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A Simple Tweak to Enhance Glute and Reduce TFL Activity

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Hip weakness is a common area of focus in both the rehabilitation and fitness fields.  Combine our excessive sitting postures and the majority of activities during the day that occur in the sagittal plane of motion, and hip weakness in the frontal and transverse planes is common.

There are many exercises designed to address glute medius and glute maximus strength in the transverse plane.  But a simple tweak to your posture during one of the most common exercises can have a big impact on glute activity and the balance between your glutes and TFL.

 

The Effect of Body Position on Lateral Band Walking

A recent study in JOSPT analyzed EMG activity of the glute max, glute medius, and TFL muscles during two variations of the lateral band walking exercises.

The subjects performed the lateral band walk in a standing straight up posture and a more flexed squat position.

A Simple Tweak to Enhance Glute and Reduce TFL Activity

I’ve personally used both variations in the past but tend to perform the exercise more often in the slightly flexed position, which we consider a more “athletic posture,” as we don’t really walk laterally with our hips and knees straight very often.

Results showed that EMG of both the glute max and glute medius was enhanced by performing lateral band walks in the partial squat position, and that TFL activity was actually reduced.  Glute activity almost doubled.

 

A Simple Tweak to Enhance Glute and Reduce TFL Activity

The finding of reduced TFL activity is just as important as enhanced glute EMG activity, as the ratio of glute medius to TFL is greatly enhanced by performing the lateral band walk in this athletic position.

Sometimes it’s the simplest studies that make the most impact.

The TFL also acts as a secondary hip flexor and internal rotator of the hip.  In those with glute medius weakness, which is fairly common, the TFL tends to be overactive to produce abduction of the hip.

Considering how our chronic seated posture can cause shortening of the hip flexors and we know many knee issues can arise from too much dynamic hip internal rotation and glute medius weakness, we often try to focus on developing the glute medius ability to become more of the primary muscle involved with abduction, instead of the TFL.

Another interesting finding of the study was that the stance limb, not the moving limb, had higher EMG activity for every muscle in both positions.  This shows the importance of the stance abductors in providing both a closed kinetic chain driving force as well as a lumbopelvic stabilizing force when the moving limb transitions to nonweightbearing.

We focus a lot on abduction based exercises to strengthen the glute medius, but closed kinetic chain exercises in single leg stance may be just as important to train the hip to stabilize the lower extremity.

One thing I would add is that I rarely perform this exercise with the band at the ankles as the authors did.  I much prefer to put the band around the knee and feel it helps develop better hip control.

Based on this study, I’m not sure I see why I would perform a lateral band walk in a tall upright posture.  I’m going to maximize glute activity and reduce TFL activity by doing the exercise in a more flexed athletic position.

 

Should We Stop Blaming the Glutes for Everything?

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Today’s guest post comes from John Snyder, PT, DPT, CSCS.  John, who is a physical therapist in Pittsburgh, has a blog that has been honored as the “Best Student Blog” by Therapydia the past two years.  He’s a good writer and has many great thoughts on his website.  John discusses some of our common beliefs in regard to the role of the proximal hip on knee pain.  I’ll add some comments at the end as well, so be sure to read the whole article and my notes at the end.  Thanks John!

 

Should We Stop Blaming the Glutes for Everything?

should we stop blaming the glutes

Anterior cruciate ligament (ACL) rupture1,2 and patellofemoral pain syndrome (PFPS)3,4,5 are two of the most common lower extremity complaints that physicians or physical therapists will encounter. In addition to the high incidence of these pathologies, with regards to ACL injury, very high ipsilateral re-injury and contralateral injury have also been reported6,7,8.

With the importance of treating and/or preventing these injuries, several researchers have taken it upon themselves to determine what movement patterns predispose athletes to developing these conditions. This research indicates that greater knee abduction moments9,10, peak hip internal rotation11, and hip adduction motion12 are risk factors for PFPS development. Whereas, for ACL injury, Hewett and colleagues13 conducted a prospective cohort study identifying increased knee abduction angle at landing as predictive of injury status with 73% specificity and 78% sensitivity. Furthermore, as the risk factors for developing both disorders are eerily similar, Myer et al performed a similar prospective cohort study finding that athletes demonstrating >25 Nm of knee abduction load during landing are at increased risk for both PFPS and ACL injury14.

 

Does Weak Hip Strength Correlate to Knee Pain?

With a fairly robust amount of research supporting a hip etiology in the development of these injuries, it would make sense that weakness of the hip musculature would also be a risk factor, right?

A recent systematic review found very conflicting findings on the topic. With regards to cross-sectional research, the findings were very favorable with moderate level evidence indicating lower isometric hip abduction strength with a small and lower hip extension strength with a small effect size (ES)15. Additionally, there was a trend toward lower isometric hip external rotation and moderate evidence indicates lower eccentric hip external rotation strength with a medium ES in individuals with PFPS15. Unfortunately, the often more influential prospective evidence told a different story. Moderate-to-strong evidence from three high quality studies found no association between lower isometric strength of the hip abductors, extensors, external rotators, or internal rotators and the risk of developing PFPS15. The findings of this systematic review indicated hip weakness might be a potential consequence of PFPS, rather than the cause. This may be due to disuse or fear avoidance behaviors secondary to the presence of anterior knee pain.

 

Does Hip Strengthening Improve Hip Biomechanics?

Regardless of its place as a cause or consequence, hip strengthening has proved beneficial in patients with both PFPS16,17,18 and following ACL Reconstruction19, but does it actually help to change the faulty movement patterns?

Gluteal strengthening can cause several favorable outcomes, from improved quality of life to decreased pain, unfortunately however marked changes in biomechanics is not one of the benefits. Ferber and colleagues20 performed a cohort study analyzing the impact of proximal muscle strengthening on lower extremity biomechanics and found no significant effect on two dimensional peak knee abduction angle. In slight contrast however, Earl and Hoch21 found a reduction in peak internal knee abduction moment following a rehabilitation program including proximal strengthening, but no significant change in knee abduction range of motion was found. It should be noted that this study included strengthening of all proximal musculature and balance training, so it is hard to conclude that the results were due to the strengthening program and not the other components.

 

Does Glute Endurance Influence Hip Biomechanics?

All this being said, it is possible that gluteal endurance may be more influential than strength itself, so it would make sense that following isolated fatigue of this musculature, lower extremity movement patterns would deteriorate.

Once again, this belief is in contrast to the available evidence. While fatigue itself most definitely has an impact on lower extremity quality of movement, isolated fatigue of the gluteal musculature tells a different story. Following a hip abductor fatigue protocol, patients only demonstrated less than a one degree increase in hip-abduction angle at initial contact and knee-abduction angle at 60 milliseconds after contact during single-leg landings22. In agreement with these findings, Geiser and colleagues performed a similar hip abductor fatigue protocol and found very small alterations in frontal plane knee mechanics, which would likely have very little impact on injury risk23.

 

Can We Really Blame the Glutes?

The biomechanical explanation for why weakness or motor control deficits in the gluteal musculature SHOULD cause diminished movement quality makes complete sense, but unfortunately, the evidence at this time does not agree.

While the evidence itself does not allow the gluteal musculature to shoulder all of the blame, this does not mean we should abandon addressing these deficits in our patients. As previously stated, posterolateral hip strengthening has multiple benefits, but it is not the end-all-be-all for rehabilitation or injury prevention of lower extremity conditions. Proximal strength deficits should be assessed through validated functional testing in order to see its actual impact on lower extremity biomechanics on a patient-by-patient basis. Following this assessment, interventions should be focused on improving proximal stability, movement re-education, proprioception, fear avoidance beliefs, graded exposure, and the patient’s own values, beliefs, and expectations.

 

John SnyderJohn Snyder, PT, DPT, CSCS received his Doctor of Physical Therapy degree from the University of Pittsburgh in 2014. He created and frequently contributes to SnyderPhysicalTherapy.com (Formerly OrthopedicManualPT.com), which is a blog devoted to evidence-based management of orthopedic conditions.  

 

Mike’s Thoughts

John provides an excellent review of many common beliefs in regard to the influence of the hip on knee pain.  While it is easy to draw immediate conclusions from the result of one study or meta-analysis, one must be careful with how they interpret date.

I think “anterior knee pain,” or even PFPS, is just too broad of a term to design accurate research studies.  It’s going to be hard to find prospective correlations with such vague terminology.  Think of it as watering down the results.  Including a large sample of people, including men, women, and adolescents and attempting to correlate findings to “anterior knee pain” is a daunting task.

Imagine if we followed a group of adolescents from one school system for several years.  Variations in gender, sport participation, recreational activity, sedentary level, and many more factors would all have to be considered.  Imagine comparing the development of knee pain in a 13 year old sedentary female that decided she wanted to run cross country for the first time with an 18 year old male basketball player that is playing in 3 leagues simultaneously.  Two different types of subjects with different activities and injury mechanisms.  But, these two would be grouped together with “anterior knee pain.”

What do we currently know?  We know hip weakness is present in people with PFPS and strengthening the hips reduces symptoms.  As rehabilitation specialists, that is great, we have a plan.  I’m not sure we can definitely say that hip weakness will cause knee pain, but I’m also not sure we can say it won’t.  Designing a prospective study to determine may never happen, there are just too many variables to control.

John does a great job presenting studies that require us to keep an open mind.  I’m not sure we can make definitive statements from these results, but realize that there are likely many more variables involved with the development of knee pain.  Hip strength and biomechanics may just be some of them.  Thanks for sharing John and helping us to remember that it’s not always the glutes to blame!

 

 

Hip Rotator Cuff

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Hip Rotator CuffThe latest Inner Circle webinar recording on the Hip Rotator Cuff is now available.

Hip Rotator Cuff

This month’s Inner Circle webinar on the rotator cuff of the hip was great.  We discussed how our knowledge of the hip has continued to increase over the last decade and has resulted in a much better understanding of how the hip is involved in the mechanics of the lower body and stabilization in multiple planes of motion.  We then broke down the hip musculature as either prime movers or prime stabilizers, and discussed how different positions and exercises impact both of these different muscles groups.

If this sounds familiar, it is, we use the analogy of the shoulder to show the similarities between the hip and the shoulder.

To access the webinar, please be sure you are logged in and are a member 0f the Inner Circle program.

Simple Tweak to Maximize the Hip Clam Exercise

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This week I wanted to share a quick video of a very simple tweak to maximize the hip clam exercise by really firing the glutes.  Rather than perform a standard hip clam exercise, the tweak is what you do after you lay down on your side with your hips bent to 45 degrees and knees at 90 degrees.  From this position, I want you to push your top knee outward, as if it were longer than the bottom knee.

Hip Clam Exercise with a Plus - Mike ReinoldI like to coach this by placing the hand on your hip to assure that you stabilize the upper half of your body from rolling too much.  In this position you can also really palpate the glutes with that hand while they are firing.  I also like to again coach them to push their knee out at the top of the clam, as well.

Notice that the amount of hip opening is not that much.  Essentially, by pushing your top knee outward, you are rotating your pelvis and placing the hip in a more abducted and externally rotated position.  This will allow the posterior fibers of the gluteus medius to really turn on, and also kick in the external rotation fibers of the gluteus maximus.  But you also preposition yourself in some external rotation, so the amount of clam opening will be less.  You should avoid opening the knees too much and rocking your upper body backward.  This is a common goal in the PRI world, who often describe this exercise and use it for pelvic reposition and integration exercises on the right side.  (For the PRI clinicians reading, this will obviously be familiar, for the fitness enthusiasts reading this, I recommend you get evaluated to see exactly what your body needs).

I’ve talked about how important the hip clam exercise is in the past and my past videos were pretty popular on the Mike Reinold Youtube page, so this is just another tweak you can add to your toolbox.

Simple tweak, right?  Try it!  Do a set of standard clams and then another with your top knee pushed outward, your glutes will be on fire!

If you are wondering, I called this the “Hip Clam Exercise with a Plus” in an article in Men’s Health, sort of like the “Push Up with a Plus” exercise for the serratus anterior.

 

Hip Clam Exercise with a Plus

 

Did you try it?  Are your glutes on fire?  What did you think about this simply variation of the hip clam exercise?

 

 

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Working the Glutes in 3D

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A common limiting factor in program design for both rehabilitation and performance programs is working on isolated movement patterns.  Initially there is often a need to focus on working hip extension or shoulder external rotation, for example, but once strength has improved and the movement pattern is improving, you really need to start thinking in 3D.  I talked about this concept in a past Inner Circle webinar on how we need to look at alignment in three dimensions, but this also is important for muscle function.

Gluteus maximusUsing the glutes as an example, we all know that the glutes do more than extend your hips.  I’m not just talking about the gluteus medius and minimis, but also the gluteus maximus.  If you look anatomically at the glute max, you can see the fiber orientation is ideal to provide hip extension, external rotation, and abduction.  That is the glute max’s function in 3D.  Once you groove your correct movement patterns, progress to exercises that incorporate two dimensions and then finally all three dimensions at once.  Photo from Wikipedia.

Here is a great example.  In this video, we are doing a single leg RDL.  The RDL alone works on hip extension.  By making it a single leg exercise, your body wants to drop at your hip, thus making you abduct.  Finally, to add the third dimension of external rotation, I have the person using a TRX Rip Trainer, which is essentially providing a unidirectional pull into internal rotation, and thus firing his hip external rotators:

 

Working the Glutes in 3D

 

Learn More About Functional Stability Training

If you want to optimize movement, you’ll want to check out Eric Cressey and I’s Functional Stability Training series.  We have modules on the core, lower body, upper body, and optimizing movement.  Essentially, you get a peek into how Eric and I integrate functional performance therapy and training to optimize movement and performance.

 

Top 5 Tweaks to Enhance Hip Exercises

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Inner Circle Premium Content

The latest webinar recording for Inner Circle members is now available below.

Top 5 Tweaks to Enhance Hip Exercises

In this month’s Inner Circle webinar, I review my top 5 simple little tweaks to really enhance your hip exercises.  I love topics like this as I really feel that the small attention to detail items are what can really help you set yourself apart.

  • Why we want to focus on the hips and maximizing the results of our exercise selection
  • How hip flexor tightness can ruin a great glute exercise and what to do about it
  • My top exercise to turn on the glute max and it’s ability to extend the hip
  • How to maximize sagittal plane hip exercises and make them more functional
  • How to get more out of your hip clam exercise

To access the webinar, please be sure you are logged in and are a member of the Inner Circle program.

A Simple and Effective Gluteus Medius Exercise

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Gluteus MediusI have to admit, sometimes we all get carried away with exercise selection that we overlook some of the most basic, yet highly effective exercises.  I know I fall victim to this at times!

Strengthening the gluteus medius is often an important part of our rehabilitation and performance programs.  Like I always preach regarding both shoulder rehabilitation and core exercises, there is a difference between the role and function of a muscle.  The gluteus medius has more than just a role to abduct and rotate the leg, it has a function to dynamically stabilize the pelvis and lower extremity.

But realistically, weak muscles can’t stabilize, so we still need to focus on exercises to work on activating and strengthing the gluteus medius in addition to working on dynamic stabiliztion.

Two of the most popular posts on this website have discussed Assessing and Treating Dysfunction of the Gluteus Medius and The Best Exercises for the Gluteus Maximus and Gluteus Medius.  In these posts, I discussed a bunch of great gluteus medius exercises.  I even posted specifically about the clamshell exercise.

All of these exercises discussed are great, but there is a very simple exercise that is really effective for strengthening the gluteus medius.

A Simple and Effective Gluteus Medius Exercise

OK, get ready for this…  the simple and effective exercise for the gluteus medius is…  sidelying hip abduction!  I know what you are think, wow that is really boring.  I agree, it is boring!  But it is effective.  There are many other gluteus medius exercises that work well and have other qualities that make them important to consider, but it is hard to argue about sidelying hip abduction.

Here is a good video demonstration.  Note that the leg is straight, the hip is not flexed or rotated, that is key:

Some of the past articles that I reference in the links above have stated that sidelying hip abduction has great EMG activity of the gluteus medius.  A new study in the Journal of Athletic Training agrees with these past studies.  The authors concluded that simple hip abduction straight leg raise was superior at eliciting gluteus medius EMG to the clamshell exercise and externally rotating the leg during the abduction straight leg raise.

The study also notes that the sidelying hip abduction exercise does a better job at enhancing the ratio of activity of gluteus medius and TFL.

Reducing the TFL component to hip exercises is often desired especially in those with anterior pelvic tilt, who tend to exhibit too much TFL activity and compensatory contraction to rotate the hip internally.  This is one of the reasons that sidelying hip abduction is probably even better than band walking for the gluteus medius because people tend to flex their hips while band walking, firing their TFL

Clinical Implications

There are two take home messages here for me:

  1. Sometimes taking a step back and performing a simple, or “boring” exercise may be indicated.
  2. The sidelying hip abduction straight leg raise should be included in many of our patients’ and clients’ programs, especially when trying to maximize the gluteus medius to TFL ratio of muscle activity.  This would be something I would add to an active warm-up or corrective exercise component to a program, much like the clamshell exercise.

Side Plank Clam and Side Plank Hip Abduction Exercises

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side plank clam shellThere is no doubt that the core and pelvis intricately work together to produce spine and pelvic mobility and stability.  Most of us tend to focus on both core stabilization and hip mobility and strength separately, at least initially in the program.   But we should also consider working them simultaneously.

In this model, I tend to emphasize exercises that require core stability and hip strengthening exercises.  This is a major concept in what I have always referred to as Functional Stability Training (get ready, you are going to be hearing that a lot more from me in the next several months).  Many of the basic exercises we already routinely perform achieve this goal, even if indirectly.  Bird dogs and bridges come to mind, for example.  Both exercises require core stabilization while performing hip movements, although fairly basic in regard to challenge.

 

Side Plank Hip Abduction Exercise

Recently I have seen the incorporation of side planks and hip abduction on various websites around the web.  That is a great example of the type of Functional Stability Training i am referring to here, simple stated:

[box]Train the core to stabilize while simultaneously incorporating hip mobility and strengthening exercises[/box]

Performing side lying hip abduction from a side plank position achieves this well.  However, I should note that I see many people recommending that we perform this up against a wall.  By doing this, you essentially are putting training wheels on the exercise and using the wall to help perform the side plank and abduction movements with proper form.  To me, if you need the wall, you are not ready for the exercise.

This simultaneous incorporation of spine stability and hip mobility is not a beginner exercise.  One should be able to perform each exercise perfectly as individual exercises prior to performing them together.

 

Side Plank Clam Shell Exercise

In addition to the side plank and hip abduction exercise, I also often perform a side plank and clam shell exercise.  I have talked about the many benefits of the hip clam shell exercise and why I think it is so important to include in our programs.  This is the next progression of the exercise in my mind, but in order to perform it well, you need to master both the clam shell exercise and the side plank exercise.

 

Video of the Side Plank with Hip Clam Shell and Abduction

Here is a video demonstration of the side plank with hip clam shells and with hip abduction exercises:

 

Here is another view of the side plank with clam shell exercise from my friend Masai Takahashi, who showed me how he likes to incorporate the clam shell into his side planks.  He is pretty advanced and includes a resistance band around his knees:

 

A few things to notice in the video:

  • The clam shell exercise is performed while performing the side plank from the knees, making this one a little easier at first and probably a good place to start.  Not that when performing the side plank from the knees, you need to make sure your hips move forward and your body is in alignment, as Masai demonstrates well.
  • The hip abduction exercise is performed with the legs straight.
  • The most important aspect of these exercises is maintaining core stability.  Your body should perform the plank and be able to keep the core stabilized.  If you can’t keep your form during the plank, you shouldn’t progress to include hip movements.
  • The second most important aspect is to assure you are using good hip form without compensating by rotating or losing core stability.
  • These exercises can be progressed by added weight or resistance bands around the legs

 

Remember, these exercises are not for beginners.  They require pristine form on both the side plank and hip exercises individually.  This is a key component to Functional Stability Training:

[box]If you can not perform these exercises individually, you should not progress to perform them simultaneously.[/box]

Try the side plank exercise with hip clam shells and hip abduction exercises, I think you’ll be surprised at how challenging this is for both core stability and hip strengthening.