By adopting gluteal muscle activation techniques, back pain patients can re-awaken inhibited gluteal muscles.
The gluteal muscles in back pain patients are subject to deconditioning, need to be trained to function normally and can be treated with muscle activation techniques. Back pain patients can re-awaken inhibited gluteal muscles, so they become more active during trunk flexion extension movements. More specifically, patients should train the gluteals to be active for longer to provide more stability for the lumbar area.1
How to treat overuse injuries
Recovery or performance exercises are coupled with the hamstrings because they have tremendous effects across the lumbar spine, pelvis and lower extremities. There is a fascial force coupling between the biceps femoris, sacrotuberous ligament, glute max, thoracolumbar fascia and contralateral latissimus (not to mention the foot upward connections).2,3 Weakness in any of these posterior structures causes the biceps femoris to overwork and can lead to overuse injury. Most hamstring injuries are in the down leg when running. The gluteals should activate in a timely manner with enough range of motion and strength to cause coordinated hip extension.4 Gluteal muscle activation techniques are a great treatment option.
Muscle activation process
The following are some common physical exam tests to evaluate glut muscle activation:
Palpation: Feel for tenderness, knots, densification or abnormalities in the gluteal and hip flexor (quadriceps, TFL, psoas is key) muscles, especially along attachment areas.
Range of motion assessment: Evaluate hip flexion, extension, abduction, adduction, internal and external rotation, and hip circumduction. A limited range of motion can indicate muscle or joint issues; regaining lost range of motion is the first step in my glut activation process.
Strength test: Identify weakness or inhibition by watching the movement patterns and strength evaluation for hip abduction, hip extension and hip adduction.
Gait analysis: The patient walks or performs a series of movements to assess their walking pattern.
Straight leg raise test: Helps evaluate the flexibility of the hamstrings and the presence of sciatic nerve compression.
Trendelenburg test: Ask the patient to stand on one leg observing for any hip drop or abnormal pelvic tilt. A positive Trendelenburg sign may indicate weakness in the gluteus medius muscle.
Single-leg squat test: This test assesses so much especially the foot, ankle, knee, gluteal muscle strength, stability, balance and coordination.
Prone heel to buttocks, side-lie Ober’s test and supine Thomas test: These three tests assess the quads vs iliotibial (IT) band/tensor fasciae latae (TFL) vs psoas tightness. In hundreds of cases, it is not tightness in the psoas that must be cleared out to help the glutes activate.
The functional exam
When we detect a problem in the glutes, it is important to first remove the negatives in a person’s posture, such as prolonged uninterrupted sitting, anterior pelvic tilt, and even ankle and foot dysfunctions.5 The glutes can become dehydrated from sitting all day and this can “shut off” glut muscle activation. Our functional examination should help us determine the kinetic chain deficiency that must be addressed so the appropriate muscles can be targeted in a systematic and progressive exercise program that activates the glutes. Other basic hip-leg functional tests and exercises include squats, lunges, step-ups and jump squats.
How to treat common issues?
Traditionally, I see a lot of “tight” hips, “sloppy” core and “stiff” thoracic spines. Knee pain syndromes can be related to hip movement impairment or dysfunction, specifically weakness of the hip abductors and external rotators, which then contribute to increased hip adduction and internal rotation during weight-bearing activities. In this case, strengthening the hip abductors, extensors and external rotators should be the primary corrective exercise focus. Exercises such as bilateral (2-legged) bridging, side-lying clams and side-lying hip abduction are excellent starting points for activating these muscles in a non-weight-bearing position. I still find side-lying hip abduction is the best exercise for targeting awareness of the gluteus medius. It is a great beginning exercise in a non-weight-bearing position. Isometric strengthening for the gluteus medius using the side-lying abduction exercise without the contribution of the tensor fascia latae is essential.6
Since the glute is attached to the TFL, a weak glut allows for overactive TFL and the IT band pulls around the knee to cause knee pain. If the TFL and the glute max are not properly length and strength balanced, it increases the tensile pull on the attachment on the distal femur. The result is inflammation in the area where the ITB blends into the sheath around bone and into the periosteum. In this situation, exercise rehabilitation includes one-legged squats and lateral stepping with a loop band. Strengthening the hip muscles helps relieve knee pain. Although most rehab protocols call for reducing tension in the ITB, do not forget what a tight calf can do to the Achilles tendon. A tight calf increases the potential for an injury at the Achilles tendon attachment point and don’t forget the ankle bone is connected to the knee bone.7,8
When I examine patients who learned how to perform side-lying hip abduction by another DC, PT or trainer, they are not isolating/activating the gluteal muscles while minimizing TFL activation. My progression is some combination of the clam, standing sidestep, unilateral (1 leg) bridge and quadruped hip extension (“Birddog”) exercises. Ultimately, in all my glut cases, I want my patients to progress to a one-legged squat. The “pistol” exercise is just not a realistic goal for my 55+ members, but I still try.
The exclusive use of floor exercises versus integrated weight-bearing exercises during rehab helps to decrease pain and increase function Floor exercises also improve vastus medialis oblique (VMO) to vastus lateralis neuromuscular timing.9 However, do not let your patient finish therapy until you see them transition to weight-bearing exercises. These should include lateral step-downs, squats, single-leg squats, forward lunges and mini-band side-stepping that target the gluteal muscle group. Also, make sure to give them an ankle, knee and hip proprioceptive exercise.
JEFFREY TUCKER, DC, DACRB, is in private practice in West Los Angeles, Calif. His website is DrJeffreyTucker.com.
- Leinonen V, et al. Back and hip extensor activities during trunk flexion/extension: Effects of low back pain and rehabilitation. Arch Phys Med Rehab. 2000;81:32-37. AAHKS website. https://pubmed.ncbi.nlm.nih.gov/10638873/. Accessed Oct. 4, 2023.
- Jacobs CA, et. al. Electromyographic Analysis of hip abductor exercises performed by a sample of total hip arthroplasty patients. The Journal of Arthroplasty. 2009;(24)7:1130-1136. PubMed website. https://www.arthroplastyjournal.org/article/S0883-5403(08)00569-X/fulltext. Accessed Oct. 4, 2023.
- Bolga LA, Uhl TL. Electromyographic analysis of hip rehabilitation exercises in a group of healthy subjects. Journal of Orthopaedic and Sports Physical Therapy. 2005;35(8):487-493. PubMed website. https://pubmed.ncbi.nlm.nih.gov/16187509/. Accessed Oct. 4, 2023.
- Distefano LJ, al. Gluteal muscle activation during common therapeutic exercises. Journal of Orthopaedic and Sports Physical Therapy. 2009;39(7):532-540. PubMed website. https://pubmed.ncbi.nlm.nih.gov/19574661/. Accessed Oct. 4, 2023.
- Heiderscheit B. Lower extremity injuries: Is it just about hip strength? Journal of Orthopaedic and Sport Physical Therapy. 2010;40(2):39-41. PubMed website. https://pubmed.ncbi.nlm.nih.gov/20118533/. Accessed Oct. 4, 2023.
- Mascal C, et. al. Management of patellofemoral pain targeting hip, pelvis and trunk muscle function: 2 case reports. Journal of Orthopaedic and Sport Physical Therapy. 2003;33(11):647-660. https://www.jospt.org/doi/10.2519/jospt.2003.33.11.647. JOSPT website. Accessed Oct. 4, 2023.
- Boling M, et. al. Outcomes of a weight-bearing rehabilitation program for patients diagnosed with patellofemoral pain syndrome. Arch Phys Med Rehab. 2006;87(11):1428-35. PubMed website. https://pubmed.ncbi.nlm.nih.gov/17084115/. Accessed Oct. 4, 2023.
- Brindle T, et. al. (2003). Electromyographic changes in the gluteus medius during stair ascent and descent in subjects with anterior knee pain. Knee Surgery, Sports Traumatology, Arthroscopy. 2003;11:244–251. PubMed website. https://pubmed.ncbi.nlm.nih.gov/12695878/. Accessed Oct. 4, 2023.
- Krause DA, et al. Electromyographic analysis of the gluteus medius in five weight-bearing exercises. J Strength Cond Res. 2009;23(9):2689-94. PubMed website. https://pubmed.ncbi.nlm.nih.gov/19910807/. Accessed Oct. 4, 2023.