The pelvis is one of the commonly problematic areas to experience musculoskeletal pain and inefficiency with movement. This often manifests as pain in the lumbar spine, sacroiliac joint, or the posterior hip capsule and musculature. These issues are incredibly common, and there is good reason for that. Anatomically, the lumbopelvic area is a crossroads for many different muscles, kinetic chains, and important bony structures.
Almost all human movements require optimal function around the lumbopelvic area. If we are lacking in functional capacity in this area, we increase the likelihood that we will experience difficulty with movement, pain, or decreased performance.
In this article, we will go over what the most common issues are that involve the lumbopelvic complex, what key functional movement components need to be improved upon, and how to specifically address these things in your rehab and training protocols.
Common Lumbopelvic Issues
Lower back pain is the most common presentation of pain in general, and is definitely one I see clients for often in my clinic. The origin or cause of lower back pain can be as variable as anything else, and largely depends on the individual, their history, their anatomy, training background, etc. That said, there are a handful of causes I find most often, and I want to briefly share some insights on each.
Lumbar-related low back pain is typically associated with disc issues. What I find is that while discs are often involved, they are seldom the sole cause of the pain, and even if they are the primary driver, it doesn’t drastically change the protocols we would want to use in order to eliminate the pain and restore normal function. The lumbar spine often overly compresses itself in attempts to create stability if the muscles are not embracing their role as stabilizers. This leads to decreased space between the vertebrae, and makes us more susceptible to the discs or nerves becoming irritated as a result. Nerves not having ample room to send efficient signals to the muscles they innervate compromises the function of those muscles, creating less stability around the spine, and reinforces the compensation of lumbar compression even further. This can become a vicious cycle.
The sacroiliac joints (SIJ) are often symptomatic for many of us, and if not symptomatic, then they are at the very least not functioning as optimally as they could. The SI joints are technically located in the pelvis rather than the lumbar spine, and we often lump pelvic pain together with low back pain, but it is important to make the distinction. When it comes to SIJ dysfunction, the most common cause is a lack of integration of the lower extremities, and rotational instability. The muscles involved often include the hamstrings, glutes, lumbar erectors, and deep hip rotators. In order to find and address the cause, we often need to do some additional detective work via movement and palpatory assessment to identify the muscles and kinetic chains involved.
Hip pain is seldom limited to just the hip. While hip mobility issues can often be accompanied by pain and pinching in the front of the hip, the two are not usually causative of each other. One of the more common presentations of pain in the hip, and one that largely relates back to the integration of the entire lumbopelvic complex, is pain in the deep posterior hip/glute area. Pain in this area is typically associated with sciatica, however, it’s only rarely actual sciatica. If you are not experiencing nerve pain, numbness, and/or tingling throughout the leg from the hip down to the foot, the chances are good that the sciatic nerve is not the issue. Sometimes nasty trigger points and muscle tension in the posterior hip can create sciatic-like symptoms. The sciatic nerve can be compressed in the lumbar, but it can also become irritated from chronically tight hip rotators like piriformis (often referred to as piriformis syndrome), as well as other nerve entrapment sites in the lower extremity.
While there are plenty of other common pain issues in the lumbo-pelvic complex, these are by far the most common, and the ones I see most regularly in my clinic. Now let’s dive a bit deeper into some of the key functional training components that can be improved upon through rehab protocols and training.
How to “Fix” Your Lumbopelvic Pain
There are hundreds if not thousands of exercises out there that may or may not help you in your quest to figure out and fix your symptoms. While I will be providing some helpful exercises that have become go-to’s for me and my clients, I want to spend more time educating you on how and why these common presentations of pain show up in the first place.
For now, let operate on the assumption that your MRI’s are clean, and there are no significant structural issues in the lumbar spine that are producing your symptoms. No disc herniations or bulging. No spondylolisthesis. No vertebral fractures. Just chronic, achey, irritating if not debilitating muscular pain.
The lumbar spine has several primary roles, but none more important than providing a stable pillar for the core musculature to work off of. The nerves that innervate the lower extremities are housed in the lumbar spine, and need adequate protection and room to send and receive signals further downstream. What unfortunately ends up happening in the lumbar spine as a less-than-optimal compensation strategy is that the lumbar spine compresses, resulting in less room for the nerves to send and receive signals properly. Not only that, but the connective tissues in the lumbar spine create constant neurological signaling to the brain that often creates muscular inhibition and hypertonicity through the whole lumbopelvic region.
What causes the lumbar spine to compress? More specifically, why does the nervous system feel the need to create compression in the lumbar spine as a compensation strategy? More often than not, clients who come to see me with lower back pain related to lumbar compression are athletes and lifters, or those are generally sedentary. It is impossible to say for certain what causes compression to happen vs another form of compensation. Too many repetitions. Too much load. Too much time spent in one position. Etc. However, there is some common ground between weight lifters and sedentary folks when it comes to lumbar compression: breathing. Rather a lack of efficient breathing mechanics as they relate to functional core strength.
One of the most common issues with core function in general is the lack of ability to breathe and stabilize simultaneously. I often find that folks have a hard time knowing how and when to breath parasympathetically and reflexively vs. creating effective intra-abdominal pressure by holding the breath in order to support the spine during the lifting of heavy loads. Lifters tend to not include enough exercises in their programming that train dynamic stabilization of the spine while maintaining normal breathing mechanics. On the other end of the structrum, sedentary folks usually don’t know how to create intra-abdominal pressure during strength training, and by nature of being relatively disconnected from their bodies, also lack fundamental breathing mechanics during low-intensity activity. Ultimately it boils down to being able to breath properly, brace properly, and knowing when to do which.
In order to improve your breathing mechanics, below are a handful of drills that have become go-to’s for me.
Supine Pallof Press:
The SIJ serves two primary roles. First, it is one of the primary joints involved in shock absorption. Walking gait, running, jumping, and landing all require the SIJ to properly transfer kinetic energy from the lower extremities through the pelvis, through the lumbar spine, and into the contralateral side of the torso. Secondly, the SIJ must have adequate rotational stability as it serves as the intersection for the spiral kinetic chains. How well our body can manage rotational stability and thus rotational power depends largely on the stability of the sacroiliac joint.
In my clinical practice, there are no shortage of SI joint related issues. Sometimes they are bilateral (both SI joints are affected), and sometimes just one side is an issue. Sometimes the pain resides within the SIJ itself as a result of chronic overloading of the joint. Sometimes the ligaments within the SIJ create neurological compensation that affects local muscles like the QLs, hip rotators, psoas, obliques, or lumbar erectors, and pain instead shows up in the muscles.
Whether or not the SIJ has movement available, and whether it is even meant to move is still largely debated. However, to what degree the SIJ should move matters less than whether or not the joint can tolerate load. When I assess the function of the SIJ, I use a palpatory assessment to feel whether or not the SI joints have a natural springiness to them, or if they feel “stuck in mud.” Generally speaking, a healthy and functional SI joint should feel springy. If it feels stuck or lacks that natural springiness, the joints are likely compressed, inflamed, and/or the ligaments are holding excessive neurological tension. A stuck SI joint does not have the ability to carry out its roles of shock absorption or maintaining tensional balance through the pelvis very well. If both SI joints are compressed, typically there is an anterior-posterior chain imbalance. Both excessive anterior pelvic tilt as well as posterior pelvic tilt often accompany compressed SI joints. If just one side is symptomatic, it is usually more to do with a left-right rotational imbalance.
As well, I have noticed that SI joint issues often show up in people who have a hard time stabilizing properly through their feet; excessive foot pronation results in poor shock absorption. If the body can’t absorb shock efficiently through the feet, knees, or muscles of the lower extremity, the SI joints will often lock down in a compensatory attempt to create more stability through the system.
As you can see, the SI joints can become symptomatic from improper breathing mechanics and core function, as well as poor strength and shock absorption capabilities in the lower extremities. Just like the lumbar, overly compressed SI joints can then create additional layers of muscular compensation, further feeding into the dysfunction over time. Chicken or the egg scenario, but our approach to resolving SI joint issues should involve improving function in the feet, the core, as well as focus on integrated the two together. Below are a few of my favorite go-to drills for working with SI joint clients.
Ankle Wall Mobilization:
Kettlebell Armbar - Rollover:
Pelvic Torsion & Rotational Stability
Rotational forces are at the core of power development. In order to crawl, walk, run, kick, punch, throw, or swing...basically any motion involving the limbs, we need our body to be able to handle the storing and releasing of kinetic energy through the transverse plane. This is done primarily through the anterior and posterior spiral kinetic chains.
If you’ve done even a little bit of research to better understand the lumbopelvic complex and why you might be experiencing symptoms there, you’ve probably heard of the terms “anterior pelvic tilt,” or “posterior pelvic tilt.” Generally speaking, these postural deviations of the pelvis are associated with sagittal plane (front-back) stability issues. What you may not be as familiar with is “pelvic torsion,” which is when one side of the pelvis is anteriorly or posteriorly tilted relative to the other side. This presentation is more indicative of full-body rotational imbalances. Since the lumbopelvic complex is essentially the crossroads for most of our kinetic chains, the pelvis will deviate from a neutral position as a postural adaptation to these rotational imbalances.
In my clinical experience, pelvic torsion is incredibly common. In fact it is so common that I’d venture to say I see it some degree in almost everyone I assess. Almost everybody is more efficient rotating or stabilizing rotation in one direction compared to the other. Think of it this way: if you can’t throw a ball with the same level of coordination with either arm, chances are good that your rotational capacity is skewed in one direction. This unidirectional rotational bias is what often feeds into a torsioned pelvis posture.
I want to make it very clear that while postural deviations are common, particularly pelvic torsion, these asymmetrical postural adaptations are likely not what is CAUSING your symptoms or pain. You may be experiencing symptoms, and improving on rotational balance can help to some degree. However, restoring left-right rotational balance is not even close to a guaranteed fix. Instead, what we should focus on is recognizing this postural asymmetry, addressing any tissue-related stress that come as a result of these asymmetries, and to adjust our training to improve upon the areas that may be functional movement blind spots for us as a result.
By making sure that our body is strong and moves well in a variety of contexts, we increase the likelihood that our tissues adapt well, and our movements continue to feel good. An effective way of doing this from a training perspective is to utilize exercises that simultaneously extend one hip, flex the other hip, and generate torsional forces around the pelvis. Below are a few exercises that I like to utilize to both assess and well as improve upon rotational asymmetry in the body.
Supine Pallof Press:
The first step to resolving your lumbopelvic symptoms is to understand the functional anatomy and possible causes. Just understanding these things can go a long way in reducing the fear-based response to pain. The better we understand something, the less we fear it.
Next, start to train in a way that improves upon the lumbar spine’s ability to stabilize without compression, the sacroiliac joint’s ability to effectively dissipate ground reaction force, and the pelvis’ ability to balance out rotational forces. Start conservatively with changing how you move. Chances are good that if you improve the biomechanical efficiency of your movement, your lumbopelvic area will feel a lot better.
If that doesn’t help, it might be a good idea to get some imaging done to confirm whether or not there may be a hardware issue contributing to your symptoms. If images are clean, there are likely more psychosocial factors feeding into your symptoms. In that case, while biomechanical efficiency is still important, emotional or environmental stresses may be trumping your ability to properly heal.
If you need any help getting a better understanding of your low back, pelvic, or hip pain, please feel free to reach out directly! I’d be happy to help.