Lower back pain can be the result of a vicious cycle of instability, spasm and inhibition. The key to prevention is right behind you…
As health and fitness professionals we have a duty to observe our clients’ movement patterns and identify the key muscles for prevention of injuries in the future.
As a physiotherapist, I am witnessing an increasing amount of recurring low back pain in otherwise fit, healthy and strong clients. I have had patients in need of treatment for lumbar disc injury who haven’t been prescribed a single exercise for the key preventer muscles, such as core and pelvic floor activation. Others come in with shoulder bicep tendon pain, yet not one rotator cuff exercise (key preventer muscle) has been advised to offload the biceps tendon.
We must remember to look at the whole body when designing exercise programs for our clients, and to closely observe their bodies when they’re working out in order to prevent injuries and keep them fit and moving!
Knowledge gaps
A client experiencing chronic lumbar pain recently showed me her prescribed program of lunges and squats, hip flexor stretches and mid-back strengthening exercises to help reduce her lumbar lordosis and address her lower back pain. On paper this would have been a good program, addressing leg strengthening, stretching tight hip flexors and strengthening the mid back. Problematically, however, the client was arching and extending her lower back with each exercise, increasing her low back pain. She had not been taught to activate her core and pelvic floor, or to activate her gluteus maximus during her functional squat and lunge exercises. She was frustrated and ready to give up the gym even though she loved it.
Let’s take a look at one common problem that many clients have following lumbar injury – and then learn some tricks and tips to rehabilitate your client and help them prevent recurring back pain.
Gluteus maximus – pay attention!
Gluteus maximus needs special attention to ensure it is actually being activated and used during an exercise program. As a hip extensor, it brings a flexed thigh in line with the trunk, prevents the forward momentum of the trunk in standing and supports the hip during gait. It is active in functional movements such as walking, cycling, running, sit to stand, rising from a stooped position and in climbing stairs. It is continuously active in strong lateral rotation, extension and abduction of the thigh. The inferior gluteal nerve that supplies the gluteus maximus muscle originates at the lower lumbar and sacral areas L5/S1/S2. Damage to the lumbar spine structures at these levels can therefore affect the gluteus maximus function.
Gluteal atrophy can be caused by poor neural activation as a result of nerve damage, stenosis (narrowing of the spinal canal) or lumbar vertebral damage. Furthermore, lower limb injuries such as ankle sprains can also decrease the coordination of firing or reflexive inhibition of the gluteus maximus muscles.
Reflexive inhibition refers to a ‘switching off’ reaction of the muscle due to either an injury to the muscle, a fracture in a nearby bone or a problem in the spine at the level from which the nerve supplies that particular muscle. It is a protective mechanism to relax the muscle and reduce severity of trauma. Unfortunately, the reflexive inhibition doesn’t necessarily turn back on once recovery begins, and the compensatory patterning of using co-existing muscles will start to become habit. For example, in a left sided L5/S1 lumbar spine disc injury, the nerve supply to gluteus maximus can become affected, and the gluteus maximus muscle on the left side can become inhibited. Consequently, the hamstrings on the left will start to get loaded, as will the left lumbar erector spinae muscles. Slowly, the piriformis muscle may tighten as a response to decreased pelvic stability and hip flexors will take more workload as a result of the inhibited gluteus maximus.
So, how do we address this vicious cycle of instability, spasm and inhibition? First, get the gluteus maximus working!
1. Educate your clients
Teaching your clients to focus on particular muscles with each exercise, and to be able to understand and feel when they are using certain muscles, is an extremely important connection. Show your client a picture of the muscle and explain its function so they understand why it is important to activate it.
2. Place a hand on the muscle
Placing a hand on the muscle you want to activate facilitates that muscle. Ask your client to stand up, place both hands onto their gluteus maximus, and squeeze their bottom muscles together to feel the movement and contraction. Sometimes this results in a good connection.
3. Lumbar spine rotation stretch
Get your client to perform this stretch with knee bent and in a high hip flexed position. Ask them to lie on the floor, bring one knee in towards their chest and then slowly rotate the knee across to the other side of their body. This will open the facet joints, helping to take pressure off the inferior gluteal nerve. Following the stretch, repeat the gluteus maximus exercise to see if there is any better activation.
4. Lumbar spine side-to-side gentle rocks
Performing mild side-to-side rocking motions addresses lower lumbar facet joint tightness and reduces compression on spinal nerves. It does this by massaging the lower back into the floor, gently opening the facet joints either side of the lumbar spine, and reducing external oblique gripping and rigidity in the trunk. Again, repeat the gluteus maximus exercise to see if there is any better activation.
5. Piriformis stretch
This stretch can help reduce muscles spasm compression on nerves. If gluteus maximus is wasted and weak, then the piriformis muscles can be loaded and become chronically shortened to help with stability around the pelvis. The piriformis needs to sometimes be ‘downtrained’ and lengthened to allow the gluteus maximus to start firing up again.
6. Hamstring stretch
Get your client to perform a hamstring stretch to reduce involvement and lengthen hamstrings. As a secondary hip extensor, the hamstring is the first muscle to be recruited to assist a weak gluteus maximus muscle. Again, downtraining or reducing tension via stretching, foam roller releases or PNF (proprioceptive neuromuscular facilitation) stretching can help focus on getting gluteus maximus to start working functionally.
7. Hip flexor stretches
Performing hip flexor stretches, to help reduce lumbar erector spinae tension and facet joint compression, may reduce pain in the back and help facilitate a good gluteus maximus contraction.
8. Involve the latissimus dorsi muscles
Involving the latissimus dorsi muscles will help facilitate the posterior oblique system. The gluteus maximus works functionally with the latissimus dorsi muscle via thoracolumbar fascia in the posterior oblique system. Some clients feel they have a stronger gluteus maximus connection when they gently exercise lats whilst doing a gluteal exercise, e.g. pushing hands into the floor when performing a pelvic roll.
9. Change posturing to involve gravity
I have found that when clients are lying on the floor with full support, it is more difficult to activate their ‘antigravity’ muscles, such as the hip extensors. Therefore, instead of starting the client in supine on the floor to activate their gluteals, a better contraction can be achieved in standing or performing standing up from a chair.
10. Change foot position
This could involve: positioning the feet closer to, or further away from, the gluteals, making sure their feet are in good alignment or slightly externally rotating their feet. Don’t be shy to slightly change the way your clients weight bear through their feet in order to help that gluteus maximus to strengthen!
All of these tips will help strengthen the gluteus maximus at the beginning of an exercise program. Before adding in load or speed to your client’s sessions, they must master the gluteus maximus activation. Forget the squats, lunges and leg press until they’ve nailed the glutes!
Failure to do so will result in structures such as the low back being unnecessarily loaded, and training for those ‘buns of steel’ will be a waste of time. Switch on the gluteus maximus and your clients will feel stronger, be in less pain and be able to continue exercising without the frustration of recurring pain.
Merrin Martin, BAppSc (Phty), BAppSc (Ex.Sc) is the founder of Active Anatomy Physiotherapy & Health Professional Workshops in Sydney. An experienced physiotherapist, exercise scientist, health educator and qualified Pilates instructor, Merrin is a highly respected expert in exercise rehabilitation. activeanatomy.com