Some Lesser Well-Know Risk Factors Associated With Developing Back Pain: Balance

Many of my patients report a decline in balance awareness as they’ve aged causing routine activities such as walking on uneven ground, or having to balance on one foot to become increasingly difficult.  For others, this has come about after an injury.   This end result is a change in lifestyle with many forced to sacrifice continuing to do the things they used to enjoy.

With a decline in balance comes an increased risk for falls which can have catastrophic results.  Early onset of knee arthritis and back pain have also been linked to individuals with balance problems.  What I have found interesting in my practice is that many people have issues with balance long before they ever injured their back, and these poor balance strategies are now known to be a cause of low back pain.

Causes Of Poor Balance

The presence of back pain has been shown to cause disruption in a person’s balance.  Studies now reveal that our balance is not quick to recover even when the back pain has resolved.  One reason for this is a delay in trunk muscle activation which compromises the ability of the trunk to make necessary corrections during functional activities.  We don’t think about these subtle corrections… they take place automatically.  Weakness and compensatory strategies soon follow (see yesterday’s post in this series).  The good news is that a physical therapist knows where to look for the cause, therefore the problem can usually be easily corrected.

Testing For Poor Balance Strategies

Even if you don’t have a falling or stumbling tendencies, you may still be using inefficient balance strategies.  People are able to discover ways to balance even when they are using the wrong muscles. The stronger and more athletic you are, the more I find you can remain ‘balanced’, even when you are using these less efficient muscle patterns. To determine whether you are using inefficient balance strategies try the following tests:

Test 1: The Toddler

Stand in front of a mirror with someone standing directly behind you.  Have them position their head directly behind yours.  You shouldn’t see any part of their face.  As you stand on one leg you will naturally shift to one side however if your balance is good, you should only see about ½ of their face at any given time.  An adult shifts about 6” to be able to stand on one leg.  If you are shifting excessively, it would be wise to begin working on a program to address this shift.  Even if you passed the 1st test, you may still be ‘cheating’.  Go through tests 2 and 3 to be sure.

Test 2: The Salsa Dancer

Thread a light, long stick into the front two belt loops of your pants, i.e. a paint stick. Stand in front of a mirror and position the stick until it is level with the ground.  Stand on one leg and watch to see if the stick moves. If you are using your hip muscles properly the stick will stay level, or slightly drop on the leg you are standing on. If it goes up this means your hip muscles are not supporting your body weight correctly.  This movement looks like the hip drop seen in Latin dancing i.e. salsa or rhumba.

This lack of support is not a healthy pattern to be using in everyday life activities, i.e. walking, standing.  If you see this pattern you, should discuss it with your therapist as it is most likely caused by weak or poorly coordinated hip abductor muscles (gluteus medius/minimus).

Test 3: The Masterful Faker

The final test requires you to feel which muscles are working when you balance.  Even when my patients perform the first two tests correctly, I sometimes find they are utilizing a compensatory pattern that makes it look as if they are doing it correctly – no excess shift, no hip drop.  But when I ask them to tell me which muscles they are using to balance, I will get insight as to whether they are using the proper strategies.  As you stand on one leg, note which muscles you tend to predominately use:

  • Toe and feet muscles
  • Calves
  • Muscles at the front of your ankle
  • Muscles at the front of thigh (Quadriceps)
  • Inner thigh or groin muscles (Adductors, hip flexors)
  • Muscles at the back of thigh (Hamstrings)
  • Back muscles
  • Buttocks (gluteus maximus)
  • Outer hip muscles (gluteus medius/minimus)
  • Abdominal muscles

Healthy Balance Patterns

Balance is best coordinated using the large muscles of the hips and torso.  It has been discovered that people with more difficulty balancing initiate correction for a loss of balance with their feet whereas the healthier patterns begin with the hip and pelvis muscles.

I often see this pattern in my patients with back pain.  This will work only for a short as these muscles are small and must work hard to balance our entire body weight.

Involving your gluteus medius and minimus muscles is crucial to healthy balance strategies.  Unfortunately, these muscles often weaken after injuries to the back.  This pattern is also an seen in people with hip arthritis and knee injuries producing increased strain on these joints.

Correcting Balance Issues

If you had difficulty passing any of these three tests, I would recommend spending some time working on improving your balance strategies.  Ideally, work to improve these patterns before you are having issues. To effectively correct balance, you need to get to the source of the issue.  Your therapist should look for weakness and poor muscle coordination patterns.

Balance is a very complex mechanism.  It is important to rule out other causes such as inner ear dysfunction, or that of a neurological origin.  Once you determine the source is from the muscles & joints, a program including both strengthening and coordination exercises will help to correct the underlying issues.  The final step is to ensure that you rapidly activate your hip muscles for balance when you are doing stairs, walking, sports or practicing “tree pose” in Yoga class. A salsa hip may be a great pattern for dance, but it should be saved for the dance floor!   With just a few minutes of effort per day, it’s amazing how much improvement can be made, even if you have had “poor balance” your entire life.

David. E. Ebbecke

After becoming a physical therapist in 1996, David continued his path toward specialization in orthopedics and manual therapy with the University of St. Augustine. He returned to his alma mater in 2004 to receive his doctorate which provided a stronger foundation for the diagnosis and management of musculoskeletal conditions. In 2009, David took ownership of Piedmont Physical Therapy (formerly Mizener, Ebbecke & Associates) from his predecessor, David Mizener who he continues to seek guidance and wisdom from to this day.

Integrating manual therapy with personalized exercises to reinforce efficient movement, David appreciates the science behind what he enjoys doing so much. What the years of practice have taught him, however, is that there is an art to caring for people, and that forging this bond between caregiver and client is what truly makes the rehabilitation process a successful one.
David. E. Ebbecke