This is a post by Dr. Dustin Lee PT, DPT
Have you ever heard from a health professional, personal trainer or that one friend who knows a surprising amount about health and fitness that, “You have a weak butt”? I am going to go out on a limb and assuming that most of you have, especially if you have been experiencing pain anywhere from the lower back to the foot. Why is this such a common phrase? A simple answer to this is based on a biomechanical model of the human body and how it interacts with the ground while we perform activities in the upright, standing position. To keep things from becoming overly complicated, we will only be considering one point of view: biomechanical problems from the top down (pelvis/hip).
Every step that we take requires a dynamic process of muscular control to make sure we stay upright. Our body reacts to the forces imparted on it by the ground as well as gravity as we perform activities on our feet. For a toddler learning how to walk, this process is quite the task. It requires countless attempts to master walking in a somewhat controlled fashion, but then it becomes automatic as we progress into childhood. It becomes yet again more complicated as we start to play and run, and occasionally we all stumbled to the ground and received our fair share of “boo-boos and ouchies.”
However, these activities soon become seemingly automatic as we mature further into adolescence and then adulthood. Our muscles are continuously being modified in their structure as we learn new tasks and exert different amounts of effort – especially for muscles surrounding the hip joint. There are three muscles – gluteus maximus, gluteus medius and gluteus minimus -- that make up the gluteals. The gluteal muscles begin developing their role in function from the onset of walking. They are commonly known as hip extensors, but they also have functional roles in controlling/performing other motions around the hip, including rotation and abduction. Returning to our top-down approach, the gluteals are just some of the muscles that help support the pelvis on the leg below when making contact with the ground. Specifically, the gluteus medius has the important role of maintaining the level of our pelvis as we walk or run. The gluteus maximus, medius and minimus all contribute to limiting the amount of rotation and “falling in” of the knee underneath the pelvis when we make contact with the ground.
Unfortunately, this seemingly automatic process can become altered with disease, lack of exercise and decreased activity (such as sitting at a desk or on the couch for a long time). The gluteal muscles can be modified for better or worse. It is a basic principle of “use it or lose it.” They can also be modified for better or worse depending on the type of training you are performing. Runners, for instance, spend a lot of time performing activities of flexion and extension in the sagittal plane. Other motions, rotational and side-to-side, can be affected by this unless cross training takes place that involves rotational or side-to-side motions. Ball sports require stability in all three planes of motion, so participants are more likely to have fully functional gluteal muscles necessary for their sport. Injury, particularly related to overuse, may occur when muscles are not functioning well enough to maintain efficient joint movements with activity. The authors of the study state that, “Numerous pathologies have been described which are related to the inability to maintain proper alignment of the pelvis and the femur, including tibial stress fracture, 5 low back pain, 6,7 iliotibial band friction syndrome, 2,4 anterior cruciate ligament injury, 3,4 and patellofemoral pathology.” Part of my job is to help retrain and strengthen the gluteal muscles to function well and allow for better joint mechanics with all activity. A common exercise prescribed to do exactly this is called “clams,” better known as hip abduction or external rotation. This exercise is not a bad option for those relearning how to use their gluteus medius, but it is often over-prescribed and not advanced enough for those looking to return to activities on their feet. My standpoint is that clams are better described as seafood and less so an exercise. There is a time and place for them in rehabilitation, but the exercise should be progressed appropriately to allow for the most functional improvement of the targeted muscles.
The research study mentioned above specifically looked at muscular activity from the gluteus medius and gluteus maximus, with particular exercises commonly prescribed by health professionals 1. The details of the study will not be discussed for purposes of this blog. The following activities listed produced activation of the gluteus medius and gluteus maximus muscles that was greater than the amount needed for strengthening to occur 1. It is important to note that the individuals that were studied were healthy subjects who were able to perform exercise for approximately one hour. It should be taken into consideration that these exercises are all very challenging and would not be appropriate for initial strengthening in patients with weak core musculature due to their high degree of difficulty and the amount of core stabilization required 1. Now that the logistics are out of way, let’s look at how health professionals, especially physical therapists, can better strengthen and retrain the gluteal muscles necessary for basic and dynamic standing activity.
Top 4 exercises for gluteus medius and gluteus maximus activation
1. Front plank with hip extension (Alternative: perform from knees)
2. Side plank with dominant leg on top performing a leg lift (Alternative: perform from knees)
3. Side plank with non-dominant leg on top performing a leg lift (Alternative: perform from knees)
4. Single leg squat
Boren, K., Conrey, C., Coguic, J. L., Paprocki, L., Voight, M., & Robinson, T. K. (2011, September). Electomyographic Analysis of Gluteus Medius and Gluteus Maximus During Rehabilitation Exercises. Retrieved March 06, 2017, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3201064/
Ferber R, Noehren B, Hamill J, et al. Competitive Female Runners With a History of Iliotibial Band Syndrome Demonstrate Atypical Hip and Knee Kinematics. J Orthop Phys Ther. 2010; 40: 52–58
Hewett T, Myer G, Ford K., Anterior Cruciate Ligament Injuries in Female Athletes: Part 1, Mechanisms and Risk Factors. Am J Sports Med. 2006; 34: 299–311
Leetun D, Ireland M, Wilison J, et al. Core Stability Measures as Risk Factors for Lower Extremity Injury in Athletes. Med Sci Sports Exercise. 2004; 36: 926–934
Milner C, Hamill J, Davis I. Distinct Hip and Rearfoot Kinematics in Female Runners With a History of Tibial Stress Fracture. J Orthop Sports Phys Ther. 2010; 40: 59–66
Nelson-Wong E, Flynn T, Callaghan J. Development of Active Hip Abduction as a Screening Test for Identifying Occupational Low Back Pain. J Orthop Sports Phys Ther. 2009; 39: 649–657
Nelson-Wong E, Gregory D, Winter D, et al. Gluteus Medius Muscle Activation Patterns as a Predictor of Low Back Pain During Standing. Clin Bio. 2008; 23: 545–553