Hidden Cause of Knee and Back Pain

By: Darryl Viegas

Could the warmer weather finally be here? Post-winter hibernation you may be noticing a few aches and pains centred around your low back, knees, and feet. The winter of 2020/21 obviously presented some unique challenges to most of our activities and may have left you in a different physical condition than in previous years.

Your gluteal muscles

Your gluteal muscles, commonly known as your butt, are the muscles that you're sitting on and likely not using at all as you're reading this. If you’re lying down they are the muscles that kick your leg to the ceiling when you’re lying on your side (hip abduction) or your stomach (hip extension). 

Hip abduction when you’re standing occurs when the muscles of your right leg contract as your left left foot lifts off of the ground to create a hip hiking movement. This hip hike shortens the leg that’s swinging forward making it easier to stride forward and stopping you from falling to the side. 

Functionally hip extension occurs as your leg pushes you forward when you’re walking and running. 

Why is sitting a factor?

When we sit we are positioned with our hip flexed (knee approaching your hip level). Even if you're sitting in good ergonomic posture, this is a stretch position for the muscles on the back of your hip including your gluteal muscle group. Stretching a muscle is a way of calming down and relaxing a muscle, a great way to inhibit a muscle from working.

But I'm able to get up from sitting and walk around!

Muscles work together with other muscles to do work. These groups of muscles are known as synergists. If your gluteal muscles aren’t in ideal shape to work to abduct your hip when you’re walking, then you may engage some of your back muscles and other hip muscles to help. This is fine when it comes to a small amount of walking or movements, but as your workload increases this can place strain on the overused muscles. This change in workload can be an increase in the amount that you’re walking, the terrain, or building up to running

I get what that has to do with my back, but how does that affect my knees?

In addition to controlling hip abduction, your gluteal muscles for the most part are also outward rotators of your hip. They don’t physically turn your feet out as you’re walking, instead they control the inward rotation of your hips as we walk. If they are weak, then your hip internal rotators, including your tensor fascia lata muscle, can increase the tension on your IT band and contribute to knee and kneecap pain. This can be experienced as pain when you’re sitting, outer knee pain with running, or morning stiffness of your knees. Additionally, a weakness of your gluteals as hip extensor muscles requires your hamstring and calf muscles to be more active on the push off phase of walking.

So increased use of the calf muscles affects my feet?

Yes! Your hamstring and calf muscles attach near the back of your knee. Increased use of your hamstrings and calf muscles can result in muscles that never fully stretch out, even though you feel like they need to. Imbalances in your calf muscles with their attachment at your heel can increase the pull on your plantar fascia and result in heel and foot pain.

Do I have weak gluteal muscles?

A quick way to check the functional strength of your hip abductor muscle group is to perform a single leg standing test. Lift one leg off of the ground and balance on one leg and then repeat for your other leg. Most people find this relatively simple because many muscles can work to perform this task. If your gluteals are weak your body will shift your centre of gravity more laterally to balance you. 

To more specifically check the functional strength of your gluteal muscles, perform the same test, but this time stand with one hip a few centimeters from a wall. Repeat the test lifting the leg that isn’t near the wall. Are you able to lift your leg without your hip touching the wall and without bending your back?

How can I strengthen my hip abductors?

A good functional retraining exercise for your gluteal muscles is to train the movement in a way that prevents you from compensating with your back muscles. This could include a side-kick exercise in a controlled range of motion, or progressions of core exercises including side plank progressions.

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If you’ve already tried exercises such as these and have not found them to be effective or you experience pain when performing them, then there may be underlying causes preventing this muscle group from engaging properly. These can include:

The above situations shouldn’t mean that you’re doomed to have continued low back pain. They just mean that you may need modifications of the above exercises. In these situations an assessment by a physiotherapist that has experience in assessing and treating conditions of the back, hips, and knees with manual therapy techniques and progressive exercise therapy should get you back to pain free movement.

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