Supine Bridging – Bilateral and Unilateral

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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

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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

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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

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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

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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

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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.

Side Lying Hip Abduction with Elongation at the Wall

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Side Lying Hip Abduction with Elongation at the Wall

To strengthen the Left Gluteus Medius:

The patient is lying on their right side with their shoulders and hips up against a wall and the right knee bent with the right foot flat against the wall.
Patient places their left hand flat on the floor in front of them for support.
Keeping the left knee straight and the heel of their left foot touching the wall instruct the patient to slowly lift the leg up the wall.
To further facilitate the gluteus medius, have the patient reach away with their left leg (elongate) and turn the left knee slightly up towards the ceiling while lifting the leg.
They hold for 10 seconds and repeat 3-5 times initially.
The patient is instructed to avoid hiking their left hip up when raising the leg and to keep their left heel against the wall throughout the exercise to avoid substitution of hip flexion and IR by an overactive TFL and hip hiking by the quadratus lumborum.
Side lying hip abduction with both legs extended and not lying up against a wall was reported to produce the highest % of MVIC for the gluteus medius out of 12 exercises that are commonly prescribed for gluteal strengthening (DiStefano et al. 2009).

The Clam Exercise

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The Clam Exercise

To Strengthen the Left Gluteus Medius:

The patient is lying on their R side with their shoulders, hips and feet touching against a wall. The shoulders and hips are perpendicular to the table or floor and the hips and knees are flexed to 45-60 degrees.
Instruct the patient to draw in the abdomen using the transversus abdominis without holding their breath.
Ask the patient to lift the left knee toward the ceiling, keeping the feet in contact.
The instruction to the patient is to attempt to lift the leg up to touch the wall and then hold for 10 seconds.
The patient repeats the movement 3-5 times initially, then increases the number of repetitions as their strength improves.

Dysfunctional Hip Abduction Tests

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Dysfunctional Hip Abduction Tests

Anatomy and Biomechanics:

Side lying hip abduction is a test designed to assess the patient’s ability to activate the gluteus medius which is the primary stabilizer of the hip in the frontal plane. If the gluteus medius is inhibited the hip joint is subjected to long lever forces by the prime hip abductor, the tensor fascia latae (TFL). In an early degenerative hip we often see hypertonicity of the TFL and the hip adductors. If the TFL and hip adductors are hypertonic and the gluteus medius is unable to stabilize the head of the femur in the acetabulum the femoral head may be forced to migrate superiorly and laterally. This migration can result in an expulsive hip with impingement of the labrum. In addition to examining the muscle recruitment pattern in the frontal plane with this test we also test hip abduction range of motion by asking the patient to raise the knee in side lying with hip abduction/external rotation (clam). In addition to giving us information about hip joint mobility this movement test is more selective for activation of the posterior fibers of the gluteus medius and superior gluteus maximus with reduced participation of the TFL (Selkowitz, Beneck, Powers, 2013).

Innervation – Superior gluteal nerve; L4, 5 and S1
FRS dysfunctions at L4,5 or L5,S1 can result in inhibition of the gluteals

Substitution patterns to watch out for during retraining:

When the gluteus medius is inhibited, especially the posterior fibers, the patient will overutilize the TFL resulting in hip flexion and IR during the performance of this test. Therefore the therapist should watch for any deviation of the leg from the frontal plane during retraining of the gluteus medius by instructing the patient to keep the leg as straight as possible. The patient may also hike the hip up due to overutilization of the quadratus lumborum. Instructing the patient to elongate and slightly ER the leg as they perform side lying hip abduction helps to nullify these substitution patterns.

Retraining Exercises for the Gluteus Medius (from easiest to the most difficult

Ebert et al., 2017 did an extensive literature review of 33 exercises that have been traditionally given for strengthening the gluteus medius ranking them based upon the % of MVIC generated for each exercise to help give guidance in prescribing the appropriate exercise for a patient based upon their health status and the integrity of the gluteal muscles, ie., gluteal atrophy, post-surgical, OA of the hip, etc.

Jeong et al., 2015 investigated the effect of combining gluteal strengthening with lumbar segmental stabilization exercises versus retraining with lumbar stabilization exercises alone in a group of chronic low back pain patients. They reported that although both groups benefited the group that received the combination of gluteal strengthening with lumbar segmental stabilization exercises had a greater decrease in the low back disability index, and a greater increase in lumbar muscle strength and improvement in balance.

Abdominal Oblique Retraining Exercise

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Abdominal Oblique Retraining Exercise

The patient is lying on their back with the knees and hips flexed and feet flat on the floor.
They are instructed to slowly drop their knees to the right approximately half way to the floor.
Ask the patient to slowly bring the knees back to the midline by flattening their back working from above down segmentally without engaging their hips, ie., T12, L1 then L2, etc. (Tell the patient to think about moving the pelvis towards 1 and 2 o’clock).
Once they’ve returned to the midline have the patient drop their knees slowly to the left, about half way to the floor.
Ask the patient to slowly bring the knees back to the midline by flattening their back working from above down segmentally without engaging their hips (Tell the patient to think about moving the pelvis towards 10 and 11 o’clock).
The patient repeats these movements alternating back and forth 3-5 times initially, gradually working up to 10 reps as their control/strength improves.
Make sure that the patient does not initiate the return to midline movement through the hips, but rather through the spine.

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