The gluteus medius is a muscle that has peaked a considerable amount of
interest among those who actively engage in sports and physical activity as
well as healthcare professionals alike. This muscle plays an important role in
stabilizing the pelvis during the stance phase of gait and for controlling the
sagittal, frontal and coronal planes of movement of the lower extremities
during stance phase. An injury or condition affecting the gluteus medius can
frequently be associated with a wide variety of musculoskeletal syndromes,
including back, hip and knee complications from sports injuries.
Anatomy and Biomechanics of the Gluteus Medius
During single extremity weight bearing exercises, such as stance phase
of walking or running, lunging and landing from a jump, amongst others, the
lower extremity joints are designed to naturally absorb the impact of gravity
being placed against the body. When the force of gravity acts upon the body,
the joints move into distinct directions and the muscles need to properly
function as to counteract these forces. Generally, these muscles function
isometrically and/or eccentrically. For instance, with the absorption movements
of a pelvic lateral tilt, the hip abductors work to stabilize the movement. With
an anterior pelvic tilt absorption movement, the pelvic posterior tilters such
as the gluteals and hamstrings work to stabilize mobility. With hip joint
flexion, adduction and internal rotation, the muscles are controlled by the
gluteus medius and other hip joint external rotators, such as the gemellus
muscles, quadrutus femoris, obturator muscles and the piriformis. And finally,
the quadriceps controls the absorption movements of a knee joint flexion, the
soleus of an ankle dorsiflexion and the tibialis posterior, FHL and FDL,
stabilizes midfoot pronation.
The gluteus medius is a proximal hip muscle which purpose is to control
proximal pelvic/hip joint motion that in turn controls lower limb kinetics
around the knee and ankle. The gluteus medius attaches to the iliac crest and
inserts onto the greater trochanter, functioning as a hip abductor, hip
external rotator and stabilizer of the pelvis on the femur during stance phase
of gait. It’s most significant role, however, is to compress the femoral head
into the acetabulum during the stance phase of gait. The muscle is divided into
three equal parts: anterior, middle and posterior.
The fibres which make up the posterior section
of the muscle travel parallel with the neck of the femur while the middle and
anterior sections travel vertically from the iliac crest to the anterosuperior
feature of the greater trochanter. It’s been suggested, that each individual
part of the muscle functions independently from each other as each of the three
portions contain their own supply of nerves which run through the superior
gluteal nerve.
Several conducted EMG studies found that the gluteus medius is not
completely active during isolated abduction of the hip, an interesting find
contrary to previous studies. The researchers also observed that the tensor
fascia lata, or TFL, is considerably more active during isolated hip abduction.
It was additionally suggested that the three portions of the gluteus medius
muscle have a phasic muscle action during the stance phase of gait. First, the
posterior fibres of the muscle are far more active at heel strike and then, the
muscle is gradually inducted from posterior to anterior as the movement of the
structures occurs from an early stance to a late stance of gait. Most
specifically, the front section of the muscle is most active while at full
stance during the single extremity support phase while the back fibres function
effectively at the beginning of a heel strike.
During the same study, it was suggested that the primary purpose of the
gluteus medius is to restrain the head of the femur into the acetabulum, or
socket of the hip, throughout normal movement as well as to help stabilize the
pelvis on the femur in single limb stance. They also proposed the assumption
that each of the three distinct portion of the muscle performs a unique
function of movement.
Primarily, the posterior fibres of the gluteus medius contract during
the early stance phase to secure the joint into the socket. According to the
study, this notion was supported by the observation that the posterior fibres
have an almost parallel fibre alignment along the neck of the femur. Therefore,
it can be concluded that the posterior fibres essentially function to stabilize
and compress the hip joint.
Subsequently, the middle and anterior fibres of the gluteus medius,
which travel vertically, initiate hip abduction, which is then completed by the
TFL. These fibres function together with the TFL to stabilize the pelvis on the
femur, in order to prevent the other side from dropping. The researchers
demonstrated that the TFL plays the most crucial role when supporting the
pelvis against the hip while the gluteus medius only aids this process. The
anterior fibres allow the femur to rotate internally in relation to the hip
joint during the mid-to-end stance phase. This is important towards pelvic
rotation so that the opposite side leg can swing forward furing gait. The
anterior fibres play this role along with the TFL.
Furthermore, the study hypothesized that the primary functions of the
gluteus medius are to stabilize the femur against the ilium, to perform as hip
rotators and to near the head of the femur into the acetabulum, creating a very
tight and stable hip joint during gait.
The gluteus medius has been considered to only function while in neutral
hip/pelvic postures as it would when supporting the pelvis and hip during single
extremity stance. Exercises and physical activities which force these muscles
into lengthened or overly shortened positions may in fact not target the
gluteus medius but other hip abductors and external rotators instead. The
gluteus medius has the largest CSA of the hip abductors and is considered to be
the most dominant of the hip abductors. It can generate tremendous amounts of
force despite of its size due to its short fibres which are packed tightly
together. However, it does not create large forces over a wide range of
lengths. Instead, it is designed to function isometrically to balance the hip
on the femur.
Injuries to the Gluteus Medius
Injuries or conditions affecting the gluteus
medius can be associated with a wide variety of musculoskeletal complications.
These type of issues can occur when the muscles of the gluteus medius are unable
to properly control the movements and alignment of the pelvis, femur and tibia.
These injuries or conditions include but are not limited to: patellofemoral
pain syndromes, lumbar spine complications, ITB friction syndromes and hip
joint pathology.
For some time, it’s been believed that hip
internal rotation is an undesired pathomechanism of the hip joint as hip joint
rotation allows the femur to move inwards and develop valgus collapse at the
knee. It’s been suggested that this unwanted hip internal rotation is a
consequence of a weak gluteus medius and other hip joint external rotators. However,
studies have also suggested that, as a matter of fact, these muscles seem to
function better physiologically if the hip is placed in some internal rotation.
Direct trauma from an injury to the gluteus
medius, such as trigger points, strain injuries, tendon tears and relative
trochanteric bursitis, have also been closely associated to having a weak
gluteus medius.
Rehabilitation Exercises for the Gluteus Medius
A wide range of studies have investigated the purpose of the gluteus
medius whilst performing several lower extremity exercises. The following
conclusions were based on corresponding electromyographic, or EMG, data during
specific exercises. In a more recent study, researchers looked at the relative
contribution between the gluteus medius and the TFL and identified five
exercises that best utilized the muscles of the gluteus medius with minimal
TFL: Clam with Thera band, sidestep with Thera band, unilateral bridge,
quadruped hip extension, knee extending and quadruped hip extension, knee
flexing.
Because there’s many exercise variations which may be beneficial to
strengthen the gluteus medius, many healthcare providers may utilize a
rehabilitation approach depending on the individual’s level of pain when
performing the initially recommended exercises. If the individual experiences
pain while participating on weight bearing movements, then non-weight bearing
variations may be used. Healthcare providers may often also recommend specific
exercises according to what they believe may be the most effective program for
the individual’s gluteus medius complication. Furthermore, it’s been previously
argued that what an individual feels in and around their posterolateral hip,
may be the gluteus medius and/or other hip abductors, such as the gluteus
minimus, or other deep hip rotators, such as the piriformis, the obturator
group, quadrutus femoris and gemellus muscles. Studies utilizing both surface
EMG and fine wire EMG on deep muscles are required to demonstrate the
interactions between these muscles.
The gluteus medius functions in various ways during hip flexion to
extension as demonstrated in the gait cycle, suggesting the muscle works
through very neutral hip and pelvic positions, essentially functioning
isometrically or through very short ranges of movement. The following exercises
direct weight bearing through the hip joint or simulate weight bearing through
the hip joint, making them more functional in terms of activation in weight
bearing positions.
Standing Short Range Hip Abduction
This specific exercise, manages both the stance limb, isometric, and the
non-stance limb, concentrically. First, the individual should stand with a band
around the foot with the hand on the same side supported by a broomstick for
balance. Then, the individual must carefully move the banded leg into
abduction, then external rotation and extension. The stance limb must be in
slight hip flexion and remain in this position. Follow by performing 8 to 10
repetitions of slow hip abduction/external rotation/extension. The individual
should feel the effects of the exercise in both the stance side of the gluteus
medius while in slight hip flexion as well as the abducting side of the gluteus
medius into slight hip extension.
Start Position
Finish Position
Kneeling Clam
This exercise is a variation of a popular clam exercise which has been
demonstrated in several studies to activate the gluteus medius muscle. This is
performed in weight bearing as the limb can accept axial loading via kneeling. First,
the individual should kneel on a bench with a band wrapped around their knees.
Keeping the feel together, holding onto a broomstick may be used for balance.
Then, the individual must carefully move their knees apart whilst maintaining
foot contact. This moves the hip into slight abduction and external rotation.
Follow by performing sets of 10 to 15 repetitions and ensure the movement is
kept small, about 2 to 3 inches only.
Start Position
Finish Position
Modified Clam
This is another variation of the clam exercise which resembles the
traditional clam exercise but with several variations. The first important
difference is that the heels push into a wall or box to simulate weight bearing
through the extremity. Then, the exercise is performed as an isometric hold and
not an active abduction and adduction movement. Finally, the exercise is
performed in two positions: slight hip flexion and slight hip extension. A
light weight is generally placed on the knee to act as an external resistance.
The goal is to hold the limb static for a specific period of time.
Start Position
Finish Position
Hip Strengthening Exercises
Before attempting any of the above exercises, make sure you’ve consulted
a healthcare professional to avoid further injury. The muscles around the hip
can also be strengthened prior to experiencing any complication or may be occasionally
directed by a specialist as part of the rehabilitation process. By
strengthening the tissues around the hip, an individual can avoid damage and
injury by increasing the strength and flexibility of the muscles to promote
health and mobility.
Pelvic Manipulation, Massage and Chiropractic
Manipulation is the therapeutic application of manual
pressure or force to restore the normal functioning of the body by balancing
the structure. Often times, complications to the spine can affect other
surrounding tissues of the body, including nerves, which can ultimately radiate
pain and symptoms to various organs. Best known as osteopathic manipulative
treatment, or OMT, this technique is typically utilized to treat a variety of
musculoskeletal injuries or conditions, such as low back pain, neck pain and
pelvic pain, caused by sports injuries, repetitive stress injuries and even,
tension headaches. Foremost, a healthcare professional must properly evaluate
and diagnose an individual to determine the presence of an injury or condition
which may be causing painful symptoms. Individuals with pelvic pain, or
instance, may experience painful symptoms along with connective tissue
restrictions along their thighs, and glutes, including the gluteus medius. Pelvic
manipulations may commonly be used in this case to improve blood flow to the
affected area, decrease swelling and restore mobility to the surrounding
structures.
Massage is similar to a manual manipulation. A massage is a
hands-on technique that involves applying gentle, sustained pressure into the connective
tissue restrictions, also eliminating pain as well as other symptoms and
restoring function. Massage can increase blood flow, which in turn delivers
more oxygen and nutrients to the muscles surrounding the affected regions of
the body. The increased blood flow may also help carry away unnecessary
substances which may have accumulated through time.
While osteopathic
manipulation and chiropractic often seem to overlap each other, they do differ
from each other. Chiropractic is a form of alternative treatment which focuses
on musculoskeletal injuries and conditions as well as nervous system
complications to naturally restore the structure and function of the body. After
a careful analysis of the individual’s symptoms, a chiropractor may commonly
follow through with a series of spinal adjustments as well as manual
manipulations to correct any misalignments in the structures of the body. When
certain areas of the spine are subluxated as a result of an injury or
condition, the surrounding structures can often become irritated and inflamed,
leading to complications within the tissues, including gluteus medius issues. A
chiropractor will perform chiropractic adjustments to gently re-align the spine
in order to progressively reduce the pain and swelling around the affected
area. A chiropractor may even recommend a series of exercises according to the
individual’s needs to promote healing and speed up the rehabilitation process. Chiropractic
care has become a popular alternative for many types of complications,
including back pain, neck pain and pelvic pain, among others primarily due to
its effective treatment techniques.
By Dr. Alex Jimenez