The lower back is the most common area where people suffer from pain. The simple reason is that the back is a transition point between the upper and lower body. When performing activities with the upper or lower extremities, the lower back must work to create a solid plateau for the muscles of the extremities to work from. The funny thing about this area of the body is that most people don’t know where the lower back ends and the gluteal (buttocks) region begins. This might seem like a simple case of semantics. But when talking about pain and how to resolve it, this is a critical issue and one that must be understood to treat the root cause of your pain.
I have treated thousands of patients who actually had pain in the gluteal region but were diagnosed with a herniated disc, stenosis or pinched nerve in the lumbar spine or lower back region. There is simply no way that a structural variation at the lumbar spine can lead to pain at the gluteal region. That is why these people never were able to get a remedy for their pain until they saw me. And that is when they understood the difference between the lower back and the gluteal (buttocks) region.
The way to differentiate the lower back from the gluteal region is to identify the pelvic rim (iliac crest). This is the bony surface that most people perceive to be their hips. It is the spot everybody reaches for when prompted to “put your hands on your hips” while playing the game Simon Says. And it is actually the top of the pelvis.
If you notice in the illustration, this level is generally in line with the bottom of the lumbar spine. So if you put your hand on the pelvic rim and the pain you are experiencing is above that line, your pain is in the lumbar region. If the pain you are experiencing is below this line you are experiencing pain in the gluteal region. The cause of the pain in this region is completely different.
Pain in the gluteal region is associated with hip dysfunction and has nothing to do with the spine. The muscles that exist in the gluteal region all attach to the hip joint and perform some type of hip motion. The most common muscle to strain in the gluteal region is the piriformis muscle. This muscle sits just below the gluteus medius muscle, which is responsible for creating balance and stability. If this muscle is to strain, the piriformis will try to compensate but ultimately will strain and cause pain in the gluteal region.
Resolution of pain in the gluteal region comes from strengthening the gluteus medius muscle, the hamstrings and gluteus maximus muscles. Perform these three exercises—hip abduction, hamstring curls and hip extension—on the side that is causing you pain. Do them three times a week, performing three sets of 10 repetitions each with a one-minute break between sets. Your goal is to continually increase the resistance until the muscles involved are strong enough to perform your functional activities without straining and emitting symptoms. Once muscles are adequately strengthened and you can do the exercises pain-free, you can perform them on both sides to maintain equal strength.
Exercise 1: Hip Abduction (gluteus medius). This exercise can be performed either lying on your side or standing. To do this exercise correctly, make sure you do not go too far when moving your leg outward. People falsely belief that more range of motion is better, but in this case too much range of motion means you are using the lower back muscle to create the motion, not the gluteus medius (hip muscle). The gluteus medius muscle can only move the leg out to the point where it is parallel with the hip joint. Any outward motion beyond that is created by the lower back muscle.
To do the exercise lying down, lie on your side with the knee of the bottom leg bent and the top leg straight. The top leg should run in a continuous line from the torso—if the leg is angled in front of the torso, you would use the wrong muscle. Start to raise the top leg off the supporting leg until your top leg is parallel with the floor. As you lift, try to turn the leg in slightly so the heel is the first part of the foot that is moving. This puts the gluteus medius in the optimal position to raise the leg. Once your leg reaches parallel to the floor, begin to lower it back onto the supporting leg.
If you prefer to stand, the outward movement is similar to lying down—lead with the heel, and don’t move your leg too far to keep the exercise focused on the gluteus medius. Holding on to a sturdy table or chair while you perform the exercise will make it easier to use proper form.
Exercise 2: Hamstring Curl (hamstrings). In a seated position place the resistance at the back of the ankle. Make sure you are supported in the seat. Begin with the exercising leg pointing straight out with the knee unlocked. Begin to bend the knee until it reaches 90 degrees. Then return to the start position. To isolate the hamstrings better, have the toes of the exercising leg pointing toward the face as the exercise is being performed. In the case of using a seated Hamstring Curl machine, make sure the pivot point of the machine is aligned with the knee joint.
Exercise 3: Hip Extension (gluteus maximus). In a standing position, place the resistance behind your knee and hold on to the table or sturdy chair in front of you. Start with the hip flexed to about 60 degrees. Bring the knee about 10 degrees behind the hip. Then return to the start position. Make sure your back is rounded and the knee of the leg you are standing on is unlocked.
Exercise photos and medical illustrations: From The Pain Cure Rx by Dr. Mitchell Yass, by permission of the author.