Does Intersegmental Control matter for Lumbo-Pelvic-Hip pain?

Lumbo-Pelvic-Hip (LPH) pain is often complex and multifactorial. Much of the recent research in the area has focused on loading and strengthening specific muscle groups in the rehabilitation and prevention of injuries to the LPH Complex (LPHC), e.g. Copenhagen strengthening protocol (1). As the research shows this protocol has reported positive outcomes. What this protocol fails to address however is the potential biomechanical impacts which may contribute to LPH injuries.

A recent study by Enda King and colleagues (2) examined the clinical and biomechanical outcomes of rehabilitation targeting intersegmental control in athletic groin pain (AGP). This rehabilitation approach addressed both the intersegmental strength and control at the thorax, pelvis/hip, knee and ankle joint during specific exercises, linear running and multidirectional athletic movements. The results of this study reported an improvement in return to play, Hip & Groin Outcome Score and adductor squeeze test.

Perhaps one of the most interesting findings from this study was a significant improvement in adductor strength during squeeze tests in the absence of any direct adductor loading. Of course this improvement in strength may correspond with a reduction in symptoms within the studied patients, but this finding suggests that addressing biomechanical deficits may be another contributing factor in the prevention and rehabilitation of LPHC injuries alongside the Copenhagen protocol.

Another potential application of this study is the impact on a range of further LPHC pathologies and lower limb conditions such as hamstring and ACL injuries. With regards to other LPHC pathologies such as low back pain (LBP) and femoroacetabular impingement (FAI), two key focuses within Enda’s study during early stage intersegmental control and strengthening was the improvement in gluteal and iliopsoas strength, and the loss of lumbopelvic control into anterior pelvic tilt, both of which has been linked to LBP & FAI respectively (3, 4).

There are also commonalities between focuses within the study, such as addressing overstriding during linear running drills, and hamstring injury risk-factors such as late-swing phase which places high mechanical stress on both proximal and distal ends of the muscle group (5). In addition to this, addressing trunk side flexion and rotation, pelvic rotation and knee valgus which are potential risk factors for ACL injury.

It is also important to note that there were no differences in rehabilitation outcomes and time to return to play depending on diagnosis. Considering the psychosocial impact of injury and pain, building a rehabilitation plan with clear objective targets related to strength and control may prove particularly reassuring and motivating for a client or patient whilst avoiding over-medicalisation with common expectations and beliefs surrounding specific diagnosis. Furthermore key rehabilitation outcomes achieved by focusing on intersegmental control elicited changes in change of direction biomechanics associated with improved cutting performance which will have positive carryover to athletic performance.

As you can see there are a number of ways that this study may impact on clinical practice. I have personally experienced a large amount of clinical success in both an athletic and non-athletic population adopting this approach within assessment and rehabilitation.

Here are some examples of specific exercises I have used with success, progressing through intersegmental strength and control to linear and multi directional movement mechanics. I hope you find them useful!

Side Lying Lift Offs

Key Focus: Lateral Hip Strength, Achieve Hip Lock Position

Single Leg Hip Extension Bias

Key Focus: Dynamic Pelvic Control Through Hip Extension

Dead Leg Skips

Key Focus: Linear Running Mechanics (Force Application), Dynamic Pelvic & Ribcage Control, Dowel Provides Feedback On Excessive Trunk Activity

Lateral Shuffles

Key Focus: Change Of Direction Mechanics, Dynamic Pelvic & Ribcage Control, Med Ball Throw To Promote Torso Angle