"The foundation of stability for the pelvis is fundamentally supplied through activity in the gluteal muscle group."
This quote from Oliver and Keeley (2010) highlights the importance of including a sound gluteal-strengthening component for patients with lumbopelvic-hip dysfunctions. In my rehab programs, whether I am coaching a "regular" rehab patient or an athlete, I use numerous exercises to help strengthen the gluteal group. For the glute medius, I use anything from "clams" to side-lying hip abduction, to lateral band loop walks, to "hip hinging" progressing to single-leg squats. For the glute maximus, I could use deadlifts, transverse lunges, step-ups / step-downs and "bridges." These are all often-used exercises in my in-office programs.
Exercise Specifics
In part 1 of this article, I discussed the side-lying hip abduction exercise, which is a common exercise in Pilates. Distefano, Blackburn, Marshall and Padua (2009) compared gluteal muscle activation across 12 common strengthening exercises and found the side-lying hip abduction exercise produced 16-30 percent more gluteus medius activation than other remedial exercises.
Again, I prefer taking the side-lying exercises to a standing exercise as soon as possible to incorporate more core work. For example, I have patients perform repetitive standing hip abduction with slight hip extension while holding a kettlebell in one hand. This exercise creates functionality. My purpose in bringing the participants to a standing position is to incorporate more stabilization into the exercise.
As long as the participants are "standing tall" with a level pelvis, toes pointing forward with minimal (less than 15 degrees) foot rotation, my opinion is that they are still effectively working the gluteus medius. However, they are also working the other stabilization muscles (other hip muscles, multifidus, etc.). If they are standing on the left leg and abducting the right leg, patients usually complain about both hips working, not just the right hip.
In my non-athletic patients with lumbopelvic-hip pain related to glute medius dysfunction, I like to recommend the side-lying hip abduction maneuver and lateral band loop walks (with the loop around the knee and/or the ankle), and progress to single-leg hip hinging. For my athletic patients recovering from lumbopelvic-hip pain, I like to provide a greater challenge and teach them how to do single-leg squats and single-leg Romanian deadlifts. Single-leg maneuvers are especially valuable in the warm-up section of every workout, especially a speed-agility-quickness (SAQ) session. More single-leg exercises can be performed during the strength-training section, and can be done with resistance from bands or weights. The gluteal muscle group acts to stabilize the torso over a leg that is planted; therefore, single-leg training is essential.
Progression Protocols
While we progress toward continuous improvement in all areas of our rehab treatments, especially athletic performance, one of the major goals is avoidance of injuries. Nicholas, et al. (1977), and Nadler and Malanda, et al. (2002), describe the link theory in which the ankle, knees and hips act as a link system, making it possible to transmit forces into the pelvis and spine during running, jumping, kicking and throwing. Since these movements activate a kinetic chain, all of which involves the gluteus muscles as a stabilizing force, we understand the importance of a sound gluteus-strengthening program.
It is equally important to make sure the hips are not stiff and that they have reasonable mobility. I recommend that before starting a glute-strengthening routine, it is time well-spent to mobilize the hip joints and stretch to release tightness in the hip flexors. Once you get the hips moving properly, the lumbar spine can follow.
Do you remember the bell curve for tests results in school? I always talk to my students about the bell curve. If I focus my rehab treatment on the number of people in the middle of the bell curve, those are the majority of the LBP patients we see. Some are to the extreme right of the center; these are usually the professional athletes. Some are to the extreme left of the center; these are the chronic LBP patients (failed lumbar surgery, severe fibromyalgia, severely deconditioned from complicating conditions).
For the majority of those in the middle of the bell curve, as my patient improves during acute care from a lumbopelvic-hip injury, and as soon as possible, I explain to them that my plan is to introduce corrective exercise designed to progressively increase strength, conditioning and endurance. I teach them how to stretch the hip flexors, perform the birddog, planks (forearm to toes), bridges for the glutes and side bridges for the oblique abdominals.
For more athletic patients, I might try the Romanian deadlift (hanging position), progressing to the single-leg hip hinge; along with the front squat (catch position) with a single kettlebell held in the rack position, then the overhead press, to walking with the kettlebell held overhead in a locked-out position.
Through observational assessments, my patients confirm Nadler, Malanda et al.'s (2002) statement that the Romanian deadlift may be the most challenging lift for patients (non-athletes and athletes alike) to perform correctly, especially athletes who present with posterior chain segment dysfunction. Therefore, to decrease the probability of injury and increase the strength progress, extra time and effort is spent to ensure the athlete has the correct technique before progressing to the next level.
One of the problems I hear about in the typical chiropractic patient setting / practice is that our patients do not have the flexibility, motor control and strength to begin a weight-lifting program. I believe it is our job to help patients get flexible, gain mobility, achieve muscular development and prepare for the aging experience. I understand the challenge to get patients to perform exercises, especially correctly, and then to ask them to lift weights correctly.
Have you had experiences that validate these statements? I am always looking for strategies to implement to decrease the time patients spend developing competency in exercise techniques. These are three of my most often used "cues" during exercise drills: 1) Maintain length in the spine or think "tall spine." 2) Initiate movement from the hips. 3) Reach with the scapula first (not the hand or arm).
Regardless of age, ranking, sport, gender, or even strength and conditioning experience, all of my patients begin with the basics. I have them show me that they can establish a solid athletic position, perform some basic mobility maneuvers in the hips and shoulders, perform a squat, step over a hurdle, perform multi-directional lunges, and perform a push-up and a rotory birddog, all gracefully and efficiently. The list goes on, but the common thread is that each patient must master body-weight-based exercise first before moving on to loaded (free weights or kettlebells) exercise.
An Example Circuit
Here is an example (circuit) progression for developing an improved hip abduction movement pattern. I have the patient build up to 10-15 reps and perform this circuit three times.
- Clam shells
- Forward lunges
- Sideways lunges
- Transverse lunges
- Single-leg deadlifts
- Lateral tube walks
- Single-leg squats
There are many ways to train your patients to engage in strength training. My template for recovery and preparing patients to experience weight loading is: body and posture awareness; self myofascial release using a foam roller or similar device; stretches and body-weight moves; and band resistance. Hopefully they will take the next step in the progression toward strength and conditioning with kettlebell training or free weights. I teach all the same exercises to young kids (7-10 years old) and old kids (65-85 years old) without load in hope that through repetition, they will develop motor control and earn the right, later on, to add weights.
References / Resources
- Neumann D. Kinesiology of the hip: a focus on muscular actions. J Ortho & Phys Ther, 2010;40(2):82-95.
- Tonley J, Yun S, Kochevar R, et al. Treatment of an individual with piriformis syndrome focusing on hip muscle strengthening and movement reeducation: a case report. J Ortho & Phys Ther, 2010;40(2):103.
- Jacobs C Lewis M, Bolgla L, Christensen C, Nitz A, Uhl T. Electromyographic analysis of hip abductor exercises performed by a sample of total hip arthroplasty patients. J Arthroplasty, 2009 Oct;24(7):1130-6.
- Bolga LA, Uhl TL. Electromyographic analysis of hip rehabilitation exercises in a group of healthy subjects. J Ortho & Phys Ther, 2005;35(8):487-493.
- Distefano LJ, Blackburn JT, Marshall SW, Padua DA. Gluteal muscle activation during common therapeutic exercises. J Ortho & Phys Ther, 2009;39(7):532-540.
- Oliver G, Keeley D. Gluteal muscle group activation and its relationship with pelvis and torso kinematics in high school baseball pitchers. J Strength Cond Res, 2010;24(11):3015-22.
- Bird S, Barrington B. Exploring the dead lift. Strength & Cond J, 2010;32(20):42-50.
- Nadler SF, Malanda GA, et al. Functional performance deficits in athletes with previous extremity injury. Clin J Sport Med, 2002;12:73-78.
- Fredericson M, Cookingham CL, Chaudhari AM, Dowdell BC, Oestreicher N, Sahrmann SA. Hip abductor weakness in distance runners with iliotibial band syndrome. Clin J Sports Med, 2000;10(3):169-75.
- Green ST. Patellofemoral syndrome. J Bodywork & Mov Ther, 2005;6(1):16-26.
- Hardcastle P, Nade S. The significance of the Trendelenburg test. J Bone & Joint Surg, 1985;67(5).
- Presswood L, Cronin J, Keogh JWL, Whatman C. Gluteus medius: applied anatomy, dysfunction, assessment, and progressive strengthening. Strength & Cond J, 2008;30(5).
Part 1 of this article appeared in the last (Aug. 15, 2013) issue.
