One of the aspects of physical therapy that I really love is prescribing and teaching exercises. Over the past few weeks of clinic work and teaching, I have been pushed to justify and adapt my exercise selection for patients presenting with lumbopelvic pain. Many of these patients present with some weakness in hip and core muscles. Studies have shown weakness in gluteal muscles (gluteus maximus and/or gluteus medius) in individuals with low back pain (Sadler, 2019), sacroiliac joint pain (Added, 2018), and patellofemoral pain at the knee (Ireland, 2003). Additionally, studies show that adding exercises for the gluteal muscles can improve outcomes for individuals with chronic low back pain compared with just training “core muscles” (low back and abdominals) (Jeong, 2015).  Thus, part of my care for these patients, and others presenting with gluteal muscle weakness, is attempting to strengthen these muscles. Please note: this does not necessarily mean that these are the only treatments that I choose, but this type of training is the focus of this post.

A few sources of information have guided my recent exercise selection for the “glutes” (gluteus maximus and medius muscles primarily). This new information has also bolstered my justifications for utilizing these exercises.  My hope is that this improves the effectiveness of my strength training and functional improvement with the patients I see with “glute” weakness.

The first source of information is a nice review paper of Electromyography (EMG) data for muscle activation of gluteus maximus and gluteus medius muscles with different exercises (Reiman, 2012). The findings from this review can be summarized in the table below. I have also added findings from other notable studies with regards to exercises for the gluteus maximus muscle. As you can see: single leg deadlifts and squats come out pretty high on the priority list!

Another motivator for me to tinker with my exercise selection for training these hip muscles was a podcast that I listened to decrying the default prescription of hip bridges for training hip extension (and gluteus maximus strength). The podcast comes from “Institute of Clinical Excellence” (ICE) with presenter Dr. Alexandra Germano, PT, DPT: Episode # 727 “Is Bridging The New Ankle Pump?”

The overall theme of the podcast is that there are more functional and effective ways to build strength for hip extension, such as squatting and deadlifting with load. After taking a critical look at my exercise selection, I would have to agree- and I have gotten away from using hip bridges, even with patients who present with moderate to high levels of pain.

The research I have cited above also seems to agree. According to the above cited review (Reiman, 2012), the hip bridge exercise (double leg bridge) produces only about 30% of MVIC recruitment of the gluteus maximus! (vs. about double that for the single leg squat and deadlift and 80% for the forward step up). In the podcast, Dr. Germano also makes the point that if we are really aiming for functional strength gains and task transfer to activities that patients care most about, we should think about choosing exercises in standing such as squats or deadlifts. The bridge may have some beneficial carryover for improving bed mobility for weaker patients, but for most of our patients getting them performing standing and stepping exercises under load is much more efficient and effective!

Also, it was interesting to see that another very commonly prescribed exercise for the gluteus medius muscle: the side lying leg raise (side lying hip abduction), is equally inefficient: only recruiting to about 55% (vs. side plank 75%, SL squat 65% and SL deadlift 55-60%) (Reiman, 2012).

I hope that these thoughts have helped you to evaluate your exercise prescription choices for the “glutes”. Of course, this brief post is not comprehensive and I would encourage you to read the cited studies if you are interested in learning more.

 

References:

Added MAN, de Freitas DG, Kasawara KT, Martin RL, Fukuda TY. Strengthening the Gluteus Maximus in Subjects with Sacroiliac Dysfunction. Intl J Sports Phys Ther. 2018;13(1):114-120.

Ireland ML, Willson JD, Ballantyne BT, Davis IM. Hip Strength in Females With and Without Patellofemoral Pain. J Orthop Sports Phys Ther. 2003;33(11):671-676.

Jeong U-C, Sim J-H, Kim C-Y, Hwang-Bo G, Nam C-W. The effects of gluteus muscle strengthening exercise and lumbar stabilization exercise on lumbar muscle strength and balance in chronic low back pain patients. J Phys Ther Sci. 2015;27(12):3813-3816.

Macadam P, Feser EH. Examination of gluteus maximus electromyographic excitation associated with dynamic hip extension during body weight exercise: a systematic review. Intl J Sports Phys Ther. 2019;14(1):14-31.

Neto WK, Soares EG, Vieira TL, et al. Gluteus maximus activation during Common Strength and Hypertrophy Exercises: A Systematic Review. J Sports Sci Med. 2020 Mar; 19(1): 195–203.

Reiman MP, Bolgla LA, Loudon JK. A literature review of studies evaluating gluteus maximus and gluteus medius activation during rehabilitation exercises. Physiotherapy Theory and Practice. 2012;28(4):257-268.

Sadler S, Cassidy S, Peterson B, Spink M, Chuter V. Gluteus medius muscle function in people with and without low back pain: a systematic review. BMC Musculoskelet Disord. 2019;20(1):46.