Everyone loves a nice butt. Walking down the street, at the mall, or at the bar, there is bound to be a butt that catches your eye. Like a kitten following a piece of yarn, there is the occasional butt that walks by and causes heads to turn, leaving onlookers with a severe neck strain and mouths agape. Don’t act all innocent and holier than thou, we’ve all done it! Therapists and rehabilitation specialists are no different. In fact they can spend an entire day staring at booty. However, we are not looking to see if “Baby Got Back” or how that plump bump fills a pair of Wranglers, Levis, Seven, or True Religion jeans. We have a reason to look and it is strictly professional; is the little butt working?
For several years now rehabilitation journals have published articles linking a myriad of lower extremity injuries to poor gluteal control. While the glute max – that which makes our heads turn – and the glute minimus are both important, the glute medius is the real problem. We have learned the important role the glute medius has on controlling lower extremity mechanics. Glute medius inhibition precipitates many lower extremity injuries such as ACL tears, Patellofemoral pain, Iliotibial band syndrome, Achilles tendinopathy, plantar fasciitis, MTSS (shin splints), the list goes on. Rehabilitation specialists must pay special attention in strengthening the glute med., but how? What is the best exercise?
That is a tough question to answer. Each clinician has his/her own unique exercise that they think works best. I have a bunch, but two of my favorites are were fire hydrants (peeing dog) and side plank variations. Ask my clients, I love loved fire hydrants. They cringe when I say hydrants. It gives you that good glute burn, however, it has its problems. Not until recently did I notice a significant issue with fire hydrants. The good news for my clients is that you will likely never have to do fire hydrants again!
When a muscle is weak it is subject to getting extra help from a synergist (synergist dominance). With fire hydrants I ask the client to keep the leg parallel to the floor and externally rotated to best engage the glute medius. However, over time I began to notice that clients were unable to maintain externally rotated at the hip, thus compensating by using the biceps femoris as a synergist. Take a look at the photos below. The figure on the left demonstrates normal hydrant technique. Notice the hip is externally rotated and parallel to the floor. Now look at the image on the right. As fatigue sets in, the thigh drops below parallel, causing compensatory tibial external rotation (foot pointing up). The hip, unable to maintain external rotation is being helped by the biceps femoris. We do not want this and if it is exhibited we must choose an alternative exercise.
Below are two more images from another angle. Again you will also notice that the thigh has dropped below parallel and there is compensatory tibial external rotation in relation to the femur.
So, what exercises are best to target the glute and also avoid compensation? February of last year I posted a blog titled The Glute vs. TFL Muscle Battle. The post reviewed an article by Selkowitz, et al., in the Feb 2013 edition of JOSPT. This study examined, which exercises elicit the greatest gluteal (medius / maximus) activation while minimizing activation of the Tensor Fascia Latae (TFL). This is exactly what we need to know when designing a rehabilitation program to target injury resulting from lower extremity compensatory patterns.
The study looked at 11 exercises and found seven exercises that significantly targeted the glute and not the TFL -bilateral bridge, unilateral bridge, side step, clam, squat and two quadruped variations. Side-lying hip abduction, hip hike, the lunge, and the step-up were either not significant or demonstrated higher TFL values compared to the gluteal group. The authors ranked the exercises in order of highest gluteal to TFL ratios. Clam, side step, and unilateral bridge had the highest ratios, while lunge, hip hike, and squat had the lowest ratios.
Clinicians: keep learning and watching that booty. You could be missing something that you always thought was great. I always thought fire hydrants were fantastic, but I was missing a significant compensation and synergy of the biceps femoris. Hopefully the content here helps guide our clinical decision making. For now I will stick with side plank, side-step, and clams. Rest assured, you will find me staring at some butt to make sure it is working ;)!
If your booty needs correcting, send me an email!