Gluteus Medius – evidence based rehab

This is in part advice for runners and in part something else….

…you’ve heard of a “dance off” and probably a “sing off” this my friends is a geek off!

It’s come about after I’ve heard lots of people being advised not to bother with sidelying exercises for glutes because they “aren’t functional”. Several well-meaning websites even describe them as harmful and more likely to cause “regression” than rehab. I say in my home page for this site that I appreciate everyone’s opinion and I do. I also agree that sidelying work isn’t functional, but I feel it still has a valuable place in glutes rehab and it shouldn’t be treated as ineffective quackery! My point here isn’t that sidelying work is the best, but simply that it has it’s value in rehabbing glutes and should be used as part of a comprehensive programme including weight bearing exercises.

So let’s examine some glutes exercises you can do and some research behind them. All pictures are reproduced from research articles freely available on the web and will be referenced and linked.

Sidelying abduction – reproduced from Distefano et al. 2009 (below). There is also a video although it doesn’t work on the iPad. This page contains links to videos for all the exercises in this article (links may take you to a “mobile page” if using iPad or iPhone. Use the search box and you can locate the full article without signing in).

Distefano et al. 2009 used an EMG study to determine which exercises produced most activation of Gluteus Medius. EMG (Electromyography) uses electrodes to examine muscle activation. They compared a number of exercises including hip clam, single limb squat, single limb deadlift, lateral band walks, multiplanar lunges and multiplanar hops. They concluded that,

“The best exercise for Gluteus Medius was side-lying abduction”

They found single limb squat to produce the second most EMG activity and lateral band walk the third.

Now you may be wondering does this translate to changes that I can feel and see? Will it improve my symptoms? It’s fair to question this, EMG change is all good in theory but what about in practice?

Fredericson, who’s written quite widely on ITB problems and their treatments did a study on runners in 2000. They found that,

“Long distance runners with ITBS have weaker hip abduction strength in the affected leg compared with their unaffected leg and unaffected long-distance runners….symptom improvement with a successful return to the pre injury training program parallels improvement in hip abduction strength.”

So hip abduction, one of the roles of Gluteus Medius, is weaker on the side runners have ITBS. No great surprise there. What exercises did they use to rehab it and return people to running?…..

…..you guessed it side lying abduction and pelvic drops.

Update 3/6/12:

Thanks to Stuart Palma (a nice bloke despite being a Liverpool fan!) we also have another article to add to the mix. McBeth et al. 2012 compared 3 sidelying exercises sidelying abduction, the clam, and sidelying abduction with external rotation in healthy runners. Unlike previous articles they used a leg weight and a “biofeedback unit” to monitor trunk position. They compared muscle activation in Gluteus Medius, Gluteus Maximus, anterior hip flexors and Tensor Fascia Latae with each exercise. They concluded that,

The sidelying hip abduction exercise was the best for activating Gluteus Medius with little activation of Tensor Fascia Latae and anterior hip flexors”

A few key points here then;

  1. It gives us an indication of specificity – sidelying abduction appears to be able to activate the muscle we are targeting without working the muscles we are not targeting.
  2. Gluteus Medius activation was similar to Distefano’s earlier work at 79.1% of MVIC.
  3. Important to note there is no comparison with weightbearing exercise

 

Now I could stop there. I’ve made my point – sidelying abduction clearly has a role, but part of this is not about cherry picking a couple of articles to prove a point, it’s about looking at the bigger picture even if that includes research that goes against your theories….

Side plank abduction

This is reproduced from Boren et al. 2011 who did an excellent study and also compared their results with earlier work. Their top 3 exercises for Glute Medius were side plank abduction with dominant leg down, side plank abduction with dominant leg up and single leg squat (in that order). Notice again that these positions, despite being “non-functional” do create a lot of activity in Glute Medius and again more so than weight bearing positions such as single leg squat. Of note too is that they found less activity with side-lying abduction than the previous studies. This raises a good point with research and rehab. Nothing is concrete. You simply cannot say “this exercise has no role” as you will find evidence to support your claim and evidence to refute it. Also they used a slightly different technique which might account for the difference.

The Clam

Again reproduced from Boren et al. 2011 but I’ve modified them with some instructions to clarify (thanks to Debra for the suggestion). The link above also includes detailed descriptions of this exercise and its progressions (it’s all in the appendix at the end of the article). Most people think of the clam as the exercise described in Clam 1 above. In this study 3 progressions of the exercise were included. In many exercises they can be progressed by increasing resistance, this one is progressed by a change in position. The article demonstrated an increase in glutes activity from Clam 1 being lowest to Clam 4 being the highest. Compared to other exercises in the study Clam 4 had a high level of Gluteus Medius activity (77% of MVIC – Maximal Volitional Isometric Contraction) only slightly lower than Single Limb Squat (81% of MVIC). Distefano et al 2009 showed lower levels of activity with the clam but didn’t include the same progressions.

So we’ve seen 3 exercises, all in sidelying, that produce high levels of Gluteus Medius activation, at least comparable to, and in some cases higher than weight bearing exercise. It’s no great surprise then that the English Insitute of Sport uses a selection of sidelying exercises in its “Glutes Circuit”. We were given this by one of their team at a Strength and Conditioning lecture but sadly can’t reproduce it online.

Next we look at weight bearing exercise

Single Limb Squat

Once again from Boren et al. 2011. Single Limb Squat as above showed good Gluteus Medius and Gluteus Maximus contraction with 81% of MVIC for Gluteus Medius and 71% for Gluteus Maximus. Both muscles are hugely useful for runners and so this exercise clearly has its benefits. As a result it’s one I use regularly. The only issue here is the risk of aggravating pain. The deep dip position places greater stress on the ITB and patellofemoral joint. As a result I often start with a shallow knee dip or use this exercise after first rehabbing with sidelying exercises. There is also an issue of control, some patients struggle to even balance on one leg let alone perform a squat.

Distefano et al. 2009 used the slightly different technique shown above, they also reported good activation of both Glute Med and Max. Lateral Band Walk shown below, also showed good Gluteus Medius activation (although less than side lying abduction). This doesn’t appear to have been assessed by Boren et al. 2011.

Wall Press – reproduced from O’Sullivan, Smith and Sainsbury 2010. In the picture below the right Gluteus Medius is being exercised by pushing the left knee, hip and ankle against the wall and maintaining a contraction for 5 seconds.

Wall press was compared to Pelvic Drop and Wall Squat and achieved the highest MVIC of 76%.

Pelvic Drop – picture below reproduced from Bolgla 2005 who found reasonable activation of Glute Medius on pelvic drop of 57% of MVIC and was similar to Boren et al 2011 (58%). In Bolgla’s study it scored the highest of 6 exercises which also included sidelying abduction.

For pelvic drop the standing leg (right in this case) stays straight and you lower your other leg by lowering the pelvis on that side.

Krause et al. 2009 (abstract only) studied the effect of doing exercises on a balance cushion and found an increase in Gluteus Medius activity (compared to balancing on normal floor) although it should be noted this difference wasn’t thought to be statistically significant.

Lubahn et al. 2011 looked at the effect of using resistance band to pull the knee more medially (towards the other knee) during weightbearing exercises. The idea behind this is that the medial pull of the band should increase activation of Gluteus Medius. They found it didn’t increase activation during single limb squat or step up and may result in poorer limb alignment during the exercise.

 

Acknowledging Limitations and closing thoughts

An important part of any theory is acknowledging limitations. Like I’ve mentioned above nothing is concrete. I’ve barely scratched the surface of research in this area and I acknowledge there is more research out there, undoubtedly with different findings. I also realise that the main measure involved in these studies is surface EMG recording of muscle activity in healthy individuals. This measure is only related to Maximal Volitional Isometric Contraction presented in a percentage and has not included people with injuries. Endurance activity such as running rarely needs maximal voluntary contraction. So we can’t conclude that because sidelying abduction has a higher % of MVIC than single limb squat that it is a better exercise for rehab in return to running. Neither can we conclude that certain exercises are better for rehabbing certain conditions as the research above (with the exception of Fredericson et al. 2000) doesn’t examine the effect of exercise on injury. That said I think the research is a useful indication for strength work – Boren et al suggested that an MVIC of greater than 70% was needed for strength work while ealier research suggested a range of at least 40-60%. Sidelying and weightbearing exercises have both achieved greater than this range and should be capable of producing strength changes.

The aim of this blog was not to prove sidelying exercises are more effective but only to show that they create good levels of glutes activation and have a role in rehab. This idea that exercises must be functional is a slightly limited one. The very fact that sidelying work isn’t functional may be its advantage – it is a task that we don’t do as part of our day, a task that can potentially isolate a muscle to gain good activation. If functional tasks were so good at glutes rehab, we’d all have great glutes just from walking around, climbing stairs and running!

The other advantage of sidelying work is that it can often be done without aggravating symptoms if done correctly. For people with painful ITBS or irritable patellofemoral pain a range of weightbearing exercises can make symptoms worse.

Selecting exercises for yourself or a client is very individual and should be based on addressing specific weaknesses. Take sidelying abduction, some people can do 40-50 with good form and minimal glutes fatigue. There is little point asking them to do this as an exercise as it probably won’t overload the glutes to achieve strength changes. Some people get to 9 or 10 reps and start to fatigue or lose control and they are more likely to benefit from it. For some the issue actually isn’t strength at all, some studies show poor correlation with Glute strength and pelvic position, this is because control of movement can be poor even with good strength. In that situation it’s control and form that needs to be addressed and this is where functional weightbearing movements are more important. I think if your control of pelvic position is poor, but Glute strength is good it’s unlikely sidelying work will be of great benefit.

 

So what to do for your Glutes? The answer is what works for you. If you find sidelying exercises are getting you results without causing symptoms then great. If not try some of the others above and see which ones seem to work your glutes and get results.

 

What about reps and sets? Assuming we are working endurance roughly speaking people usually start at around 10-15 reps 3 sets in a session with a rest of 1-2 minutes between each set. Then progress up towards 25 reps, you’re aiming to fatigue the muscle so there will be lots of individual variation in the reps needed to do that. That said if you can do more than 30 reps without fatigue maybe you need a harder exercise? These recommendations are based on those by the American College of Sports Medicine research (abstract only) which I’ve summarised in a table below (click to expand). Remember too that form and control are very important and you should feel it in your glutes not the side of your knee or front of the thigh.

Closing thought, from the research I’ve read and patients I’ve seen, a combination of both functional weight bearing and less functional (sidelying) exercises is most likely to be effective in glutes rehab.

 

Please feel free to comment, I welcome other opinions even if very different from my own. Where possible back up any claims with research evidence.

 

 

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65 Responses to Gluteus Medius – evidence based rehab

  1. Alex July 12, 2012 at 2:29 pm #

    Ciao, scrivo dall’Italia. Soffro di ITB da circa 4 anni. Ho fatto riposo, tecarterapia ma non riesco a risolvere il problema. Ogni volta che riprendo a correre dopo 2-3 Km mi viene il dolore.
    Ho letto molto su internet e su siti stranieri per cercare di risolvere il problema. Di recente dopo la corsa con dolore mi sono fermato 1 settimana e poi, quando non avevo più dolori, ho provato a seguire il protocollo stretching e potenziamento ITB e glutei ma sento indolenzimento e poi dolore alla ITB. Dall’ecografia fatta un anno fa emerge solo un modesto ispessimento della bandelletta ileo tibiale, il resto è tutto OK! Cosa posso fare?
    Ciao, grazie

  2. Robert Leavitt August 31, 2012 at 10:12 pm #

    I have heard that barefoot running requiring 50% more Gluteus Medius strength for an effective running stride. Are you aware of any research that confirms this statement?

    • PhysioTom September 7, 2012 at 10:29 am #

      Hi, I’m not aware of any research on this, I’d be dubious of any very specific claims like that. If I come across anything I’ll let you know

  3. Sam Murphy September 18, 2012 at 4:12 pm #

    Great post, Tom. I’ve never had any joy with clams so will try the variations out..
    Robert, I agree with Tom that it’s unlikely that barefoot running per se requires greater glute strength but I think padded running shoes facilitate a lazy stride which uses less muscle recruitment in general, and tend to encourage a sort of ‘semi-seated’ posture with a heavy heel strike which will not allow the runner to harness the power of the glutes either for stabilising or propulsion. Sam

  4. Kathy McCulloch January 12, 2013 at 7:40 pm #

    Hello,

    Just wanted to say thanks for such a great blog/post. I am physio working in orthopeadics for 20 years now-primarily private clinic with a mixed client list. Your post was well written , practical and open minded. Rarely see that together in one spot. I tried the clam progressions and already my “gluts ” are talking to me-excellent!!

    Would love to know if you have anything for scapular stablity and for thoracic mobility?? Comments, thoughts and exercises.

    Thanks very much,
    Kathy McCulloch BHSc PT.

    • PhysioTom January 17, 2013 at 1:37 pm #

      Hi Kathy,
      Thanks for your nice comments.
      I’m afraid I don’t have much on scapula stability or thoracic mobility. I tend to focus my work on the lower limb really. If I find any good articles I’ll be sure to let you know!
      Tom

  5. Alfred Mulee February 20, 2013 at 8:34 am #

    Great post. . I am Physio in Kenya and articles like yours are very enlightening to some of us in Africa where research materials and exposure is very limited. We have great sportsmen and women known all over the world, but knowledge to most of us is very basic. Keep us posted

  6. Chris Kendall March 6, 2013 at 9:52 am #

    Great article, one of the best written I have seen and very well referenced. I am a final year medical student with an interest in sports medicine and a BSc in sports science. Non functional glute exercises have helped me rehabilitate my patellar tendinopathy, it has been a very long road and I can back up your claims about functional exer use aggravating symptoms. It has been a personal goal of mine to progress to single limb squats for a long time but every time I try I increase pain. Also very good point well made that if functional exercise was always so good for glute activation, us highly active people would have no problems!

    • Colin December 8, 2015 at 5:47 pm #

      Hi Chris, Ive had patellar tendinopathy now this 3 years. Which specific exercises did you find that benefited you most?

      Regards
      Caolan

  7. Patsy March 25, 2013 at 11:22 am #

    Hi Tom,

    A great read, thank you!
    I don’t suppose you have a different link for the McBeth 2012? It doesn’t seem to like it. I’m preparing to have a Glut Med reading week ahead of me! 🙂

    Patsy

  8. Wendy Edwards, PT, ScD, COMT April 16, 2013 at 7:07 am #

    Nicely done! Concise lit review and solid clinical reasoning regarding the utility/appropriateness of ‘nonfunctional’ therex. Maximizing neuromuscular recruitment is fundamental to functional strength gains. I appreciate your thoughts on the incongruence between strength and motor control, as well. Clinically, I have found that some patients struggle with postural awareness and form control with glut med exercises, requiring greater visual or tactile feedback initially. A nice addition to the wall press adds a pillow or Airex between the patient’s leg and the wall…cues for perceived exertion can be given intermittently…minimum effort to avoid losing the Airex, 50%, max effort…also standing on Airex for dynamic challenge, or wall dribbling if the patient is placed in a corner. Good post! Thanks!

  9. Gordon April 25, 2013 at 11:19 am #

    Have been suffering from a chronic glut strain probably pirofomis and needed to strengthen my med gluts, am starting to feel some relief after applying the clam variations plus glut stretches and my itb seems stronger too. Thanks very comprehensive discussion.. has allowed me to get back on the paddle board!
    cheers Gordon.

  10. Chris April 29, 2013 at 10:53 pm #

    Good article Tom. I just wanted to add a couple of points having just come from Dr Grimaldi’s Hip and Pelvis course. She isn’t a big fan of open chain abductor exercises because they tend to upregulate the superficial system, including more superficial medial part of glut med, which can increase compressive joint loading at the expense of deeper muscles (glut min, ant and post glut med) which control the joint position and retract the joint capsule. As you mentioned, much of the work has been carried out by surface EMG, which tends to reflect the activity in the more superficial parts, and there are few fine wire EMG studies to help our understanding. This one by Adam Semciw helps a bit (http://www.jelectromyographykinesiology.com/article/S1050-6411(13)00069-2/abstract), but Dr Grimaldi tells us that even this group did not use fine wires in the deepest parts of the muscle!
    Anyway, the crux of it is that she advocates closed chain work such as the ones mentioned in your article, and abduction work done on a pilates reformer.
    I hope I am accurately portraying Dr Grimaldi’s views here. She is a leading light in hip and groin injuries, and her course is well worth a visit.
    Keep the interesting stuff coming….. Chris

    • PhysioTom April 30, 2013 at 6:44 am #

      Thanks Chris, really helpful comments!

      I like Dr Grimaldi’s work, she’s starting to really explore hip stability and pathology around the hip and pelvis. Did she say if she had evidence that weight-bearing exercise improved recruitment of deeper stabilising muscles? Also has she proved this to be more beneficial when treating pathology? I’m not aware of many studies comparing different types of glutes ex’s and their effectiveness.
      The issue is that much of this is still very theoretical and largely unproven!

      There remains the question of whether we can, or should aim to make muscles work in isolation. Is it just more about the relative contribution each makes? I’m also always a little wary of very specific exercises – is it realistic to expect a patient to be able to target 1 muscle group? How does this all fit in the biopsychosocial model and the view that it’s not how we move that’s important but how often we do it?

      Lots of questions still to be answered!

      Tom

      • sharmila November 21, 2014 at 4:03 pm #

        HI
        Could anyone suggest some online/day courses for taping techniques please?

  11. Joe D July 10, 2013 at 8:54 pm #

    Tom,
    New to the site, really like it. Would like to get your thoughts on recruitment and timing of the glute med vs the TFL. Background – i’ve had a long recovery from FAI/labral tear incl ITB release surgery. I’ve been able to battle though most of my issues with a few good Doctors/PTs but it seems that my TFL is always hypertrophic (it’s plainly larger than the other side to the point where my surgeon called it “the incredible hulk’s TFL” when he looked at an MRI) and full of trigger points. At this point, my glute med and max are fairly strong, it just seems that the TFL always gets overly involved when doing exercises like the ones above (even if I externally rotate my leg) and when running. Any thoughts?

    (not a PT, so pardon any errors I may have made with the medical jargon)

    • Sam August 12, 2014 at 7:35 pm #

      You may want to try performing the side-lying hip ABD exercise against a wall so you can also push into hip extension to help inhibit the TFL (which also acts as a hip flexor). You can progress the exercise with ankle wt or bands.

    • Debbie Greaves April 7, 2016 at 1:27 pm #

      Joe, did you ever get to the bottom of this? My right TFL/ITB is overactive in side lying ABD and also in standing pelvic drops. I have glute pain on right after only running 2 miles, physio just gave ultra sound and acupuncture. I need to strengthen glute med but TFL just won’t give up. I tried Sams modification but still my TFL burns. Did you find a modification that helped you?

      Thanks

  12. Barbara August 26, 2013 at 3:20 pm #

    I have had Gluteus Medius troubles for the past 5 or 6 years, on and off. I keep tearing or reinjuring (my own diagnosis) this muscle during my exercise routine. I am not sure which exercise or stretch causes the injury, but it has once again become very painful and I am avoiding a trip to doc’s office. Can you give me a list of exercises to avoid that would cause injury to this muscle? I plan to start the side lying hip aduction movements and also the clam shell with hopes that this will get me back to normal very soon so I can get back on the treadmill and the bike, as well as the weight machine. But I want to know what to avoid once I heal and strengthen my GM. I am 68 years, soon to be 69, so that may make a difference in your answer. I so appreciate any help you can give me. Barbara

    • PhysioTom August 26, 2013 at 7:23 pm #

      Hi Barbara,

      It’s hard to advise without examining you properly I’m afraid. I always recommend seeing someone for a proper diagnosis.

      You may have a gluteal tendinopathy. These are quite common in ladies in their 60’s and would explain why your symptoms are aggravated by exercise. This article has lots of info – http://www.running-physio.com/gluteal-tendinopathy/

      I would stop your stretches and ‘clam’ exercise for the mo as this can aggravate but, like I said, make sure you see a Physio to determine exactly what the problem is and how to manage it.

      Tom

  13. Ken November 17, 2013 at 8:14 pm #

    HI Tom,

    I’m curious if you have come across any studies involving gluteus medius activation with standing abduction exercises? It just seems like the resistance on the abductors would be greater in a standing positions vs. lying.

  14. Barry Nelson November 20, 2013 at 1:04 am #

    Hi Tom,

    Any distance over 10K causes my form to suffer with left foot drop, splay. Right side is fine but I can see in my running shadow that left hip is dropping, trying to keep up. I suspect a weak left gluteus medius/max is causing this problem. Seven years ago I suffered a tear there of some sort where I had trouble even lifting myself out of chair or walking up stairs. It took about 2 1/2 months to get back to running. A dull stiffness there still when sitting. The tear probably weakened this area so these exercises, primarily the single leg squat, should help tremendously.

  15. Carol Freer February 3, 2014 at 3:06 pm #

    Hi Tom
    I came across your article while searching for gluteus medius rehab. I am a 68 yo female physician home at moment recuperating from surgery for torn g medius, minimums tendons and Tera’s in all 3 glut muscles and vast us lateralis. Lots of sitting and driving in my position. This was initially dx as a trochanteric bursitis. I am concerned it may have been precipitated by Arimadex, a post breast cancer med. I suspect that in order to regain pelvic stability I will need intensive rehab but with the right person. Do you have any thoughts on rehab post surgery? I suspect it will be a long road for me to even get my gait back let alone skiing, tennis, and riding which I once did. Thanks

    • Lynn January 31, 2016 at 5:34 pm #

      HI Carol,

      I wanted to know how you did with recovery for your gluteus medius tears. Are you still in pain and can you sleep on them. How long did it take you to recover and who was your surgeon? Was the repair successful too? I have a gluteus medius tear and cystalization where the tendon attaches to the trochanter. I tried laying on that hip last night and after 5 minutes I couldn’t even move to get in and out of bed. I’m now having horrible pain and trouble walking. I’m considering PRP but heard it won’t help the crystallization but could help the tear. I’m so scared because I’m 45 and a mom of a 7 year old and can’t take pain meds because it bothers my stomach so I’m really scared about having surgery. Any imput would be so appreciated and from anyone on here. Thanks,
      Lynn

  16. Jennifer March 11, 2014 at 11:18 am #

    Hi PhysioTom,

    I was looking at at this and if I have gluteal tendinopathy is it good to do exercises like the clams. That has accerbated my problem of recovering when I had a laberal tear. I would tell the physical therapist I can’t do that and then they’d have me doing it. That was two and I didn’t go back to them. Then this person told me to bend my leg out to the side and over my other leg which made everything ten times worse. Then told me to go to a pain doctor. The original pain doctor I went to told me to try physical therapy again and she was telling me I had IT band syndrome and shooting me with PRP shots at $500.00 a pop when it said that I had gluteal tendinopathy. (Made me so mad). Then I go to this other pain doctor who told me to try and work through things – like maybe I would rupture my tendon. I am really discouraged by these people. In addition they told me to do the Gerston technique – rubbing hip – tendon area, bone and IT band with a metal instrument. All the postings on the gluteal tendinopathy say not to do all that stuff – no Gerston Technique, no foam roller, no clams shells, no sitting on hard chairs, no bending your leg to the left or right (use pillow if you do that). I’m not sure how I can restore the muscular strength to the glutes? Do you have any thoughts. As, everything I try is painful. (Especially sitting.)

  17. laura abel March 15, 2014 at 7:36 am #

    Brilliant article, as always with your work. I’d like to raise a point regarding effectiveness of clams (and to an extent some of the other exercises). Some physios point out they have little results with them. My bugbear is that sadly, many physios do not strictly teach good form to the patient. Poor form, mainly poor lumbopelvic disassociation, and allowing lumbar and thoracic rotation as opposed to hip joint pure movement (which the patient will do when glut med is very inactive), is often the overlooked cause for the patient not improving. Why o why are physios not picking up on this. I have lost count of the patients I have treated second after a physio who has not. Form form form! That is all

  18. Gerrit Koops April 12, 2014 at 8:33 am #

    Dear Tom,

    Allways have pleasure with your ‘to much good quality articles and tweets to reed’.

    About training the gluteus part I also often use the one leg goodmorning where the whole body is stabil / isometric position except the flexion and extension in the hip.
    Extension fase of the standing hip with some speed and extra flexion with the controlateral hip. And go ‘slow’ back to start position and repeat.
    If done with hand on fixation: good training without trouble for balance.
    If done without extra stabilisation: powertraining including balance training.

    Why so good: training position is equal to functional use position and you don’t have to lay down on the floor. That’s why people are more committed to do the excersize.

    Go on (running),

    Gerrit
    Another running sportsphysio

  19. Jane Hewitt June 23, 2014 at 1:38 am #

    I found this article most informative.
    I have suffered with hip pain off and on for the past 7 years.
    In 2007 I walked in the 60 km. Walk to End Breast Cancer in Toronto. Ever since I have been suffering from hip pain especially when walking up stairs and any incline.
    An MRI indicated possible bursitis and tendonosis.
    The comment from another about the implications of the breast cancer drug Arimidex was also interesting.
    Am seeing a physiotherapist and hoping I will soon have some relief.

  20. Kjartan Vaarbakken October 9, 2014 at 10:17 pm #

    This article is very near to be as good as the evidence of muscle function in the medical litterature allows it to be. Unfortunately the litterature is too confined to knowlege of superficial eletrical muscle signals. As professor Hodges says in his 2014 article which is assessing EMG-signals of the Obturator Internus, EMG can be high when the muscle has a mechanical disadvantage. The latter means, EMG can be high when a muscle has a low moment arm, thus compensating for bad rotating ability by increasing its EMG signal. Then, what do we know of the relationship between strenght or primary function of single muscles? What more is there to care about?

    Muscle length is hugely important for strength. We do know from frog studies of tendon-deprivated isolated muscle fibers that its strenght increase enormously with increasing lenght and that further increasing muscle lenght will lead to decreased active force. Although in the lengthened position, passive force takes over, depending on the amount of stiffness of the connetive tissue of the muscle fiber. In vivo the case is even more interesting: for the gastrocnemeus and soleus of the leg, they actually provide highest torque in the most lengthened position (straight knee and dorsal flexed ankle) (Maganaris 2003). The same increase in muscle strenght or torque with a simultanous reduction in EMG and reduction in moment arm is seen in two studies by todays professor Neumann (1988, 1989) published in Physical Therapy. He and coworkers examined EMG and strenght of 30 healthy persons performing abduction in the frontal plane (in the plane of the floor while lying supine). The results showed the force of the abductors to raise 2.5 to 3 times from the 40 degree abducted position to the 10 degree adducted position. And the relationship was linear. Today Neumann writes a impressive book called Kinesiology of the musculoskeletal system – foundation for rehabilitation (on Elsevier). I recommend you all to take a look at his curves.

    Grimaldi in her 2014 podcast on BJSM (recently tweeted from Karim Kahn) talkes about the risk of compression on the gluteal entheses by the Tractus illiotibial band. But I wonder, can the pain the patients are reporting just as reasonable be due to the patient in this addutcted position are so strong that the tendon can not tolerate the tension? Or is it even a combination: higher muscle tension and higher compression due to Gmed’s origin into the illiotibial band itself? None of us know, I guess. For diff diagnosis we also have bursas.

    I have 2 months back published a paper about a “new” primary abductor muscle of the flexed hip. This is done together with, amongst 2 professor at University of Oslo and Oslo University Hospital, former olympic physiotherapist of the Norwegian speed skating squad (40 years of hip spesialized practise) and PT, PhD, Britt Stuge (30 years of pelvic hip specialist clinical care). The paper measures the lengthening and moment arms of the deep pelvic hip muscles of the hip. That is, the piriformis, obturator internus, gemellus superior, and gemellus inferior (Vaarbakken et al 2014 Clinical Biomechanics). We call these 4 muscles the Quadriceps Coxa muscle. If you check the favourited tweets of sports medicine professor Roald Bahr, you will find this one: Can the m. quadriceps coxa (QC) be the most important hip abductor during one legged jumping and squatting? There we also attached the free authors link from Elsevier. These muscles have the same physiological cross sectional area as the Gmed and we believe on basis of measurements in three different planes, that these muscles are important for abduction and extending the flexed hip.

    Reflecting further on Grimaldi’s podkast, her squatting abduction exercise in the doorway with one foot on a slippery surface, is in my opinion more likely a QC exercise than a Gmed one. Ward (2010, JOSPT) indicated in an interesting gluteal simulation that the Gmed has only 9% strength at 60 degrees hip flexion and zero abduction strength at 90 degree hip flexion. To broaden one’s mind further on muscle function, I hope you will take a look at our paper in Clinical Biomechanics. At leaset the Introduction and the the Discussion part. There is a lot more to muscle function than moment arms, muscle lengthening and EMG. An extremely important part of muscle function is the relationship between muscle fiber length and tendon length. Maganaris reported the gastrochemeus to traverse from the decending part of the force-length curve to the ascending part by stretching the acchilles tendon. The same thing can in my opinion easily happen to the ITB due to TFL, GMed and Gmax activation. Then we might talk about ITB tendinopathy, as one of the laydies above tried to explain us.
    Kjartan Vaarbakken, PT, MSc, @kvaarbakken

    • PhysioTom October 21, 2014 at 3:14 pm #

      Hi Kjartan,
      Thank you so much for your comments. You raise a number of important points. I agree there certainly are limitations to EMG findings. I’ve sourced your research paper and will be reading it as soon as time allows! I’ll be in touch via twitter.
      Many thanks
      Tom

      • Kjartan Vaarbakken October 23, 2014 at 1:34 pm #

        Hi Tom,
        Thanks for your kind feedback on my comment and for having sourced my article. If you have trouble getting it, let me know and I will attach it to you in an e-mail. In my commentary, maybe you can remove the “now I am goint to bed” at the end. It was getting pretty late, but that looks rather odd now, doesn’t it?
        Kjartan

  21. Ben Smith December 2, 2014 at 12:33 am #

    Hi physio Tom – I wonder about these exercises for my son who is 11 years old, growing very fast, going to be very tall, 6’8” and has knock knees and constant knee pain that we manage with taping and orthotics, and some basic leg strengthening exercises (heel raises, one legged squats) on advice of physic. I’ve heard that gluteus weakness can contribute to this problem? And that some kind of pelvis rotation and gluteus strengthening can help? Any suggestion much appreciated, as not much is working at the moment.

    • Ben Smith December 2, 2014 at 12:36 am #

      …and forgot to mention he is very keen basketballer, so knees are fairly important 🙂

  22. Andy DuBois January 16, 2015 at 6:58 am #

    Interesting Article Tom and as you probably know I’m one of those who argue against side lying glue exercises and I’d like to debate a few pints in a friendly professional manner

    We place so much emphasis on EMG studies finding the “best” exercises to “activate” the glutes but as you well know runners dont come to us saying I need you to activate my glutes – they come to us in pain and want to be running again asap. We tell them their glutes are weak and then give them exercises to strengthen them.

    But surely the test of a good exercise is not whether it scores the highest on EMG studies but if it gets the person running again pain free asap.

    The study you linked to by Fredericson regarding resolving ITB issues with side lying exercises doesnt really prove a lot since there was no control group ( as they admit in their limitations) . A much stronger case could have been made if they compared injured athletes who did nothing to injured athletes who did side lying hip adduction

    As you said we can all pick a few studies to prove our points ( that doesnt mean that study is worthless just means it may need to be considered in a bigger picture) but there are studies that show that side lying hip abductor strength is independent to frontal plane pelvic control in running (eg Isometric gluteus medius muscle torque and frontal plane pelvic motion during running
    Evie N. Burnet and Peter E. Pidcoe
    Journal of Sports Science and Medicine (2009) 8, 284-288)

    So theoretically speaking – if there were dynamic tests and dynamic exercises that could be performed in an upright position and tailored to the individual wouldnt that be better than side lying ?

    Surely the closer we can get an exercise to function the better the carry over ( obviously making sure the exercise is not too difficult or overload other muscles etc ) to running and the quicker the patient can return to pain free running?

    The further away from function the exercise is the longer it takes to transfer that strength to function ( running in this case) and vice versa.

    Could we theoretically agree on that point? Whether such exercises exist is a different argument – I’m just interested in hearing if you agree on the theory and if not why not ?

  23. sian c June 9, 2015 at 10:45 am #

    where can I find a physio to help me with this I live in Devon ? Thanks

  24. Brittney D. June 25, 2015 at 2:50 pm #

    Good article Tom.

    It’s a largely underutilized point that there is a need for different levels of rehab for any given person. If someone cannot complete 10 reps of sidelying abduction without fatigue or poor form, how can their glute med possibly be controlling a single leg squat? Even if one exercise reportedly creates more “activation”, but the person feels no work being done in their glute, is it the right exercise for them? That’s where we need to test and retest patients as we work, not rely on the same protocol for every person. MMT hip abduction, paying attention to pelvic position, do an exercise (or a few), and retest. There should be even a small difference. Dr. Craig Liebenson does a great job explaining this process in his work.

    I would add that there is a large difference, when doing sidelying abduction, when varying the position of the pelvis during this and other glute med exercises. If someone has an anterior pelvic tilt or rotation, I find it hard to get good work from the glute until that is addressed. Whether it be verbal cueing during the exercise, or retraining of the core beforehand. Again, depends on the patient.

    To those who take a stand against all sidelying exercises for the glute medius, let’s try to back away from dogmas and realize that every exercise has it’s place for somebody, and even the “best” exercises don’t work for every person. Trial and error isn’t a bad thing, always explore!

  25. PTMagnus December 6, 2015 at 5:07 pm #

    Great article.Research is essential but of limited utility. Practice must be evidence informed, not evidence dictated. Much research is flawed and all must be read critically. If the research has not been done but my 35 years of clinical experience tells me something will probably be useful I’m going to try it. Absence of evidence is not evidence of absence. To argue that an exercise is not useful because it is not functional is absurd. Functionality is a continuum. When deficits exists the body will find a way to do what we ask of it. “Non functional” exercises can give the body the tools it needs to perform an exercise or activity, eg. running in better form, with the payoff being increased efficiency and /or decreased injury risk or aggravation.

  26. Carol December 31, 2015 at 5:48 am #

    I have been struggling with ITBS following a road marathon. I usually run ultra marathons on the trails and have had no problems. I had worked out that side lying hip abduction is the best exercise for me but I have a modified version. As the likely difference between road and trail running is the increased hip adduction on the road, I do this exercise over the side of a bench so I lower my top leg into hip adduction. I also do circles both ways to add it some TFL and GMax strengthening. I am a physio also and thought quad strengthening was required, but I found the single leg squats aggravated my knee (along with my longstanding hamstring tendinopathy)

  27. Denise January 13, 2016 at 2:41 am #

    Hi Tom
    I’ve read your thoughts on gluteas media exercises and plan to give some of them a go. I have had a fused hip for quite a few years and would like to have it taken down. Obviously the question of muscle condition is premium. So that’s why I need to work on this area. I can use a modified stationary bike (just). How much do you think this could help? Do you have any other suggestions because with the fusion I have a great deal of difficulty isolating and activating this muscle. I’ve seen local physios but we are yet to get really useful exercises for me.
    Any suggestions will be gratefully accepted.
    Denise

  28. Guni Hinchey June 5, 2016 at 1:35 am #

    thank you Tom for this great article. I have worked with gluteus med and min tendinopathies and partial and complete tears in the non runner community for many years, it’s an epidemic. Often they have been silent for many years before high levels of pain hit and just as often the other side may be effected, but not painful yet. Pain is the first thing to address here. I have been using Karin ?Graavers’ pain monitoring model to educate patients before I start my Rx programme.
    There are 3 things I like to mention:
    Quadratus femoris needs to be activated/ set in ER before ABD.
    Start in SLY position with bend knees, squeeze the heels together and pretend to lift the leg, have the patient self palpate. This prevents pain, especially in a partial tear. I do this before I start actual ABD.
    The wall press exercise becomes more effective if the leg against the wall is in extension, pressing the lateral calf against the wall, change sides. It is very important to do this in correct alignment, drawing the medial foot up, softly activating quads, TA etc and don’t lean against the wall with any other part of the body. I belief both sides of gluts are activated this way.
    Though I have no evidence (just a QI project) I am happy to talk about my treatment regimen.

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