Kinetic Chain Exercises Linking the Shoulder and Hip

Overhead activities such as throwing require proper sequencing of different body parts.   The lower body, trunk, shoulder, arm, and hands are considered links in a chain.  If any of these links are not functioning properly, the chain is compromised.  Effectively using the body as a kinetic chain maximizes overhead athletic performance and reduces injury risk.  Shoulder rehabilitation programs now integrate the kinetic chain theory for a broader approach versus focusing only on isolated muscles.

Exercises targeting the shoulder muscles receive a great deal of attention in overhead athletes and rightfully so.  The rotator cuff and scapular muscles are important for dissipating high forces created from throwing.  However, most of the energy created during throwing occurs from the lower body and trunk.  Weak links in the lower body often result in additional stress to the shoulder and elbow during throwing.  Therefore, including exercises that incorporate all links of the kinetic chain are beneficial.

lower body strength throwing

 

Lower body exercises such as the squat and lunge can be integrated with common shoulder rehabilitation exercises.  Total body exercises which incorporate resistance bands or tubing are ideal for integrating links of the kinetic chain.  This article described only 3 exercise examples.  However, there are many other variations which can be developed based on the athlete’s profile and goals.

Overhead Squat with “Y”

Stand holding a resistance band in both hands with the shoulders flexed and elbows straight.  Perform an overhead “Y” by raising both hands with the elbows straight.   Maintain this overhead “Y” position as you perform an overhead squat.  Try to reach a maximum depth of the squat without compromising the upper-body position.  Maintain the overhead “Y” until completion of the set.  Perform 8 to 10 repetitions per set.  This exercise integrates the gluteus maximus, rotator cuff, low back muscles, and trapezius.

Lunge with “T”

Stand holding a resistance band in both hands with the shoulders flexed and elbows straight.  Perform a “T” with both arms by pulling the hands and shoulder blades back with the elbow straight.   Once in the “T” position, perform a reverse lunge with one leg.  The “T” position is maintained until one alternating repetition is performed on each leg.  Reset the “T” before completing the next repetition.  Perform 6 to 8 slow and controlled repetitions on each side.  This exercise activates the gluteus medius, gluteus maximus, lats, and trapezius.

Lateral Band Walk with “W”

Perform an exaggerated sideways walk with a resistance band just above the knees. Remain in an athletic position keeping the toes pointed straight ahead.  It is important to push the knees apart against the resistance band in order to activate the hip muscles.  The shoulder blade and rotator cuff muscles are activated by using a second resistance band in the hands.  Make a “W” with the elbows in order to achieve scapular retraction.  Take 3 steps to the right followed by 3 steps back to the starting position.   Also, think about pulling the elbows to the opposite back pocket.  Perform 6 to 8 slow and controlled repetitions to each side.  This exercise activates the gluteus medius, gluteus maximus, rotator cuff, and lower trapezius.

Closing Thoughts

Combining lower body exercises with traditional shoulder rehabilitation exercises is beneficial for overhead athletes.  Muscles throughout the entire body function in a coordinated sequence during baseball and softball throwing.  Resistance bands have gained popularity in the baseball and softball communities as part of pre-throwing routines and strength and conditioning programs. These shoulder-focused exercises train only a limited number of links in the kinetic chain.   A wiser approach is to integrate upper body resistance band exercises with dynamic, full-body exercises.  Talk to your physical therapist if you are unsure about which exercises are best for you.

 

 

Hip Stiffness: Exercises to Improve Hip Mobility

Hip stiffness can contribute to many painful conditions in and around the hip.  In older adults, limited hip mobility is associated with hip osteoarthritis, spinal stenosis, and knee osteoarthritis.  In athletes, hip stiffness is linked with hip impingement, labral tears, groin pain, low back pain, and knee pain.

The hip is a large ball and socket joint similar to the shoulder.  Unlike the shoulder joint, the hip socket is much larger than the ball.  Therefore, less mobility is available at the hip in comparison to the shoulder.  Further loss of hip motion can be due to bony changes to the femur or pelvic bone.  Also common, restrictions are due to muscle or joint capsule tightness.  Muscle restrictions are treated with soft tissue techniques and various forms of stretching.  Joint restrictions are best treated with manual therapy techniques performed by a physical therapist.

In order for lasting changes in hip mobility to occur, manual therapy should be combined with self-mobilization exercise.  Self-mobilization exercises can be performed in the home with minimal space or equipment necessary.   The exercises which follow in this article are basic self-mobilization techniques which can be easily performed at home or your local gym.

Self-mobilization exercises should not be performed by people with a recent fracture, recent surgery, or any type of systemic illness such as rheumatoid arthritis.   Also those on blood clotting medication and those experiencing worsening of symptoms should only perform these exercises under direction of a physical therapist.

Prone Figure-4 Hip Self-Mobilization

The figure-4 self-mobilization can be helpful for people with limited hip external rotation.  Those who experience difficulty putting on their shoes and socks often benefit from this exercise.  It can also improve hip extension which can translate into improved walking or running ability.  When performing this exercise it is important to activate the abdominal muscles to avoid arching the low back.

Quadruped Hip Internal Rotation with Lateral Distraction

Limitations in hip internal rotation are characteristic of many hip problems.  Any sport that requires squatting, pivoting, planting and cutting require hip internal rotation.  By using a belt or band to distract the hip joint, greater hip internal rotation is available.  Be sure to place the band or belt deep into the groin to optimize the stretch.

Quadruped Rock Back with Hip Posterior Glide

Rock backs are used to promote the posterior glide of the femur and to stretch the back of the hip. Passive hip flexion is performed to facilitate this motion. Passive motion is preferred over active motion to alleviate the influence of the hip flexor muscles.  By using a belt or band to distract the hip joint, greater hip flexion is available.

Kneeling Hip Flexor Self-Mobilization

Limited hip extension flexibility is one possible cause of an increased anterior pelvic tilt and lumbar lordosis during running.   This pattern stresses the structures of the low back and hip.  Combing this self-mobilization technique with abdominal strengthening exercises can alleviate low back and hip pain.

Standing Posterior-Lateral Hip Self-Mobilization

Tightness in the back of the hip can contribute to pain in the front of the hip or groin.  Stretching this region may be painful for some.  By using a belt or band to distract the hip joint, greater hip motion is available without pain.  If pain is experienced during the self-mobilization, adjust the height of the step or shift more weight onto the opposite leg.

Closing Thoughts

Self-mobilization exercises are best performed after a dynamic warm-up.  Muscles and joint structures are easily stretched when body temperature is elevated and the nervous system is activated.  Self-mobilization exercises should result in a mild to moderate stretching sensation.  Minimal or no pain should be experienced. Muscle re-education and strengthening exercises should always be performed once new range of motion has been gained.  Finally, it takes consistency and time to achieve lasting gains.

Deadlift: Harmful or Helpful for Low Back Pain?

The deadlift is essentially a hip hinge with weight.  The hinge occurs by flexing at the hips while maintaining a flat low back.  The deadlift also involves some knee flexion but the majority of the movement occurs by hinging at the hips.  Hinging differs from stooping and squatting.  Stooping involves bending at the low back more than the hips.  Squatting involves bending at the knees more than the hips.   The deadlift is an exercise which resembles a safe technique for lifting.

The deadlift is a great exercise to strengthen your backside.  The gluteus maximus, one of the largest and strongest muscles of the body, is the prime mover when performing the deadlift.  The quadriceps, hamstrings, and low back muscles are also activated at high levels.  Adequate strength in these large muscle groups is necessary for every day function and performing sports at high levels.  The deadlift also activates smaller stabilizing muscles of the spine to a greater extent than low load exercises lying on the floor or a ball.

The deadlift sometimes gets a “bad rap”.  This is because many in the medical community have cautioned patients with low back pain from performing any heavy lifting.  It is true that improper execution of the deadlift can result in low back injury.  However, when performed properly, the deadlift is an excellent exercise to strengthen the hips and low back.  Proper instruction and coaching of the exercise should always occur for individuals with low back pain.   Most people require the help of a physical therapist or coach to learn the exercise correctly.

Should People with Low Back Pain Deadlift?

The safe answer is it depends.  However, research does show the deadlift can be very effective for strengthening the low back muscles, decreasing back pain, and improving function.  Therefore, most people with low back pain can, and should, be instructed on how to hip hinge and perform some variation of the deadlift.  This does not mean everyone with low back pain should attempt to pick up as much weight as possible from the floor.  There must be proper instruction, safe practice, and appropriate progression.

A 2015 study in the Journal of Orthopedic and Sports Physical Therapy showed both low load exercises and deadlift training resulted in similar improvements in low back pain, back muscle strength, and disability.  It was later found that people with better low back muscle endurance and lower pain levels were more likely to benefit from deadlift training.  Therefore, a wise approach is to begin with low load exercises on the floor or a table.  Once pain levels decrease and muscle function improves, progressing to deadlift training can be started.

Deadlift Progressions

It can be challenging for some individuals to learn how to properly hinge at the hips without bending at the spine.  Physical therapists use different corrective exercise approaches to teach the proper movement pattern.  Only after mastering the movement pattern is weight added.  The basics of the set up for the deadlift include a hip-width stance, soft slightly bent knees, shoulder blades back, and a chest-up position.  Your chest should be above your hips, and your hips above your knees.  The movement is initiated by extending the hips with a flat back.

Below are 5 exercise progressions for the deadlift.  There are many others which are considered when designing an individualized program.  The specific exercises prescribed depend on the individual’s current levels of strength, mobility, function, and their goals.

 

 

Closing Thoughts

 People with low back pain cannot fully function in everyday life without lifting objects from the floor.   Physical therapists can teach people how to properly lift.  Deadlift variations are ideal for this purpose.  Research shows people with low back pain can safely and effectively perform the deadlift.  For many people with low back pain, the conventional deadlift is not the best choice.  Most people require modifications.  Your physical therapist can perform a physical examination and then prescribe the exercise which is best for you and your goals.

Hip Manual Therapy Improves Low Back Pain

Research shows range of motion restrictions of the hip are associated with low back pain.  People with low back pain have less hip rotation range of motion compared to people without low back pain.  It is also common for people with low back pain to have side-to-side differences in hip rotation range of motion.  For example, one hip may rotate a total of 75 degrees, and the other hip only 60 degrees.  Hip mobility restrictions can be due to stiffness in the joint capsule or muscles which cross the joint.  Restricted hip mobility due to joint stiffness is best treated with manual therapy performed by a physical therapist.

Hip internal rotation restrictions are closely linked to low back pain.   This movement involves rotating the thigh inward towards the midline of the body.  This hip must internally rotate when the leg is behind the body during the normal gait cycle.   If this motion is unavailable at the hip, the movement must then occur at the spine.  Hip internal rotation must also occur when performing any type of pivot or change of direction when walking.   Many sports activities, such as swinging a golf club, require large amounts of hip rotation.  If the motion is not available at the hip, the spine must compensate.  This often results in abnormal movement and stress to the structures of the low back.

Proven Benefits of Hip Manual Therapy

A 2017 study published in the Journal of Evaluation in Clinical Practice investigated the effects of providing manual therapy and exercise targeting the hips in people with low back pain.  Half of the participants received treatment to the spine only.  The other half received treatment to the spine and hips.  The group who were treated with manual therapy and exercise targeting the hips were more satisfied with their treatment.  They also reported greater improvements in pain and disability compared to the group who only received treatments to the spine.

Hip Manual Therapy Techniques

Three hip joint mobilization techniques were utilized in the previously mentioned study.  Examples of these techniques are included below.   Manual therapy techniques are individualized based on findings from the physical examination.   All mobilization techniques are performed without pain.  Only a mild stretching sensation is felt by the patient during these treatments.  Immediate improvements in hip range of motion occur in most cases.  However, in order for these improvements to be sustained, home exercises are prescribed.

Closing Thoughts

There is no one magic treatment for low back pain.  Abdominal and low back strengthening exercises can be effective.  However, the best results usually occur when multiple treatments are combined and patients are taught to self manage.  Treatment focused only on the spine is often only partially effective.   The low back and hips are very closely linked.  Outcomes are improved when treatments are also directed to the hips.  In order for results to be sustained, an exercise program targeting hip mobility and hip strength are also included.

 

 

Is Hip Weakness Contributing to Your Back Pain?

The hips and low back are closely linked by multiple shared muscles.  Contraction of these shared muscles will affect motion at the spine, pelvis, and hips.  Poor movement at one of these areas can create compensatory movement at the others because of the common muscle attachments.  Often, rehabilitation exercises targeting the abdominal and low back muscles result in only partial resolution of low back pain.  The missing piece may be addressing weakness of the hip muscles.

Research Shows a Link between Hip Weakness and Back Pain

Weakness or poor endurance of the gluteus maximus has been associated with low back pain in athletes and non-athletes.  Women with longstanding low back pain have smaller gluteus maximus muscles compared to those without low back pain.  Female athletes with low back pain show side to side differences in hip strength which may predispose them to compensatory movements.  Chronic back pain in men is associated with weakness of the gluteus medius muscle, elevated body weight, and tenderness in the low back region.   Weakness of the gluteus medius is often present in those who are limited in their ability to stand because of low back pain.

It is unclear if hip muscle weakness is the result of disuse or a cause of low back pain.  In either case, exercise targeting the hips is required to restore strength and proper movement patterns.  Many people with weakness of their hip muscles overuse their low back muscles.  Overactive low back muscles leads to fatigue, pain, and abnormal movement.  This results in a viscous cycle where abnormal movement results in more pain; and more pain worsens the compensatory movements.

A 2015 study in the Journal of Physical Therapy Science compared the effectiveness of low back and hip strengthening exercise to low back exercise only.  The group of people who exercised both the low back and hip muscles showed significantly greater improvements in back strength, balance, disability, and pain.  Another study in the Journal of Back and Musculoskeletal Rehabilitation also showed better outcomes in people who performed exercises for both the low back and hip muscles.  The following 5 exercises were included in the study.   Try these to get you started.

Clamshell

The clamshell strengthens the gluteus medius muscle.  Begin by lying on one side with the hips flexed to approximately 45 degrees.  The knees are flexed and the feet kept together.  A resistance band can be placed around the thighs just above the knees.   Start the exercise by rotating the top hip to bring the knees apart.  Hold this position for 2 seconds and then return to the start position slowly.  Be sure to remain lying completely on the side with one hip stacked on top of the other.  Allowing the pelvis to roll backwards during the movement is the most common mistake.   The clamshell is a great exercise to start with because it requires minimal activity of low back muscles.

Side-Lying Hip Abduction

Hip abduction strengthens both the gluteus medius and maximus.  Begin by lying on one side with the bottom hip and knee bent.  The top knee remains straight.  The top hip is maintained in neutral or slight hip extension with the toes pointed forward.  The toes are pointed forward to orient the hip in slight internal rotation.  This increases gluteus medius activity.  Initiate the movement by lifting the top leg about 30 degrees.  Hold this position for a count of 2 seconds and then slowly lower the leg to the start position.  Ankle weights can be added for resistance once 15 proper repetitions can be performed.

This exercise activates the gluteus medius to a greater level than the clamshell.  However, it is also more challenging to perform correctly.  Similar to the clamshell, it is important to remain completely on the side with one hip stacked on top of the other.  Allowing the pelvis to roll backwards during the movement is the most common mistake with this exercise.   Also, as the muscle tires, the leg will drift forward into hip flexion.  It is important to maintain the leg lined up or slightly behind the trunk and upper body.

Quadruped Hip Extension with Knee Flexion

Begin on the hands and knees.  The shoulders are positioned directly over the hands.  The hips are positioned directly over the knees.  The spine is maintained in a neutral position throughout the exercise.  Initiate the movement by flexing one knee to 90 degrees.  Next, lift the heel up towards the ceiling keeping the knee flexed.  Hold this position for 2 seconds then return to the starting position.  Lower the leg back down before repeating another repetition on the same side.  It is important to avoid arching through the low back.  Complete the desired number of repetitions on one side before beginning with the other leg.

Cook Hip Lift

Begin by lying on the back with your hips flexed and feet lined up with the shoulders.   Flex the hip by holding one knee to the chest.  It is helpful to place a small towel roll or ball in the crease of your hip.  Lift your toes off the floor and perform a bridge from one leg.  A common mistake is to excessively arch the low back.  Be sure to achieve the bridge position by extending through the hips.   Hold this position for 2 seconds then return to the starting position.  Lower the body back down before repeating another repetition on the same side.  Complete the desired number of repetitions on one side before beginning with the other leg.

The positioning of the hips during this exercise facilitates a neutral pelvis and low back position.  This is helpful for people with a history of low back pain.  However, this also increases the challenge to the gluteus muscles compared to a standard bridge.   Raising the toes makes you press your heel into the ground as you lift your hips. This facilitates the glutes and hamstrings.

Lateral Step Down

The step down exercise begins with the hands on the hips standing with one leg on the side of a step or 8-inch high box.  Maintain balance on 1 leg and slowly squat to lower the heel of the other leg toward floor.  Gently tap the heel and return to the start position.  Throughout the exercise the trunk is maintained in an upright position.  Avoid leaning the trunk to the side or waving the arms.  The knee should not move forward past the toes.  Also, the knee should remain over the toes so it does not cave inwards into valgus.  Perform 8 to 10 slow and controlled repetitions before switching sides to the other leg.

Closing Thoughts

It is important to exercise the abdominal, low back, and hip muscles to fully recover from an episode of low back pain.  These muscles do not function in isolation.  Not addressing muscles imbalances often leads to recurrent episodes of pain.  These 5 exercises address common hip muscle imbalances in people with low back pain.   In most cases, exercises should be individually prescribed based on a physical therapist’s examination of movement and strength.   Additional individualized exercises integrating multiple muscles with functional movement patterns are often beneficial to help people achieve their goals.

Gluteus Maximus Exercise: Training in Multiple Planes

The gluteus maximus is the most powerful hip extensor.  This is important for functional activities performed in one plane such as walking, running, and climbing stairs.  However, this muscle also has important functions outside of straight ahead planes of movement.  The gluteus maximus also helps control balance and generate power in other planes.  Rotational and lateral movements in everyday life and sport require important contributions from the gluteus maximus.

Training the gluteus maximus should incorporate single-plane hip extension exercises and exercises in multiple planes.  Single-plane exercises such as the squat and hip hinge do not fully develop the glutes.  Training programs should also include exercises with rotation of the trunk or lower body on one leg.  These types of exercises prepare athletes for changes or direction, throwing, and jumping from one leg.   Performance improvements and reduced risk for injury often occur with long-term training in multiple planes.  The five exercises included in this article are only examples.  Many other exercises can be adapted to train the entire body with rotational movements.

Crossover Step Up

The crossover step up helps expose and improve any side to side difference in gluteus maximus strength.  Stand to the side with your left leg next to an elevated step or box.  Cross your right foot in front and step up onto the box.  Keep your hips square throughout the exercise.  Next, cross your right foot behind the left while stepping down to briefly touch the floor on the opposite side.  When descending think about sitting back into the hips.   Reverse the movement in the opposite direction.  Perform the exercise slowly with control.   The challenge of the exercise can be increased by holding a dumbbell or kettle bell in the hands or close to the chest.

1-Leg RDL

The single-leg Romanian dead lift (RDL) is a single-leg exercises which requires stabilization of the trunk on the lower limb in multiple planes.  These exercise begins by standing on one leg with the opposite hip and knee extended.  The weight bearing knee can be slightly bent throughout the exercise.   Initiate the movement by slowly flexing at the hip, keeping the back straight.  The non-weight bearing leg extends straight back behind the body.  Both the descending and ascending parts of the exercise should be performed in a slow and controlled manner.   Also, maintain control and the position of the weight bearing leg during the exercise.   Perform 8-10 repetitions on one leg before switching sides.   The challenge of the exercise can be increased by holding a dumbbell or kettle bell in the hand on the side of the swinging leg.

Transverse Lunge

The transverse lunge starts standing with the feet near each other and hands on the hips.  Throughout the exercise the trunk is maintained in an upright position, so the knee and hip of the lunging leg can be flexed to 90°. This prevents the knee from moving forward past the toes.  Also, the knee remains over the toes so it does not cave inwards into valgus.  During the transverse lunge, the body is rotated 135° towards the lunging side.  This involves twisting behind the body and lunging in one motion.  Add load by holding a dumbbell or kettlebell in the hand opposite the lunging leg or against the chest.  This exercise shows high activation of both the gluteus maximus and gluteus medius.

Skater Squat

The skater squat introduces rotation of the trunk on the lower limb.  The exercise begins by standing on one leg and performing a squat to a comfortable depth.  The depth is determined by the ability to maintain balance and good control of the trunk and entire lower extremity.  The non-weight bearing leg extends at the hip and flexes at the knee. The torso slightly rotates and the arms swing reciprocally as if skating.  The toe of the non-weight bearing leg can touch the floor between repetitions if needed.  Hold the downward position for 2 seconds then return to the starting position.  Add load by placing a resistance band around the thighs just above the knees.

Rotational 1-Leg Squat

 The rotational 1-leg squat is a progression of the skater squat.  Both exercises have a rotational component to the squat.  This exercise further challenges the balance and stability of the hip.  Begin by balancing on one leg holding a medicine ball in both hands.  The non-weight bearing knee and hip flex to approximately 30°. Slowly lower toward the floor being sure to maintain control of the trunk and supporting leg.  The depth of the squat is determined by the ability to maintain balance and control the movement.  Rotate the hands and medicine ball upwards and towards the weight bearing leg as you perform the squat.  Return to the starting position and keep the knees over the toes to prevent knee valgus throughout the exercise.

Glutues Maximus Exercise: Closing Thoughts

Gluteus maximus weakness is common in those with chronic back pain, hip bursitis, hip arthritis, knee arthritis, and runner’s knee (patellofemoral pain).  Training the glutes primary function of hip extension is important but often not enough for most demands of sport and everyday life.  These five exercises are challenging and not for everyone.  If you are unable to maintain balance and stability on one leg try other exercises first (basic gluteus maximus exercises).   If you are still unsure how to start, contact your physical therapist for help.

 

Gluteus Maximus: 5 Exercises to Get Started

The gluteus maximus is the largest muscle of the hip and buttock.  It functions to maintain an erect standing posture and to extend the hip joint.  The gluteus maximus is regarded as one of the strongest muscles in the body.  Strength of the gluteus maximus is required to walk with an upright posture, stand up from a chair, climb stairs, run, jump, and throw a ball.  Weakness is associated with low back pain, knee pain, hip arthritis, and poor balance.  Gluteus maximus exercises are often prescribed for hip arthritis, hip impingement, iliotobial band syndrome, low back pain, patellofemoral pain, and many other overuse injuries.

Exercises start in non-weight bearing positions such as lying on the back or kneeling.   It is recommended that each of these basic exercises is initiated with 3 sets of 8 to 15 repetitions.  When 15 repetitions can be performed, the intensity of the exercise can be progressed by adding weight or increasing the resistance band strength.  Muscle strength and hypertrophy can be achieved with any range of repetitions.  However, to optimize strength, higher intensities with lower repetitions are needed.   Each exercise should be performed 2 to 3 times per week to optimize improvements in muscular endurance, strength, and hypertrophy.  The main objective of this strengthening program is to progressively overload the gluteus maximus so muscular control, endurance and strength are developed in a systematic manner.

2-Leg Bridge

The bridge is a great hip extension exercise to start with.  Begin by lying on your back with the hips flexed and the feet lined up with the shoulders.  Perform the bridge by lifting both hips from the floor.  A common mistake is to excessively arch the low back.  Hold the bridge position for 2 seconds then return to the starting position.  Lower the body back down in a slow and controlled manner.

Be sure to achieve the bridge position by extending through the hips.  If you lack mobility in your hip joints or hip flexor muscles this may lead to compensation through the low back.  This can be corrected with manual therapy and mobility exercises.  You can also try bringing your fleet slightly closer together and the knees slightly wider apart.  This will allow you to achieve greater hip extension range of motion.

Cook Hip Lift

Begin by lying on the back with your hips flexed and feet lined up with the shoulders.   Flex the hip by holding one knee to the chest.  It is helpful to place a small towel roll or ball in the crease of your hip.  Lift your toes off the floor and perform a bridge from one leg.  A common mistake is to excessively arch the low back.  Be sure to achieve the bridge position by extending through the hips.   Hold this position for 2 seconds then return to the starting position.  Lower the body back down before repeating another repetition on the same side.  Complete the desired number of repetitions on one side before beginning with the other leg.

The positioning of the hips during this exercise facilitates a neutral pelvis and low back position.  This is helpful for people with a history of low back pain.  However, this also increases the challenge to the gluteus muscles compared to a standard bridge.   Raising the toes makes you press your heel into the ground as you lift your hips. This facilitates the glutes and hamstrings.

Quadruped Hip Extension with Knee Flexion

Begin on the hands and knees.  The shoulders are positioned directly over the hands.  The hips are positioned directly over the knees.  The spine is maintained in a neutral position throughout the exercise.  Initiate the movement by flexing one knee to 90 degrees.  Next, lift the heel up towards the ceiling keeping the knee flexed.  It is important to avoid arching through the low back.  Hold this position for 2 seconds then return to the starting position.  Lower the leg back down before repeating another repetition on the same side.  Complete the desired number of repetitions on one side before beginning with the other leg.

Prone Plank with Hip Extension

Start facedown supported on the elbows in a plank position with the trunk, hips, and knees in neutral alignment.  Initiate the movement by lifting one leg with the knee bent.   Extend the hip slightly past neutral by bringing the heel toward the ceiling.  Hold this position for 2 seconds.  Maintain the plank position throughout all repetitions on one side.  Complete the desired number of repetitions on one side before beginning with the other leg.  A common error with this exercise is to arch or overextend the spine when lifting the leg.  Also, as the abdominal muscles tire, the hips may rise.  Be sure to maintain a neutral trunk, hip, and knee alignment throughout the exercise.

Side Plank with Hip Abduction

Start side-lying supported on one elbow with the shoulders, hips, knees, and ankles in line. Rise to a side plank position with the hips off the floor to achieve neutral alignment of trunk, hips, and knees.  Maintain the side plank position and raise the top leg into abduction approximately 30 degrees.  Hold this position for 2 seconds then slowly lower the top leg. Maintain the plank position throughout all repetitions on one side.  Complete the desired number of repetitions on one side before beginning with the other leg.

A common error with this exercise is to allow the pelvis to tip forward or backward.  Also, as the top hip tires the abducting leg will move forward into flexion.  As the bottom side tires, the side plank position will be lost.  This exercise has been shown to activate the gluteus maximus and medius on both sides at very high levels.  It is also very challenging and may not be an option for everyone.

Closing Thoughts

These 5 gluteus maximus exercises do not need to all be performed during the same session.  Start with 2 to 3 of the exercises.  Exercise selection is based on your preferences and the level of difficulty.  The bridge is the least challenging and side plank with hip abduction is the most challenging.  Within 6 to 8 weeks, the exercises may feel less challenging.   This means it is time for a progression.  Progression may include adding resistance or substituting with a new exercise.  Next week we will highlight 5 more exercises which can be performed in standing.

 

Gluteus Medius Exercise: Advanced Progressions

Athletes are required to perform explosive powerful movements during sport.  The hip muscles, including the gluteus medius, help generate and transfer forces during sport-specific activities such as running, cutting, and throwing.  These types of athletic demands require high intensity training in the gym.  Gluteus medius exercise which emphasize multiple planes of movement in single-leg or asymmetrical stances are advantageous for these demands.

The advanced exercise progressions included here should first be performed in a slow and controlled manner with an emphasis on technique.  As technique becomes adequate, the speed of movement and load can be increased.  Under any conditions, control of the movement and body positions are extremely important.  Remember, the primary function of the gluteus medius is to stabilize and control the position of the pelvis.  This is mandatory for the rest of the body to generate, transfer, and dissipate forces optimally.

Skater Squat

The skater squats begins by standing on one leg and performing a squat to a comfortable depth.  The depth is determined by the ability to maintain balance and good control of the trunk and entire lower extremity.  The non-weight bearing leg extends at the hip and flexes at the knee. The torso slightly twists and the arms swing reciprocally as if skating.  The toe of the non-weight bearing leg can touch the floor between repetitions if needed.  Hold the downward position for 2 seconds then return to the starting position.   Challenge to the gluteus medius can be increased by placing a resistance band around the thighs just above the knees.

Transverse Lunge

The transverse lunge starts standing with the feet near each other and hands on the hips.  Throughout the exercise the trunk is maintained in an upright position, so the knee and hip of the lunging leg can be flexed to 90°. This prevents the knee from moving forward past the toes.  Also, the knee remains over the toes so it does not cave inwards into valgus.  During the transverse lunge, the body is rotated 135° towards the lunging side.  This involves twisting behind the body and lunging in one motion.   Challenge to the gluteus medius can be increased by holding a dumbbell or kettlebell in the hand opposite the lunging leg.

Rear Foot Elevated Split Squat

The rear foot elevated, or Bulgarian, split squat is an excellent exercise to target the gluteus maximus, gluteus medius, quadriceps, and hamstring muscles.  For this exercise, the rear foot is placed up on a 6 to 12 inch step or box.  The supporting leg should be positioned approximately one leg length in front of the box or step.  This may need to be adjusted based on comfort and balance.  However, it is important that the hip and knee of the front leg is able to flex to 90 degrees during the movement.

It is also important to maintain good upper body posture with a natural curve in the low back and the chest up.  This position should be maintained during the descent and ascent of the movement. Excessive trunk flexion or side bending are common errors.  The front knee should not move forward past the toes.  The knee should remain over the toes so it does not cave inwards into valgus.  Perform 8 to 10 slow and controlled repetitions before switching sides to the other leg.  Challenge to the gluteus medius can be increased by holding a dumbbell or kettlebell in the hand opposite the front leg.

Lateral Step Down

The step down exercise begins with the hands on the hips standing with one leg on the side of a step or 8-inch high box.  Maintain balance on 1 leg and slowly squat to lower the heel of the other leg toward floor.  Gently tap the heel and return to the start position.  Throughout the exercise the trunk is maintained in an upright position.  Avoid leaning the trunk to the side or waving the arms.  The knee should not move forward past the toes.  Also, the knee should remain over the toes so it does not cave inwards into valgus.  Perform 8 to 10 slow and controlled repetitions before switching sides to the other leg.

1-Leg Squat

 If the lateral step down can be performed with proper form, the next challenge is to progress to performing a single-leg squat.  Begin by balancing on one leg with the hands on the hips.  The non-weight bearing knee and hip are flexed in front to approximately 30°. Slowly lower toward the floor being sure to maintain control of the trunk and supporting leg.  The depth of the squat is determined by the ability to maintain balance and control the movement.  Return to the starting position and keep the knees over the toes to prevent knee valgus throughout the exercise.   This exercise can be performed with or without the assist of a chair.  Many times the chair is needed initially until control and strength improve.  Challenge to the gluteus medius can be increased by holding a dumbbell or kettl bell in the hand opposite the supporting leg.

Closing Thoughts

These five exercises require practice to perfect.  Often, a trainer or physical therapist is needed to coach an individual through these types of exercises.  These are higher level exercises which are not for everyone.  However, mastering these types of dynamic movements often translate to improved coordination, strength, and power on heavier compound lifts such as the squat or deadlift.  Team sport athletes often see improvements in explosiveness and agility on the field.  Unfortunately, many become frustrated with the amount of practice and effort it takes to perform these types of exercises.  If needed, regress back to perform less challenging exercises in non-weight bearing (here) or weight bearing positions (here).  This is all part of the process.  Be patient and stick with it and you will see results down the road.

Gluteus Medius Exercise Progressions

The primary role of the gluteus medius is to stabilize and control movement of the pelvis during weight bearing functional activities.  This is required for efficient walking, climbing stairs, running, jumping, and throwing.  All of these activities require at least a brief period of single leg support.  The gluteus medius maintains a level pelvis and prevents the opposite side from dropping.  Without adequate functioning of this muscle, balance, strength, power, and performance will be compromised.  Also, abnormal movement patterns, such as dynamic valgus, occur in the presence of inadequate gluteus medius function.

It is advantageous to progress exercises for the gluteus medius from non-weight bearing to standing positions.  The exercises included in this article are 5 options but there are many others.  The most important aspect of these exercises is that they performed in a slow and controlled manner with appropriate body alignment.   The emphasis should first be on proper technique before adding repetitions or resistance.

Band Hip Abduction

Band hip abduction is performed with an elastic band tied around the ankles standing in an upright position with the feet together.   The feet are then pulled slightly apart.  Stand on one leg while keeping the pelvis level.  Abduct the other leg about 25° while maintaining the trunk in an upright position.  The most common mistake is to abduct too far and tip the body to the other side.  It is also important to keep the toes pointing straight ahead throughout the exercise.  Tension should be maintained on the band so the feet do not touch.  Both the supporting and moving side gluteus medius are very active during this exercise but the standing leg receives the greater training effect.

Band Internal & External Rotation (IR/ER)

Band IR/ER is performed with an elastic band tied around thighs (just above the knees) standing in an upright position with the feet together.  Once the band is in place, separate the feet to shoulder width or slightly wider.   During the exercise the knees and hips are flexed about 30°.  The hands are placed on the hips.  Initiate the movement by slowly moving one knee inwards over a 2 second period.  Maintain the position of the opposite knee.  Then slowly pull the knee outwards over a 2 second period.   Perform 8 repetitions in a slow and controlled manner on one side before switching to the other leg.

Lateral Band Walk

The lateral band walk is performed with an elastic band tied around the ankles standing in an upright position with the feet together.  During the exercise the knees and hips are flexed about 30°.   The hands are placed on the hips.   Sidestepping is initiated by leading with one leg over a distance slightly wider than shoulder width.  It is important to keep the toes pointing straight ahead and the knees over the toes throughout the exercise.  Tension should be maintained on the band so the feet do not touch.  Three slow steps are performed in one direction followed by 3 steps in the opposite direction.  Each cycle constitutes 1 repetition.  Typically, 6-8 repetitions are performed each set.   To increase the challenge of this exercise, two bands can be used.  A second band can be placed above the knees.

Dynamic Leg Swing

The dynamic leg swing begins by standing on one leg with the opposite knee flexed to 90 degrees.  Initiate the movement by swinging the non-weight bearing leg (with the knee flexed).  Move into hip flexion and extension at a rate of 1 second forward and one second backward.   Move through a smooth range of hip motion and do not allow the trunk to move out of the upright position.  Also, maintain control of the position of the weight bearing leg during the exercise.   Perform the 8-10 repetitions on one leg before switching sides.   The challenge of the exercise can be increased by holding a dumbbell or kettle bell in the hand on the side of the swinging leg.

1-Leg RDL

The single-leg Romanian dead lift begins by standing on one leg with the opposite hip and knee extended.  The weight bearing knee can be slightly bent throughout the exercise.   Initiate the movement by slowly flexing at the hip, keeping the back straight.  The non-weight bearing leg extends straight back behind the body.  Both the descending and ascending parts of the exercise should be performed in a slow and controlled manner.   Also, maintain control and the position of the weight bearing leg during the exercise.   Perform the 8-10 repetitions on one leg before switching sides.   The challenge of the exercise can be increased by holding a dumbbell or kettle bell in the hand on the side of the swinging leg.

Closing Thoughts

These 5 exercises can be used as a standalone program for improving gluteus medius activation and strength.  However, all 5 exercises do not need to be performed.  Choose 2-3 exercises to perform 3 days per week.  These exercises are also ideal for athletes and exercise enthusiasts to incorporate into their warm-up routines.  Specifically, try 2 or 3 of these exercises prior to performing compound lifts such as the squat or dead lift.   Next week we’ll highlight some more advanced progressions to load the gluteus medius.  If you any further questions, give your physical therapist a call.

 

 

Gluteus Medius Exercise: Getting Started

In a previous article, we discussed the importance of the gluteus medius muscle in controlling lower extremity alignment during the squat.  This muscle also plays a critical role in positioning and stabilizing the pelvis in many other functional activities.  This includes any activity with requires a period of single-leg support such as walking, climbing stairs, and running.  Individuals with knee pain, chronic back pain, hip arthritis, and ankle injuries have all been shown to have weakness in this  important muscle.  Glutues medius exercise can help.

Getting Started with Gluteus Medius Exercise

Basic resistance exercise for the gluteus medius can be initiated in non-weight bearing positions such as lying on the side.  Progressions can include partial weight-bearing positions such as on all fours or plank positions.  As muscular endurance and strength improve, exercises can be progressed to weight-bearing positions in standing.  Standing exercises are initiated in a double-limb stance, or with both legs fixed to the floor and then progressed to single-limb stance.  Each exercise should be performed 2 to 3 times per week to optimize improvements in muscular endurance, strength, and hypertrophy.

It is recommended that each of these basic resistance exercises be initiated with 3 sets of 8 to 15 repetitions.  When 15 repetitions can be performed, the intensity of the exercise can be progressed by adding weight or increasing the resistance band strength.  Muscle strength and hypertrophy can be achieved with any range of repetitions.  However, to optimize strength, higher intensities with lower repetitions are needed.   The main objective of this strengthening program is to progressively overload the gluteus medius so that muscular control, endurance, and strength are developed in a systematic manner.

Clam Shell

Begin by lying on one side with the hips flexed to approximately 45 degrees.  The knees are flexed and the feet kept together.  A resistance band can be placed around the thighs just above the knees.   Start the exercise by rotating the top hip to bring the knees apart.  Hold this position for 2 seconds and then return to the start position slowly.  Be sure to remain lying completely on the side with one hip stacked on top of the other.  Allowing the pelvis to roll backwards during the movement is the most common mistake with this exercise.   The clam shell is a great exercise to start with because it elicits high levels of gluteus medius activity with minimal activity of the tensor fascia latae (TFL).  This is beneficial because the TFL is commonly overactive in individuals with hip and knee pain.

Side-Lying Hip Abduction

Begin by lying on one side with the bottom hip and knee flexed.  The top knee remains straight.  The top hip is maintained in neutral or slight hip extension with the toes pointed forward.  The toes are pointed forward to orient the hip in slight internal rotation.  This increases gluteus medius activation and decreases TFL activation.  Initiate the movement by lifting the top leg about 30 degrees.  Hold this position for a count of two and then slowly lower the leg to the start position.  Ankle weights can be added for resistance once 15 proper repetitions can be performed.

This exercise activates the gluteus medius to a greater level than the clam shell.  However, it is also more challenging to perform correctly.  Similar to the clamshell, it is important to remain completely on the side with one hip stacked on top of the other.  Allowing the pelvis to roll backwards during the movement is the most common mistake with this exercise.   Also, as the muscle tires, the leg will drift forward into hip flexion.  It is important to maintain the leg lined up or slightly behind the trunk and upper body.

1-Leg Bridge

Begin by lying on the back with both hips and knees bent.  Perform a bridge with both legs by raising the hips to a neutral trunk, hip, and knee position.  A common mistake is to excessively arch the low back.  Be sure to achieve the bridge position by extending through the hips.  From the bridge position, straighten the knee of one leg while keeping the upper thighs parallel.  Be careful not to allow the pelvis to drop on one side.  Hold this position for 2 seconds then return the leg to the bridge position.  Lower the body back down before repeating another repetition on the same side.  Complete the desired number of repetitions on one side before beginning with the other leg.  Resistance can be added by placing a band around the thighs just above the knees.

Prone Plank with Bent Knee Hip Extension

Start facedown supported on the elbows in a plank position with the trunk, hips, and knees in neutral alignment.  Initiate the movement by lifting one leg with the knee bent.   Extend the hip slightly past neutral by bringing the heel toward the ceiling.  Hold this position for 2 seconds.  Maintain the plank position throughout all repetitions on one side.  Complete the desired number of repetitions on one side before beginning with the other leg.  A common error with this exercise is to arch or overextend the spine when lifting the leg.  Also, as the abdominal muscles tire, the hips may rise.  Be sure to maintain a neutral trunk, hip, and knee alignment throughout the exercise.

Side Plank with Hip Abduction

Start side-lying supported on one elbow with the shoulders, hips, knees, and ankles in line. Rise to a side plank position with the hips off the floor to achieve neutral alignment of trunk, hips, and knees.  Maintain the side plank position and raise the top leg into abduction approximately 30 degrees.  Hold this position for 2 seconds then slowly lower the top leg. Maintain the plank position throughout all repetitions on one side.  Complete the desired number of repetitions on one side before beginning with the other leg.

A common error with this exercise is to allow the pelvis to tip forward or backward.  Also, as the top gluteus medius tires the abducting leg will move into flexion.  As the bottom side tires, the side plank position will be lost.  This exercise has been shown to activate the gluteus medius on both sides at very high levels.  It is also very challenging and may not be an option for everyone.

Closing Thoughts

These 5 exercises do not need to all be performed at once.  Instead, choose 2 to 3 exercises to get started with.  Exercise selection is based on your preferences and the level of challenge each presents.  The clam shell is the least challenging and side plank with hip abduction is the most challenging.  Within 6 to 8 weeks, the exercises may feel less challenging indicating a need for progression.  Progression may include adding resistance or substituting with a new exercise.  Next week we will highlight 5 more exercises which can be performed in standing.