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.

 

Bulgarian Split Squat Variations

The rear-foot-elevated or Bulgarian, split squat is an excellent exercise to train the lower body for sport or everyday life.  It is unclear where how this exercise received it’s name but this is of little importance.  The split or asymmetrical stance of the lower body introduces unique deands on the muscles and nervous system.  Acceleration, deceleration, change of direction, sprinting and jumping all require stability of the lower body in similar positions.   Elevating the rear foot increases the difficulty by allowing a deeper squat.  The Bulgarian split squat trains the hip to support the upper body while also controlling the knee position in an athletic stance.

A traditional squat is performed with the feet placed symmetrically side by side.  This creates challenges in primarily one plane.  The Bulgarian split squat is performed with a narrow split stance creating challenges in multiple planes.  Raising the rear leg on an elevated surface shifts the load to the front leg.  The front leg assumes approximately 85% of the total load.

There are many variations to the Bulgarian split squat.  Progressions and regressions can be tailored for the beginner or advanced lifter.  The purpose of this article is to describe several of these modifications.  The Bulgarian split squat can be modified so those new to strength training can incorporate the exercise.  The advanced progressions are best suited for athletes or those with several years of training experience.  The exercise can be modified to challenge balance and stability using lighter loads.  It can also be performed with heavy loads.  Under these conditions, maximal strength development is emphasized similar to training with common multi-joint exercises such as the back squat.

Muscles Involved with the Bulgarian Split Squat

The main lower body muscles involved in the Bulgarian split squat is the quadriceps, hamstrings, and gluteus maximus.  The quadriceps is the first muscle to fatigue, especially when heavier loads are used.  This then requires the gluteus maximus to compensate.  The gluteus medius and minimus are involved to maintain proper positioning of the pelvis and balance. The hip rotators are recruited in order to control the inward or outward movement of the thigh and knee.  The ankle muscles are highly active in order to maintain balance in the narrow stance. The abdominals and low back muscles help maintain a neutral spine position and balance.

Set-Up and Positioning

Taking time to position yourself before the movement will allow for proper performance of the exercise.  Assume a split squat stance with the trail leg just in front of a support box/bench on the floor. While shifting the weight toward the lead foot, place the top of the trail foot on the support box/bench.  The distance from the lead foot to the trail foot support is approximately the length of one leg.  Adjust the support box/ bench distance so the lead knee is directly above the toes. The trail leg support can range from approximately 6 inches to knee height.  This may require some experimentation.  Start with a lower height and adjust as needed.  For stability and balance, the top of the trail foot should remain in contact with the support box/bench throughout the exercise.  The width between the front and trail leg is approximately hip width.

TRX-Assisted Bulgarian Split Squat

Once proper set-up has been achieved grasp the suspension trainer in both hands.  Bend the elbows and hold the straps close to the chest.  This will assist with maintaining proper balance and a vertical position of the trunk.  Maintain this vertical trunk throughout the exercise.  A forward lean is difficult to control with the split stance and rear foot elevated.  Keep the weight of the lead foot distributed in the middle of the foot or near the heel.  Perform the movement by “sitting back” so the trunk remains vertical and the lead knee does not track excessively past the toes. It is acceptable to have the knee pass slightly ahead of the toes.  Lower the trail knee only to a position 1-2 inches above the floor.  Complete the desired number of repetitions on one leg before switching legs.

Bodyweight Bulgarian Split Squat

For many, the weight of the body is enough to provide a training effect.  Progressing away from using the suspension trainer increases balance and stability challenges.  Place the hands on the hips or arms across the chest.  If you are unable to perform the exercise without the arms in these positions you many lack adequate balance.  If this is the case, regress back to the TRX-Assisted exercise or try holding two light dumbbells with the arms at the sides.

Kettlebell (Goblet) Bulgarian Split Squat

There are a few advantages to performing the Bulgarian split squat with a kettlebell held at the chest.  First, this promotes a vertical position of the trunk.  Other variations, such as holding dumbbells at the side of the body or a barbell on the back, require the trunk to slightly dip forward.  Second, the kettlebell helps activate the core musculature and cue proper positioning of the rib cage on the pelvis.  It is important to stack the lower rib cage on top of the pelvis.  The abdominal muscles are primarily responsible for this.

2-Arm Dumbbell Bulgarian Split Squat

Holding two dumbbells to the side of the body lowers the center of mass.  For some, this improves balance and stability compared to the bodyweight exercise.  Start with light loads and progress as strength improves. If you prefer, try holding two kettlebells instead of the dumbbells.

1-Arm Dumbbell Bulgarian Split Squat

Holding a dumbbell in one hand increases balance and stability challenges.  Hold the dumbbell in the hand on the side of the trail leg.  This will increase activity to the hip musculature, especially the gluteus medius of the lead leg.  This exercise is more challenging than it looks.

TRX Bulgarian Split Squat

This variation is performed with the trail foot placed in the suspension trainer loop. Position the suspension loop so the trail lower leg is parallel to the floor.  Maintain the trunk in a vertical position.  Maintain the hands on the hips.  The knee of the lead leg should not track excessively past the toes.  Compared to the bodyweight split squat, this exercise shows greater activation of the hamstrings, adductors, gluteus maximus, and gluteus medius.  The suspended position increases stability and balance challenges.  This is a more demanding exercise for the hip muscles.  It is a progression from the bodyweight Bulgarian split squat.  To further increase the challenge, try holding a dumbbell in the hand on the side of trail leg.

Barbell Bulgarian Split Squat

Performing the exercise with a barbell allows for the progression of the load for strength development.  The barbell also causes the trunk to angle slightly forward to support the load.  Before positioning the bar, pull the shoulder blades back.  Place the bar on the base of the neck resting over the trapezius muscles. Tuck the elbows to your side and maintain the retracted shoulder blade position.  With barbell training, heavier loads and fewer repetitions are optimal.  Start with a weight which allows you to perform 6 to 8 quality repetitions.  As always, focus first on proper technique before progressing load on the bar.

Closing Thoughts

The Bulgarian split squat is an excellent exercise for rehabilitation, injury prevention, and strength development.  This exercise requires stability in multiple planes and challenges the hip muscles to control the position of the lower limb.  Performance in many sports involves lower-body, weight-bearing skills in positions similar to the split squat. Sprinting, change of direction, throwing, and kicking require the transfer of forces from one leg in a similar fashion.  If you are unsure about how to best incorporate the Bulgarian split squat, give your physical therapist or strength coach a call.

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.

 

Gluteus Medius: Controlling Knee Position during the Squat

The gluteus medius is a broad thick muscle on the outer part of the pelvis.  The muscle spans from the buttock to the upper aspect of the thigh bone (femur) on the bony part of the outer hip (greater trochanter).  The primary function of the gluteus medius is to stabilize the pelvis and femur during dynamic activities such as walking or performing a deep squat.  It is responsible for preventing the opposite side of the pelvis from dropping during walking.  The gluteus medius packs many short muscle fibers together.  This allows it to generate high forces.  However, a trade-off to its structure is its inability to produce large forces when in lengthened positions.

Poor squat due to gluteus medius weakness

The gluteus medius is lengthened when the hips flex and internally rotate.  This causes the knee to cave inward during the squat.  This may be more obvious during a 1-leg squat or landing from a jump on one leg.  This movement strategy is sometimes called, dynamic valgus, and is believed to be disadvantageous.   The gluteus medius is unable to accomplish its primary role of stabilizing the pelvis when in extreme joint positions.  This is the case when the hip is in flexion and internal rotation.  Hip internal rotation during the squat also impairs the ability of the gluteus maximus to extend the hip.  However, the hamstrings and adductors can often overcome this deficit to compensate.  Squatting with the hip internally rotated increases the demands of the gluteus medius and may be a compensation for the weakness of this muscle.

Gluteus Medius & Injuries of the Lower Extremity

It is commonly believed that squatting with hip internal rotation or dynamic valgus is indicative of hip weakness.  This is particularly thought to occur in those with knee pain and those at risk for anterior cruciate ligament (ACL) injury.  Other injuries which are characteristic of this pattern include runner’s knee, iliotibial band (ITB) syndrome, labral injuries of hip and femeroacetabular impingement of the hip.  In many cases, this pattern is likely a compensation for the weakness of the hip musculature.  Hip internal rotation may increase the force capacity of the weakened gluteus medius.   This allows for performance of the squat but subjects the knee and hip joints to excessive stress.

Lifestyle Factors Contributing to Gluteus Medius Weakness

Side sleeping with the leg crossed can place additional stress on the gluteus medius tenddons

Gluteus medius weakness can be the result of previous injury or lifestyle factors.  Standing with the body weight predominantly on one leg with the pelvis swayed sideways can lead to an underdeveloped muscle on one side.  Sleeping on one’s side with the top leg flexed and crossed over the other leg results in an elongated muscle.  Both of these scenarios can potentially weaken the muscle over time.  Repeated running on crowned roads or surfaces can also potentially lead to weakness of the gluteus medius on one side.

Closing Thoughts

Hip internal rotation and dynamic knee valgus negatively impact the gluteus maximus and increase the force generating demands of the gluteus medius.  This movement strategy may be a compensation to increase gluteus medius force production and a cause of gluteus maximus weakness.   In any case, this movement strategy should be addressed with resistance exercise targeting improvements in strength and hypertrophy of both muscles.  Next week, I will post an article about initiating and progressing exercises for the gluteus medius.

Abdominal Oblique Injuries in Rotational Sports

Abdominal oblique injuries, also known as side strains, are common in rotational sports such as baseball, tennis, golf, and track and field.  These injuries are characterized by a sudden, sharp onset of pain near or on the side of the rib cage.  The injury usually occurs during some type of rotational sports movement such as swinging a bat, club or racket; or throwing a ball.

Trunk rotation plays an important role in generating and transferring power during sport.  It is through the trunk or core, that forces are transferred from the lower body to the shoulder and arms. Activities such as throwing and swinging require the core muscles to both stabilize the trunk and create force in order to transfer power to the upper body.

Anatomy of the Abdominal Oblique Muscles

The core includes the thoracolumbar, abdominal, pelvic, and hip musculature.  These muscle groups provide trunk stability to allow integrated limb movements, such as throwing and swinging, to occur. The abdominal core muscles include the rectus abdominis, transversus abdominis, internal oblique and external oblique.  Most abdominal injuries occur in the internal and external oblique muscles.  Less commonly, injuries can occur to the intercostal muscles between the ribs themselves.

The Role of the Oblique Muscles in Sport

The internal and external oblique muscles are responsible for flexion and rotation of the trunk, as well as providing trunk stabilization during complex sports movements.    Poor mobility of the hips or thoracic spine can contribute to excessive stress and compensation through the trunk musculature during swinging or throwing.  Rehabilitation often addresses hip mobility with manual therapy techniques performed by the physical therapist.  An imbalance between right and left side oblique muscles are also common is in sports such as golf and baseball.  This may place excessive forces through the lead side oblique musculature.  Finally, the large forces generated by lower body muscles (quadriceps and hamstrings) may overpower the weaker core musculature leading to injury during explosive sports movements.

The incidence of Abdominal Oblique Injuries in Baseball

A 2010 study in the American Journal of Sports Medicine investigated the incidence and trends of abdominal injuries in professional baseball players.  From 1991 through 2010, abdominal strains accounted for approximately 5% of all injuries in Major League Baseball.   Nearly half of these injuries occurred in pitchers.   These injuries occurred most often during the early part of the season.

In both pitchers and position players, the majority of injuries occurred on the side opposite to their throwing arm.  Pitchers missed, on average 35 days on the disabled list, while position players missed 26 days on average.  Players who receive steroid or PRP injections have been shown to miss more time from injury.   More than 1 out of every 10 sustained a re-injury during their career.  Most of these re-injuries occurred during the same or the following season.   As a result of these injury trends, many MLB teams have increased their focus on preemptive core and trunk strengthening exercises for all players.

Closing Thoughts

The incidence of abdominal oblique injuries is on the rise in rotational sports such as baseball and golf.   These injuries can result in substantial loss of playing time.  Proper training can prevent abdominal oblique injuries from occurring.  In a few weeks, I will post an article describing exercises which can help reduce the risk of sustaining an injury.  These exercises can also be part of a comprehensive rehabilitation program to safely return an injured athlete back to sport.

References

  1. Camp CL, Conte S, Cohen SB, et al. Epidemiology and impact of abdominal oblique injuries in major and minor league baseball. Orthop J Sport Med. 2015;5(3):1-8. doi:10.1177/2325967117694025.
  2. Conte SA, Thompson MM, Marks MA, Dines JS. Abdominal muscle strains in professional baseball. Am J Sports Med. 2010;40(3):650-656. doi:10.1177/0363546511433030.
  3. Nealon AR, Kountouris A, Cook JL. Side strain in sport: A narrative review of pathomechanics, diagnosis, imaging and management for the clinician. J Sci Med Sport. 2017;20:261-266.

Youth Strength Training and Performance

Previously, the safety of strength training and its role in reducing youth athletic injuries was discussed. We now turn our attention to the role of resistance training to optimize performance in young athletes. High levels of muscular strength and power are essential for maximizing sport performance in any young athlete. Muscular strength is defined as the maximum force which can be exerted during a given movement. Power is the product of force and velocity and relates more to the speed at which strength can be expressed. Strength and power can be significantly improved through properly designed, supervised, and progressed resistance training programs for athletes of any age.

When to Start Youth Resistance Training

Children as young as 10 years-old can achieve substantial performance improvements through properly supervised and progressed resistance training programs. A 2014 study1 in the Journal of Strength & Conditioning Research showed young children engaged in resistance training with free weights, Olympic weight lifting with barbells, or plyometrics significantly improved vertical jump, long jump, balance, speed, agility, strength, and power. Resistance training combined with plyometrics results in superior performance gains compared to resistance training alone3. Correct performance of each exercise with proper movement patterns is always emphasized and little importance is given to the amount of weight lifted. Pre-adolescent athletes can show substantial improvements in strength and power due to neurological adaptations. Large changes in muscle mass or body composition do not occur until puberty.

Priming the Athlete to Flourish in Adolescence

Peak height velocity, or a child’s “growth spurt”, marks the point in maturation where hormones (i.e., testosterone in boys) rise exponentially and many physiological changes occur. In boys, this is the point where muscle mass spikes and young athletes begin to show large improvements in muscular strength and power. A 2016 systematic review5 in the Journal of Sports Sciences, showed boys adaptations to resistance training are greatest during and following their peak height velocity. Ideally, these athletes should have already developed the foundational movement pattern competencies during childhood. During peak height velocity, increasing the training volume and intensity often results in profound improvements in strength, power, and performance. Athletes without prior resistance training experience, or those who have not mastered fundamental movement patterns, will be at a disadvantage compared to athletes who began training earlier in childhood.

How Much Youth Strength Training is Enough

Research shows a dose-response relationship of strength training on performance in young athletes4. In order to maximize power and strength development, high school athletes should train at relatively high intensities, 2 to 4 times per week, with multiple sets per exercise, 6 to 8 repetitions per set, and with long rest periods between sets (3 to 4 minutes). High school athletes should incorporate Olympic lifts (clean, snatch) in order to maximize power development. A 2008 study2 in the Journal of Strength & Conditioning Research showed Olympic lifts resulted in superior improvements in vertical jump compared to training with traditional power lifts (squat, dead lift, and bench press).

Conclusion

The underlying key to success with any youth strength and conditioning program is related to supervision and progression by a qualified professional. Safety and performance outcomes can only be achieved when young athletes are coached appropriately. When implemented correctly, strength training can positively alter the trajectory of any young athlete’s athletic career or life.

References

  1. Chaouachi A, Hammami R, Kaabi S, Chamari K, Drinkwater E, Behm D. Olympic weightlifting and plyometric training with children provides similar or greater performance improvements than traditional resistance training. J Strength Cond Res. 2014;28(6):1483-1496.
  2. Channell B, Barfield J. Effect of Olympic and traditional resistance training on vertical jump improvement in high school boys. J Strength Cond Res. 2008;22(5):1522-1527. doi:10.1519/JSC.0b013e318181a3d0.
  3. Faigenbaum AD, Mcfarland JE, Keiper FB, et al. Effects of a short-term plyometric and resistance training program on fitness performance in boys age 12 to 15 years. J Sport Sci Med. 2007;6:519-525.
  4. Lesinski M, Prieske O, Granacher U. Effects and dose – response relationships of resistance training on physical performance in youth athletes: A systematic review and meta-analysis. Br J Sports Med. 2016;50:781-795. doi:10.1136/bjsports-2015-095497.
  5. Moran J, Sandercock GR, Ramírez-Campillo R, Meylan C, Collison J, Parry DA. A meta-analysis of maturation-related variation in adolescent boy athletes’ adaptations to short-term resistance training. J Sport Sci. 2016;414:1-12. doi:10.1080/02640414.2016.1209306.

Strength Training: Reducing Injury in Children

In our last article, we discussed the safety of youth resistance training. In addition to being safe for youth athletes, resistance training can also reduce injury and improve athletic performance. Resistance training has been shown to reduce injuries in adolescents who participate in football, soccer, basketball, and various other sports1-2. Adolescent females are especially vulnerable to knee injuries. Preseason conditioning programs that include plyometric training, resistance training, and jump training significantly reduce knee injuries in female athletes. Also, youth athletes who engage in regular resistance training recover quicker from injuries when they do occur.

When to Incorporate Resistance Training for Children

Youth athletes can benefit from developing fundamental movement skills (e.g., jumping, landing, and throwing) through appropriate fitness conditioning at early ages (6-10 years old). Once fundamental movement skills are mastered, appropriately supervised strength training programs can be initiated to reduce the likelihood of overuse injuries occurring during sport. Resistance training addressing specific risk factors associated with youth-sport injuries (e.g., low fitness, muscle imbalances, and training errors) reduce overuse injuries by as much as 50%1, 3. With early exposure to resistance training, young athletes may be able to prevent the development of deficits which predispose them to injury later in life.

Resistance Training for Youth Non-Athletes

Free-time physical activity among children and adolescents is on the decline. Strength training is beneficial for athletes and children who are not engaged in competitive sports. Physical inactivity is a risk factor for activity-related injuries in children. Youth who participate regularly in age-appropriate fitness programs, which include resistance training, may be less likely to suffer an injury.

Conclusion

Although the total elimination of injuries is unrealistic, appropriately designed conditioning programs that include strength training can help reduce the likelihood of sports- related injuries.  Clearly, incorporating resistance training supervised by qualified professionals is in the best interest of any young athlete looking to minimize risk for injury and improve performance. Our next article will discuss the role of resistance training for improving athletic performance.

References

  1. Faigenbaum, A., Kraemer, W., Blimkie, C., Jeffreys, I., Micheli, L., Nitka, M., & Rowland, T. (2009). Youth resistance training: Updated position statement paper from the National Strength and Conditioning Association. Journal of Strength and Conditioning Research, 23(5), S60–S79.
  2. Faigenbaum, A. D., & Myer, G. D. (2010). Resistance training among young athletes: safety, efficacy and injury prevention effects. British Journal of Sports Medicine, 44, 56–63. https://doi.org/10.1136/bjsm.2009.068098
  3. Lloyd, R. S., Faigenbaum, A. D., Stone, M. H., Oliver, J. L., Jeffreys, I., Moody, J. A., … Myer, G. D. (2014). Position statement on youth resistance training: The 2014 international consensus. British Journal of Sports Medicine, 48, 498–505. https://doi.org/10.1136/bjsports-2013-092952

Early Sports Specialization in Young Athletes

In the United States, it is estimated that 72% of school-aged youth (8 to 17 years old) participate in at least one organized sport. Sports participation has many benefits, including living a healthy lifestyle, having a positive self-image, and building social relationships. It is also estimated that nearly 30% of school-aged athletes specialize in a single sport year-round6.  Early sports specialization has been defined as intensive year-round training in a single sport at the exclusion of other sports4. This may include athletes who:

  1. Choose one main sport,
  2. Participate for greater than eight months per year in one main sport, and
  3. Quit all other sports to focus on one sport.

Young athletes who engage in year-round intense training programs in a single sport are prone to overuse injuries, burnout, and dropping out of sports. Sports believed to be most susceptible to these negative consequences are baseball (pitchers especially), cheerleading, gymnastics, soccer, swimming, tennis, and volleyball.

Injury, Burnout, and Dropping out of Sports

Evidence is emerging which shows specialized young athletes are at more risk for injury compared to those who engage in multiple sports. One study of 7 to 18 year old athletes, showed that those who specialized in a single sport were 2.25 more likely to sustain a serious overuse injury compared to unspecialized young athletes4. Another study of 546 high school athletes found a relationship between the development of knee injuries and single- sport training in those engaged in basketball, soccer, and volleyball3. It appears that female high school athletes who specialize in a single sport are particularly vulnerable to hip and knee overuse injuries1,3. A possible explanation for these injury trends is the lack of diversified activity which may not allow young athletes to develop the appropriate neuromuscular skills that are effective in injury prevention. Year-round training in a single sport also does not allow for the necessary rest from repetitive use of the same muscles and segments of the body. The positive transfer of skill with diversification of sport participation is important in the successful development of any young athlete2.

Young athletes are under a tremendous amount of pressure brought about by adult-driven specialized training programs, weekend tournaments, showcases, and competitions. The psychological risk of burnout, depression, and increased risk of injury is believed to result in withdrawal from sport. In the physical therapy clinic, we are faced with many young athletes who lose their desire to return to sport following injury. It is my belief that these young athletes view their injury as a means to escape from the increased pressures of youth sports.

Research has indicated that adolescents need to enjoy their sport, and that intrinsic motivators are keys to maintaining participation and goal achievement in sports. Unfortunately, this is often not the case as the temptation of collegiate scholarships and stardom causes thousands of adolescent athletes to specialize in single sports. While this may result in more highly skilled, sport-mature athletes at a younger age, it is isolating the child and has the potential to lead to increased stress and pressure. Consequently the child loses a sense of control or decision-making power over their lives. These consequences may be far-reaching with the adolescents overall maturation and development5.

Conclusion

Parents and coaches should be cautious with encouraging young athletes to engage in intense year-round training specialized in any single sport. Adults involved in instruction of youth sports should be on the alert for signs of burnout, and physical symptoms in highly specialized athletes and be prepared to take corrective action such as backing off training. A more proactive approach is the better option. Encouraging multiple sports participation has the benefits of reducing injury risk, decreasing the chance of burnout, and the promotion of basic motor skills which will enhance the young athletes overall development throughout their lifespan.

References

  1. Bell DR, Post EG, Trigsted SM, Hetzel S, Mcguine TA, Brooks MA. Prevalence of sport specialization in high school athletics: A 1-year observational study. Am J Sports Med. 2016;44(6):1469-1474. doi:10.1177/0363546516629943.
  2. Fransen J, Pion J, Vandendriessche J, et al. Differences in physical fitness and gross motor coordination in boys aged 6 – 12 years specializing in one versus sampling more than one sport. J Sports Sci. 2012;30(4):379-386.
  3. Hall R, Foss KB, Hewett TE, Myer GD. Sport specialization’s association with an increased risk of developing anterior knee pain in adolescent female athletes. J Sport Rehabil. 2015;24:31-35.
  4. Jayanthi NA, Labella CR, Fischer D, Pasulka J, Dugas LR. Sports-specialized intensive training and the risk of injury in young athletes: A clinical case-control study. Am J Sports Med. 2015;43(4):794-801. doi:10.1177/0363546514567298.
  5. Myer GD, Jayanthi N, Difiori J p, et al. Sport specialization, part I: Does early sports specialization increase negative outcomes and reduce the opportunity for success in young athletes? Sport Heal A Multidiscip Approach. 2015;7(5):437-442. doi:10.1177/1941738115598747.
  6. Myer GD, Jayanthi N, Difiori JP, et al. Sports specialization, part II: Alternative solutions to early sport specialization in youth athletes. Sport Heal A Multidiscip Approach. 2016;8(1):65-73. doi:10.1177/1941738115614811.
  7. Bell DR, Post EG, Trigsted SM, Hetzel S, Mcguine TA, Brooks MA. Prevalence of sport specialization in high school athletics: A 1-year observational study. Am J Sports Med. 2016;44(6):1469-1474. doi:10.1177/0363546516629943.