both of you face forward looking into a mirror, so you can consider the results of the assessment together. On both hands curl your third, fourth and fifth fingers toward your palms as you point your index fingers out straight and extend your thumbs toward the ceiling (like you are creating fake guns with your hands). Balance a dowel rod across the top of your two index fingers and then position your index fingers on the back of your client’s pelvis (i.e. where their pants would sit on their hips). Now look in the mirror and see if the dowel rod is level. If the rod is higher on one side, this indicates that your client’s hips have shifted to that side. It also suggests that the base of their spine (i.e. sacrum and coccyx) has shifted toward that same higher side.
If you discover that your client’s hips are not level, you can assume their neck and head are also out of alignment, due to the compensatory movements they develop in order to keep their body balanced (Price, 2011).
Corrective exercise strategies
Use the following self-myofascial release, stretching and strengthening corrective exercises to help realign the lumbo-pelvic-hip girdle so the shoulders, neck and head naturally fall back into better alignment. When performed on a regular basis, these strategies will retrain the structures of the LPHG and help alleviate neck and shoulder pain.
Exercise 1: Foam roller on side of hip and leg
A sideways shift of the hips and lumbar spine is often caused by restrictions in the opposite hip and muscles that run down the leg (i.e. the hip that appears lower on the dowel rod assessment is usually the restricted side). This self-myofascial release technique will help loosen up these structures and prepare them for the stretching exercise that follows.
Client lies on their side and places the roller beneath their body on the lateral side of the leg/hip that appeared lower on the assessment. Client moves the roller gently up and down their leg and hip, pausing on any sore spots they find. Perform at least once per day on that side for a total of 2 to 3 minutes.
Exercise 2: Door frame stretch
This stretching exercise is designed to mobilise the hip that appeared lower (from the dowel rod assessment) so the body can begin to accept weight correctly on that side and help balance the hips.
Client stands in a door frame and reaches the arm of whichever side of the hip appeared lower in the assessment over their head. Grasping the doorframe above head level with the hand of the upstretched arm, the client places their other hand lower on the frame at thigh level and tucks their outside foot behind their inside foot. Pushing their inside hip away from their hands, they shift their weight into their outside hip until they feel a stretch. Hold for 20 to 30 seconds.
Exercise 3: Side lying leg lift
A sideways shift of the hips can also result from a weakness on the side of the hip that appeared higher in the assessment, as the abductors become ineffective at stabilising the hip/leg during movement. This exercise strengthens the gluteus medius and minimus on the higher-hip side to help keep the pelvis, hips and lumbar spine centred.
With their head supported, client lies on the side of the body that the dowel rod assessment revealed to have the lower hip. Bending the knee of the top leg, they position the instep of that foot on the inside of their bottom leg at knee level. Posteriorly rotating the pelvis (i.e. tucking it under) the client gently lifts the knee of their top leg without arching their lower back or rotating their hips. This exercise should be performed slowly, allowing plenty of time for the nervous system to connect to the muscles on the sides of the hips/buttocks. Perform 10 to 12 repetitions once a day.
An understanding of how the whole body works together as a kinetic chain is essential when working with clients who experience pain. Utilising assessments that identify the underlying causes of musculoskeletal dysfunction, and addressing those issues with corrective exercises, can help you and your clients move better while eliminating long-standing aches and pains.
Golding, Lawrence A. and Golding, Scott M. Fitness Professionals' Guide to Musculoskeletal Anatomy
IDEA Fitness Programs and Equipment Trends Report. IDEA Health & Fitness Association, 2013.
Leijon O, Wahlström J, & Mulder M. Prevalence of self-reported neck-shoulder-arm pain and concurrent low back pain or psychological distress: time-trends in a general population. Spine: 2009 Aug 1;34(17):1863-8.
Price, J. & Bratcher, M. 2010. The BioMechanics Method Corrective Exercise Certification Program. The BioMechanics Press.
Price, J. 2011. The BioMechanics Method Advanced Corrective Exercise Mentorship Program.The BioMechanics.
Schamberger, Wolf. The Malalignment Syndrome: Implications for Medicine and Sport. Edinburgh: Churchill Livingstone, 2002.
Justin Price, MA is the creator of the Network Corrective Exercise Trainer Specialist Certification course, The BioMechanics Method®. His techniques are used in over 25 countries by specialists trained in his unique pain-relief methods. fitnessnetwork.com.au/biomechanics