The gluteal musculature has been implicated in many different pathologies due to its potential impact on lower extremity biomechanics. Because during weight bearing the femur moves about a fixed patella, excessive femoral internal rotation (IR) and adduction results in increased contact primarily at the lateral facet of the patella.1
Just 10° of IR can lead to a substantial decrease in PFJ contract area and a 50% increase in joint stress. Coinciding with these findings:
- Souza et al.2 found that females with patellofemoral pain syndrome (PFPS) demonstrated greater peak hip internal rotation compared to the control group during running, drop jump, and step down. The PFPS group also demonstrated 14% weaker hip abductor strength and 17% weaker hip extensor strength.
- Wilson et al.,3 Noehren et al.,4 and Nakagawa et al.5 found that individuals presenting with PFPS demonstrated increased hip adduction during running, jumping, and single-leg squats. This excess femoral adduction creates an increased valgus force about the knee joint, which in turn causes increased loading of the lateral patellofemoral joint.
Gluteal Strengthening and Rehabilitation
In support of a gluteal etiology, several studies have found the effectiveness of gluteal strengthening in the treatment of lower extremity disorders. A recent systematic review conducted by Santos and colleagues9 found gluteal strengthening to have the following effects amongst individuals diagnosed with PFPS.
- Decreased highest intensity of pain experienced during the previous week
- Decreased pain when ascending and descending stairs
- Decreased pain while squatting or sitting for prolonged periods
Additionally, with regards to rehabilitation following anterior cruciate ligament reconstruction, the inclusion of hip strengthening appears to improve sagittal plane dynamic balance at three months post ACLR as compared to traditional rehabilitation.10
EMG Activity and Exercise Goals
According to Reiman et al.11 and Escamilla et al.,12 moderate electromyographic activity (EMG) activation (21-40% MVIC) is best used to facilitate endurance and neuromuscular re-education, and high activation (41-60+% MVIC) to promote strength gains.
From Biomechanics to Exercises
Origin: External surface of Ilium between anterior and posterior gluteal lines
Insertion: Lateral surface of greater trochanter
Primary Function: Abduction of the hip joint
The anterior fibers contribute to hip flexion and hip internal rotation, and the posterior fibers to hip extension and hip external rotation. Additionally, the gluteus medius is responsible for preventing the opposite side of the pelvis from dropping during the stance phase of gait and plays a major role in providing frontal plane stability for the entire pelvis during walking and other functional activities.
During the early stages of rehabilitation or when attempting to selectively activate the gluteus medius, the following demonstrate the highest EMG levels: 13-14
- Side-lying plank with hip abduction
- Reverse clamshell with hip abduction and extension
- Prone plank with hip extension
- Reverse clamshell with hip abduction
- Single-leg bridge
|[Table] MVIC of the Gluteus Medius during Therapeutic Exercise
Additionally, you must consider the interaction of other muscles acting with or against the gluteus medius when determining exercise prescription. It has been proposed that individuals who demonstrate excessive femoral internal rotation during functional tasks may be relying too heavily on the tensor fasciae latae to control their pelvis in the presence of weak or inhibited gluteus medius musculature.
Selkowitz and colleagues determined that the following exercises achieved the best Gluteal to Tensor Fasciae Latae Activation Ratio:15
- Side-step with resistance band
- Single-leg bridge
- Quadruped hip extension with knee extended
- Quadruped hip extension with knee flexed
|[Table] Gluteal-to-TFL Index during Therapeutic Exercise (Selkowitz et al., 2013)
Finally, when progressing your patient towards more functional closed kinetic chain and sport/activity-specific exercises, the following exercises achieve the highest gluteus medius activation:13, 16-18
- Walking lunge with dumbbell in contralateral hand
- Lateral band walk
- Unilateral mini-squat
- Skater squat
- Unilateral deadlift
|[Table] MVIC of Gluteus Medius during Closed Kinetic Chain Exercise
- Powers CM. The Influence of Abnormal Hip Mechanics on Knee Injury: A Biomechanical Perspective. Journal of Orthopaedic & Sports Physical Therapy. 2010;40(2):42–51. doi:10.2519/jospt.2010.3337.
- Powers CM, Ho K-Y, CHEN Y-J, Souza RB, Farrokhi S. Patellofemoral Joint Stress During Weight-Bearing and Non—Weight-Bearing Quadriceps Exercises. Journal of Orthopaedic & Sports Physical Therapy. 2014;44(5):320–327. doi:10.2519/jospt.2014.4936.
- Willson JD. Lower extremity mechanics of females with and without patellofemoral pain across activities with progressively greater task demands. Clinical Biomechanics. 2008;23:203–211. doi:10.1016/j.clinbiomech.2007.08.025.
- Noehren B, Scholz J, Davis I. The effect of real-time gait retraining on hip kinematics, pain and function in subjects with patellofemoral pain syndrome. Br J Sports Med. 2011; 45(9): 691-6. doi: 10.1136/bjsm.2009.069112.
- Nakagawa TH, Moriya ET, Maciel CD, Serrao V, Serrao F. Frontal Plane Biomechanics in Males and Females with and without Patellofemoral Pain. Medicine & Science in Sports & Exercise. 2012; 44(9): 1747-1755.
- Qi W. Effect of Increased Iliotibial Band Load on Tibiofemoral Kinematics and Force Distributions: A Direct Measurement in Cadaveric Knees. Journal of Orthopaedic & Sports Physical Therapy. 2013;43(7):478–485.
- Hewett TE, et al. Biomechanical Measures of Neuromuscular Control and Valgus Loading of the Knee Predict Anterior Cruciate Ligament Injury Risk in Female Athletes: A Prospective Study. American Journal of Sports Medicine. 2005;33(4):492–501.
- Franettovich, SM, Honeywill, C, Wyndow N, Crossley KM, Creaby MW. Neuromotor control of gluteal muscles in runners with achilles tendinopathy. Medicine and science in sports and exercise. 2014; 46(3): 594-599.
- Santos TRT, Oliveira BA, Ocarino JM, Holt KG, Fonseca ST. Effectiveness of hip muscle strengthening in patellofemoral pain syndrome patients: a systematic review. Braz J Phys Ther. 2015;19(3):167–176. doi:10.1590/bjpt-rbf.2014.0089.
- Garrison JC. Effects of Hip Strengthening on Early Outcomes Following Anterior Cruciate Ligament Reconstruction. International Journal of Sports Physical Therapy. 2014;9(2):157–167.
- Reiman MP1, Bolgla LA, Loudon JK. A literature review of studies evaluating gluteus maximus and gluteus medius activation during rehabilitation exercises. Physiother Theory Pract. 2012; 28(4): 257- 68. doi: 10.3109/09593985.2011.604981.
- Escamilla RF, Fleisig GS, Yamashiro K, Mikla T, Dunning R, Paulos L, Andrews JR. Effects of a 4-week youth baseball conditioning program on throwing velocity. J Strength Cond Res. 2010; 24(12): 3247-54. doi: 10.1519/JSC.0b013e3181db9f59.
- Boren K. Electromyographic Analysis of Gluteus Medius and Gluteus Maximus During Rehabilitation Exercises. International Journal of Sports Physical Therapy. 2011;6(3):206–223.
- Philippon MJ, Decker MJ, Giphart JE, Torry MR, Wahoff MS, LaPrade RF. Rehabilitation Exercise Progression for the Gluteus Medius Muscle With Consideration for Iliopsoas Tendinitis: An In Vivo Electromyography Study. American Journal of Sports Medicine. 2011;39(8):1777–1785. doi:10.1177/0363546511406848.
- Selkowitz DM, Powers CM. Which Exercises Target the Gluteal Muscles While Minimizing Activation of the Tensor Fascia Lata? Electromyographic Assessment Using Fine-Wire Electrodes. Journal of Orthopaedic & Sports Physical Therapy. 2013;43(2):54–65. doi:10.2519/jospt.2013.4116.
- Stastny P, Lehnert M, Zaatar Zaki AM, Svoboda Z, Xaverova Z. Does the dumbbell carrying position change the muscle activity during split squats and walking lunges? Journal of Strength and Conditioning Research. 2015. doi:10.1519/JSC.0000000000000976.
- Krause D. Electromyographic Analysis of the Gluteus Medius in Five Weight-Bearing Exercises. Journal of Strength and Conditioning Research. 2009;23(9):2689–2694.
- DiStefano LJ.Gluteal Muscle Activation During Common Therapeutic Exercises. Journal of Orthopaedic & Sports Physical Therapy. 2009;39(7):532–540. doi:10.2519/jospt.2009.2796.