Pelvic See Saw: Combining lumbar extension with hip flexion and lumbar flexion with hip extension

in 2 Movement Tests Lower Quarter, 5 Home Exercise Strategy, All Home Exercises, All Lower Quarter, Functional Integration, Hip EXT Firing Pattern, Pelvic Clocks, Supine Curl Up, Supine Heel slide

Pelvic See Saw: Combining lumbar extension with hip flexion and lumbar flexion with hip extension

The patient is lying on their back with the knees bent and feet flat on the table.
Ask the patient to roll the pelvis toward 6:00 extending through the lumbar spine up into the thoracic spine and increasing flexion of the hips. (Top)
Then instruct the patient to relax the erector spinae and slowly reverse the position by touching the spine down to the table, rolling the pelvis up toward 12:00 and adding extension through the hips by bridging and lifting the hips up off the table. (Bottom)
From the bridge position ask the patient to slowly touch the spine down to the table working from above down segmentally, i.e., T11, T12, L1, L2, etc. until the sacrum touches the table. They then reverse directions by rolling the pelvis towards 6:00 and extending the spine segmentally from below up.
The patient is instructed to repeat this movement 4-5 times.

Single-Limb Deadlift with Straight Knee

in 2 Movement Tests Lower Quarter, 5 Home Exercise Strategy, All Home Exercises, All Lower Quarter, Hip EXT Firing Pattern, Retraining

Single-Limb Deadlift with Straight Knee

To strengthen the Right Gluteus Maximus:

The patient is standing with their hands at their sides.
Ask the patient to reach down with their left hand towards the outside of their right foot while keeping their right leg as straight as possible.
The patient should bend forward from the waist and trunk and avoid bending the right knee as much as possible.
Instruct the patient to try to touch their left fingers to the outside of their right foot.
They then return to upright standing and repeat 3 to 5 times initially, working up to 10 repetitions on each leg.
This exercise requires good extensibility of the hamstrings which should be stretched prior to doing this exercise.
Single-limb deadlift with a straight knee was reported to produce the highest % of MVIC for the gluteus maximus out of 12 exercises that are commonly prescribed for gluteal strengthening (DiStefano et al. 2009).

Single-Limb Deadlift with Bent Knee

in 2 Movement Tests Lower Quarter, 5 Home Exercise Strategy, All Home Exercises, All Lower Quarter, Hip EXT Firing Pattern, Retraining

Single-Limb Deadlift with Bent Knee

To strengthen the Right Gluteus Maximus:

The patient is standing with their hands at their sides.
Ask the patient to reach down with their left hand towards the outside of their right foot while keeping their right leg as straight as possible.
The patient should bend forward from the waist and trunk and avoid bending their right knee as much as possible.
Instruct the patient to try to touch their left fingers to the outside of their right foot.
They then return to upright standing and repeat 3 to 5 times initially, working up to 10 repetitions on each leg.
This exercise requires good flexibility of the hamstrings so the patient is allowed to bend the right knee if the hamstrings are tight.

Single Leg Bridge

in 2 Movement Tests Lower Quarter, 5 Home Exercise Strategy, All Home Exercises, All Lower Quarter, Hip EXT Firing Pattern, Retraining, Supine Hip ABD and ER

Single Leg Bridge

To strengthen the L gluteus maximus:

The patient is lying on their back with both knees bent up and feet resting flat on the floor.
Ask the patient to bring their right knee up to the chest and hold with their hands.
Instruct the patient to draw the toes of the L foot up and gently push the left heel away to inhibit the left hamstrings.
Now ask the patient to bridge up on their L foot as high as they can while they hold their R knee to chest.
Have the patient hold for 10 seconds then slowly lower their L hip back down to the table.
Have them repeat for 3 to 5 reps initially working up to 10 reps on each leg.

Supine Bridging – Bilateral and Unilateral

in 2 Movement Tests Lower Quarter, 5 Home Exercise Strategy, All Home Exercises, All Lower Quarter, Hip EXT Firing Pattern, Retraining

Supine Bridging – Bilateral and Unilateral

To activate and strengthen the gluteus maximus:

The patient is lying on their back with knees bent and feet hip width apart.
Instruct the patient to find a neutral lumbar spine, midway between the end range of 12:00 and 6:00 then draw the belly in towards the spine.
Ask the patient to lift the toes up and push the heels away to tighten the quadriceps, then lift the hips up off the table while maintaining a neutral spine.
Instruct the patient to tighten the buttocks muscles as they bridge up.
Don’t let the patient lift up so high that they arch the lower back and lose the neutral position.
Have the patient hold for 10 seconds and repeat initially 3-5 times.
As the patient become stronger, they can attempt to straighten one knee while in the bridge position. They hold for 10 seconds and alternate with the opposite leg before lowering to the table. Make sure the pelvis doesn’t drop and the hamstrings do not cramp. Cramping of the hamstrings is an indication that the gluteus maximus is not engaged enough and that this exercise is too advanced for the patient.
Pushing away with the heels activates the quadriceps to inhibit the hamstrings from working to hard.

Prone Hip Extension Off the Table

in 2 Movement Tests Lower Quarter, 5 Home Exercise Strategy, All Home Exercises, All Lower Quarter, Hip EXT Firing Pattern, Retraining

Prone Hip Extension Off the Table

The patient is lying on their stomach on a table top, positioned with their knees bent and feet flat on the floor.
Instruct the patient to find a neutral lumbar spine by rocking the pelvis towards 12:00 then 6:00, finding the midpoint in between. The therapist monitors the PSISs to insure that they are level in the frontal plane.
The patient is instructed to hold this position by drawing the belly button in towards the spine.
Ask the patient to extend one leg at a time, maintaining flexion of the knee and keeping a neutral lumbar spine. Make sure that the patient does not abduct or externally rotate the leg during hip extension and that the PSISs remain level.
The patient should feel their buttocks tighten during the movement. The therapist should also be able to palpate tone in the gluteus maximus during this exercise.
Make sure that the movement occurs in the hip joint, avoiding extension of the spine.
It may be helpful to instruct the patient to try and elongate the leg by reaching away with their knee as the hip is extended.
Have the patient hold for 10 seconds and initially repeat only 3-5 times. Alternate legs.

Dysfunctional Prone Hip Extension Functional Movement Test

in 2 Movement Tests Lower Quarter, All Lower Quarter, Hip EXT Firing Pattern

Dysfunctional Prone Hip Extension Functional Movement Test

Anatomy and Biomechanics:

This prone lying test assesses the recruitment of the gluteus maximus and hamstrings and requires 5 to 10 degrees of active hip extension mobility. Restriction of hip extension ROM can be due to tight hip flexors and/or a tight anterior hip capsule which needs to be addressed first before attempting retraining. (See Module #3) If the prone hip extension test is dysfunctional then to maximize gluteus maximus recruitment, retraining should initially begin with the hip flexed, ie,. short of neutral, thereby reducing some inhibitory factors.

Substitution patterns to watch out for during retraining:

Janda, 1990, originally described an ideal hip extension firing pattern in which the hamstrings fired first followed by the gluteus maximus then the contralateral and finally ipsilateral lumbar erector spinae. Subsequent studies have not supported this firing pattern (Pierce and Lee, 1990; Vogt and Banzer, 1997). Clinically what seems to be most important is whether or not the gluteus maximus fires at all and how well is the pelvis and trunk stabilized during hip extension. Often patients are able to extend a leg without any palpable tension felt in the gluteus maximus at all with substitution occurring by the patient using their erector spinae and hamstrings to lift the leg.

Patients will often substitute for a lack of hip extension mobility by anteriorly rotating the ipsilateral innominate as they raise the leg. This is why it’s important both during the functional movement test and during retraining that the therapist monitors the position of the PSISs during hip extension to insure that minimal anterior innominate rotation occurs (slight superior migration of the PSIS is ok).

The therapist should also watch for any pelvic rotation in the transverse plane during hip extension retraining indicative of a loss of anterior stabilization of the pelvis. This substitution pattern occurs due to inhibition of the abdominal obliques and hypertonicity of the erector spinae on one side, ie., during L hip extension the R ASIS lifts off the table excessively as the thoracolumbar junction and pelvis rotate to the R. These patients often present with an increase in tone and palpable tension of the R erector spinae muscles even with the patient lying at rest.

Star Diagram

in 2 Movement Tests Lower Quarter, 5 Home Exercise Strategy, All Home Exercises, All Lower Quarter, Functional Integration, Hip ABD Firing Pattern, Hip EXT Firing Pattern, Sensorimotor, Supine Hip ABD and ER

Star Diagram

Closed kinetic chain facilitation of the gluteal muscles:

With the patient’s arms at their sides instruct the patient to advance the right leg as far forward as possible keeping their right foot approximately an inch off the floor as they bend the left knee.
The patient then reaches back as far as they can with the right foot staying an inch off the floor.
Then ask the patient to reach with their right foot out to the side and finally to draw a star taking the right foot behind and to the left and forward to the right and finally back to the right keeping the right foot an inch off the floor each time and bending their left knee as far as possible.
Repeat in each direction 4 to 5 times, then repeat standing on the right leg.
Make sure to watch for any valgus deviation of the stance knee during this retraining, which should be avoided.

Single-Limb Squat with Hip Abduction

in 2 Movement Tests Lower Quarter, 5 Home Exercise Strategy, All Home Exercises, All Lower Quarter, Hip ABD Firing Pattern, Retraining

Single-Limb Squat with Hip Abduction

The patient is standing with the right shoulder resting against the wall and the right hip and knee flexed.
Instruct the patient to press the right knee and ankle against the wall as they bend and straighten the left leg.
Ask the patient to externally rotate the left hip and extend the left hip and knee while the right leg continues to press against the wall.
The patient should maintain a neutral lumbar spine and pelvis throughout the exercise.
Have the patient repeat 3 to 5 times on each side.
To increase the level of difficulty place a wobble board or unstable surface under the patient’s left foot.

Hands and Knees Diagonals

in 2 Movement Tests Lower Quarter, 5 Home Exercise Strategy, All Home Exercises, All Lower Quarter, Hip ABD Firing Pattern, Pelvic Clocks, Retraining

Hands and Knees Diagonals

To eccentrically work the right gluteus medius:

From the hands and knees position the patient is instructed to sit back diagonally toward their right hip as far as they can without holding on with the hands.
Make sure the patient elongates/lengthens the right side of the spine as they sit back.
Instruct the patient to hold for 10 seconds and repeat 3-5 times or they can alternate from one side to the other.
The patient should report that they feel their gluteal/buttocks muscles contract with this movement.
To increase ROM and gluteal recruitment instruct the patient to do the hands and knees quadratus lumborum/lat dorsi self stretch before this exercise.

All Lower Quarter