Assessing and Treating Dysfunction of the Gluteus Medius

The October 2008 issue of the Journal of Strength and Conditioning has an impressive review article of the anatomy, function, assessment, and strengthening of the gluteus medius from a group of clinicians in New Zealand.  The authors do a good job reviewing some of the basic anatomy and function of the muscle and relating this information to research reports looking at dysfunction and treatment of the muscle for several lower extremity injuries.

I think this is a great topic of discussion as the role of the gluteus medius in normal function and rehabilitation has been receiving attention lately as attention is being paid to strengthening and training the body in the frontal plane of motion and out of the sagittal plane.

gluteus medius

The Role of the Gluteus Medius

When you really break down the function of the gluteus medius, you see that it is far more valuable as a pelvis and lower extremity dynamic stabilizer than it is a pure hip abductor.  This is apparent when looking at the mechanism of a Trendelenburg Gait.  The role of the gluteus medius during activities such as walking and running is to dynamically stabilize the pelvis in a neutral position during single leg stance.  As you can see in the photo below, weakness of the right gluteus medius will cause the left hip to drop when standing on the right limb.  Conversely, athletic patients are often masters of compensation and may be able to keep the pelvis in neutral while the lower leg will adduct and internally rotate.

weak gluteus medius

In addition, the role of the gluteus medius as an external rotator of the hip when the hip is in a position of flexion is also important to consider.  These factors together are likely why dysfunction of this muscle is commonly found in several pathologies, such as iliotibial band, patellofemoral injuries, ACL, and ankle injuries.

Assessment of the Gluteus Medius

The authors describe several methods of evaluating the gluteus medius.  These include:

  • Standard manual muscle testing of hip abduction in sidelying.  Because the gluteus medius also has an effect on other hip motions, I often recommend a full testing of hip flexion, abduction, ER, IR, and extension as well.
  • Double- to single-leg stance test.  Simply a test such as the photo above.  The patient is instructed to stand on one limb and pelvis orientation is documented.
  • The authors also recommend adding an upper body movement to the single-leg stance test. This will further challenge the patient, specifically the athletic patient.  During this, the patient is instructed to balance on one limb while reaching the arms overhead and leaning away from the stance leg.  This will move the patient’s center of gravity further away from the stance limb and require a greater amount of gluteus medius stabilization to avoid the dropped pelvis position.
  • In addition to the above described, I would also recommend that patients should be observed during several functional activities, especially if a specific activity tends to exacerbate symptoms.  This could include eccentric step-downs, front lunges, or even running and jumping activities for athletes.  Watching the kinematics of the pelvis and lower body closely can be very beneficial.  Personally, I often try to video tape these movements as well.  For my athletes I have sophisticated camera systems but I also travel with a simple flip cam that I plug in to my laptop and quickly record and view back with my patients.  I actually do not like the actual Flip cams, the angle of the lens is terrible.  I actually use and really love the Creative Vadocheck it out on Amazon.  In addition to having a better wide angle lens, I can control the video quality.  It is inexpensive, small, portable, plugs into my computer for charging, and shots great video.  In just a few minutes I have a great quality video to watch with my patients.  I try to take it a step further a draw on my videos and photos as well.

trendelenburg during step down

Treating the Gluteus Medius

While the beginning of the paper provides a brief, yet basic, review of the normal anatomy, function, and potential for injury implications of gluteus medius weakness, the strength of the paper lies in the later half that reviews the evidence behind some exercises designed to strengthen the gluteus medius.

The authors provide a thorough table that lists the many exercises described for gluteus medius strengthening.  Most of these are basic recommendations, such as sidelying hip abduction straight leg raises and standing hip abduction.  However, the authors combine the work and recommendations of three articles to develop a gradually progressive exercise program.

The progression is designed to gradually enhance motor control, endurance, and strength.  The program is broken down into three phases:

  • Phase I: Nonweightbearing and basic weightbearing exercises such as clam shell exercises, sidelying hip abduction, standing hip abduction, and basic single leg balance exercises. Criteria to progress to stage II is that the patient can hold their pelvis level during single leg stance for 30 seconds.
  • Phase II: The second stage progresses the weight-bearing exercises and gradually progresses stability exercises by (a) translating the center of gravity horizontally via stepping and/or hopping exercises; (b) reducing the width of the base of support, (c) increasing the height of the center of gravity by elevating the arms and/or hand-held weights, or (d) performing the exercises on unstable surfaces.
  • Phase III: The third stage is used for athletes and designed to prepare them for function, sport-specific movement patterns.

I agree with this progression but think that the authors are missing one key point regarding training of the gluteus medius.  Because it is such a valuable component of dynamic pelvis and lower extremity stability.  I also would encourage clinicians to also incorporate exercises designed to promote hip stability during normal sagittal plane movements such as squatting.  To do this, I often just simply incorporate a piece of exercise tubing around the distal thigh (just higher than the knee) of the patient during exercises such as mini-squats, wall squats, and leg press.  The patient is instructed to isometrically set the hips in a neutral position while performing the exercise.  Cueing is often needed at first to be sure that the patient does not let their hips drip into adduction and internal rotation.  I have found great success in this type of exercise as it required the hips to dynamically stabilize against a hip adduction/internal rotation moment during common functional activities.

band around knee leg press

There is also a section that reviews some of the available evidence behind choosing sets, repetitions, frequency and duration of rehabilitation programs.  Overall, a great review of some of the basics regarding the gluteus medius and definitely a great starting point to develop a comprehensive rehabilitation or injury prevention program.

Check out my other post on an article reviewing more great information on gluteus medius exercises and gluteus maximus exercises.

 

Presswood L, Cronin J, Keogh J, Whatman C (2008). Gluteus Medius: Applied Anatomy, Dysfunction, Assessment, and Progressive Strengthening. Strength and Conditioning Journal, 30 (5), 41-53

 

Images from: Prevent Disease, UWO

 

Want to learn more about how to get the most out of the hips and glutes?  I have two great inner circle webinars on My Top 5 Tweaks to Enhance Hip Exercises and How Pelvic Position Influences Lower Extremity Stretching.  Click here to learn more about my Inner Circle and how you can gain access to these webinars and more for only $5.

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49 Responses to “Assessing and Treating Dysfunction of the Gluteus Medius”

  1. Although I am no pilates expert, what about sidelying, keeping the leg parallel to the table and alternating slowly between hip flexion and extension…still keeping the leg level? I hurts like the dickens on me…but a very “burn” type of hurt. Opinions?

    P.S…did you receive my post?

  2. Mike- Great post on the ever so important yet commonly functionally weak muscle (whether it’s a pure strength or neuromuscular control issue)seen in athletic patients to geriatric patients. I can agree with the “phases” proposed from the article. My phase II and III favorites include also adding a t-band around the knees for squats, leg press, and ladders. Additionally the resisted 4 way hip with a sport cord is a favorite, eventually progressing from stable to unstable surfaces (foam, dyna disc). Burners!
    Johnny May

  3. That is a good one Christie, actually it is a perfect phase I version of what I mentioned with the theraband.

    Do love the 4-way sport cord as well Johnny, great addition to the list.

  4. Trevor Winnegge PT,DPT,MS,OCS,CSCS Reply December 16, 2008 at 5:07 am

    I use lateral resistance bands available from performbetter.com. similar to your views on the stretch out strap Mike, these are cheap. Cheap is good. Cost less than 3 dollars, and if you buy 5, get 6th free. different resistance levels. put them around your ankles and do some sidestepping, as well as sideways crouch walking. We also use an exercise sometimes referred to as the “monster walk”, where you spread the band apart, keeping tension on it at all times, crouch your knees, and walk forward and/or backwards. good phase II/III exercises. Another favorite of mine for phase I/II is the simple hip hike, with foot over step. Hike contralateral hip to activate ipsilateral glut med. Only problem with this is getting the patient to activate the proper muscles. If they can do it, is a good early phase exercise.

  5. My thoughts in treating a weak glut med is to look at what its role in normal function is. It decelerates hip flexion/adduction/IR. therefore I usually have my patients forward lunge and accentuate flex/add/IR(knee over midline). this works great and they usually feel it right in the lateral hip after a few reps. I also like tandem stance hip bumps (stand 3-4 inches from a wall, ask patient to touch wall with hip). good phase 1 exs in weightbearing.

  6. For assessment I follow Ron Hruska’s work (Postural Restoration) and make sure that the glute med is predominantly active over the TFL for IR motions. In Ron’s described Left AIC pattern, the left glute med tends to be weak and inhibited. Some “phase 1″ exercises I use are sidelying hip IR with abduction and a seated ham curl with hip adductor squeeze and IR.
    Mike, what program do you use to draw those lines on the video/pics?

  7. Nice review and clinically relevant as always. One of my favorite phase 3 exercises is a theraband row during single leg stance on foam, in which the stance leg performs a 1/4 squat as the contralateral leg performs the equivalent of a SLR into flexion then abduction and then extension while the foot rests on a “glider” disk.

  8. Another new exercise I started using more is what I call the “skater” exercise. You stand on one limb and and perform a small ~30-40 degree single leg mini-squat while extending and adducting your other leg behind you. To balance you need to counteract with your upper body so you end up simulating a skating motion.

    To be honest, there is a good story behind that. I started using it after a long night of Wii Bowling! Like any other Wii Bowling enthusiast, I enjoy trying to use good bowling form, it is just more fun that way. You end up doing a similar motion to the skater exercise and I am usually sore for about 2 days. I know, pretty lame. So far high score of 247, considering in real life I cant break 100, not bad…

  9. Not arguing the use of the bands to promote improved knee alignment for squatting, lunge, etc. (it works), however, I don’t think you’re cuing improved function of the glute medius. As the hip flexes to greater angles, the moment of the Gmed becomes internal rotation, not abduction/ER

  10. An exercise I like to use is treadmill walking with a dumbell in one hand (works glut med on opposite side), progressing weight and time. While I use OKC bed exercises such as clam shells, sidelying hip abd, etc, I feel that CKC weight bearing exercises are more functional.

    P.S. This is a great blog with fantastic input and food for thought. Kudos Mike for all your hard work on this.

  11. Bill, I thought the glut medius assisted with ER with hip flexion?

  12. Curious now I am now on whether it is IR or ER with hip flexion..????

    Main reason for my post… I am the patient in this case and I am CSCS trying to self-diagnose and treat. I’ve got all the classic signs, trendelenburg gait and ITB syndrome(pain from hip down to lateral knee as well as point tenderness on trochanter). WHY IS MY GLUTE MEDIUS WEAK?? I can do phase II/III exercises. I can tell they are working the part thats weak, but the glute medius doesn’t get stronger? What nerve(s) run the GM and could there be a neuro-problem making the GM weak and unable to be strengthened? All posts will be appreciated. Les

    • Hmm…. I have had the same problem for years. After extensive research and listening to the pain in my body, I’m beginning to think it’s a matter of my body “cheating”. I did all the phase exercises and more… no strength achieved, however they did make ITB worse, as well as QL, psoas, erector sp. pain. So I think my body has overused those muscles to compensate for the glut med. Oh, and I can fake the T sign/test. On to figuring out how to address the imbalance throughout lateral line. Does that make sense!?

  13. Les, really could be many things, including neurological or musculoskeletal. Unfortunately, it is extremely difficult to diagnosis from a distance. The best advice I could give is to see an orthopedic physician and let them guide you to see neurologists or any other specialty. If you are not happy with your lack of results, see another doctor. Sorry for not being to help too much.

  14. Haven’t been on here in a while. Here’s a reference for the change in moment arm for the glute medius with hip flexion.

    J Biomech. 1999 May;32(5):493-501

  15. I am an ultrarunner with a tear of my left gluteus medius ( by diagnostic ultrasound)tear occurred 7/08. Have had 6 prolotherapy injections since 10/08. Not really any progress. Cross training does not provoke the pain; running does. Any suggestions so I can return to running?

  16. Anony, would recommend a second opinion from another doc. Beyond that, tough to say.

    Bill, nice reference!

  17. I’ve seen 2 chiropractors that specialize in sports med. and a physiatrist. What doc would you suggest I try next?

  18. Chiropractors are definitely not the answer! To your problem at least, I have no issues chiropractors in general. I am actually disappointed that none of them referred you to the right person. You need to see an orthopedic surgeon that specializes in sports medicine. Good luck.

    • Nice blanket statement. Let’s throw the whole profession under the bus.
      I never trust an absolute statement unless we are dealing with mathematics.

      • Jeff, he said chiropractors weren’t the answer in the case referenced. The very next sentence says, “I have no issues [with] chiropractors in general.”
        So, not throwing anybody under the bus. Just saying you need the right person for the situation.

      • Sorry, didnt mean for that to come across poorly. In this specific case, it sure sounds like she needs more help. That wasnt a knock!

  19. What is missing in the analysis and correctional equation is the fact that the glute medius must be trained and strengthened IN ROTATION. You can see the latest and only true solution at http://www.TheAnswer2009.com which features an FDA Registered Medical Device invented by a former Navy SEAL. It is being used by SEALs, PGA golfers and professional athletes to improve rotational strength/speed as well as PTs and chiros for lower back pain relief.

  20. Ok so i dont really know if my gluteus medius is hurt. Can you help me? It(my injury) hurts on the right side of my body right in the buttocks area. The only time it hurts is when I run or sit on that area wrongly. I have no idea what it is? Any help will be gladly appreciated!

  21. Hey, I’m looking for a little advice. I’m a personal trainer and I’ve recently gotten really involved in hardstyle kettle bell training. I have some definite dysfunction issues I’m working on but it’s brought to light how messed up my hips are. The right sits visibly higher than the left and recently, I’ve been getting increased tightness in the left side of my butt. It’s gotten so bad that I can no longer hit my usual pistol squats and and when I swing or snatch, I’m internally rotated, my shoulders too as a result of course, to compensate. I’ve tried stretches and pressure points and foam rolling but nothing’s helping and it’s only getting worse. I really just can’t tap into those muscles right now which I’m thinking are more piriformis/glute medius. Any thoughts?

  22. Sorry all, can’t give out treatment advice over the internet, my recommendation is to always see a physician and a physical therapist. Good luck!

  23. so is the picture above a weak right or a weak left as David Foo Recomended? I say Left.

  24. If you are looking at the drawing above, it is actually the right. When the glut on the right can not control the hip adduction moment on the right, it will results in a drop on the left. It seems backwards because the leg is fixed and the body is showing the compensation. Does that help clarify?

  25. Anonymous, I am a chiropractor, and I agree fully with Mike here. There are many things chiropractors can help with, but your injury is outside of our scope of practice. I agree, go see an orthopedic surgeon who specializes in athletic injuries.

  26. I am writing as an injured athlete and former runner/triathlete. I suffered a tear in my gluetus medius 5 years ago. It was diagnosed by MRI and then 1 year later showed guteal thickening, but no longer a tear (a second MRI).

    My symptoms have been ongoing, intermittent chronic pain, that worsens with running and aggressive biking. I have not been able to run since the injury. I continue to cycle and do mild weight training but am unable to push myself physically, as the injury seems to worsen.

    I have sought many treatments including physical therapy, massage, stretching and strengthening, shockwave therapy, low-level laser therapy, and have consulted with a surgeon. The surgeon has strongly discouraged surgery. All of these therapies provided mild relief that was very short term (i.e., a few days).

    Recently, I read a few promising articles on percutaneous needle tenotomy. Is anyone familiar with this treatment for this injury? I live in Toronto, Ontario, Canada and am not able to find resources up here. Any suggestions? Any thoughts on further treatment?

  27. Amy, Anonymous,

    I am just a patient, but because I too had pain similar to yours (hip pain, TFL/ITb tightness, and none of my glutes will fire, except that my glute med does all the work when I walk!).

    All this to say, I had considerable, disabling pain for ten years! I was athletic, and a runner, but the pain kept me finally from being able to even stand or sit. Last March I was FINALLY diagnosed with labral tears, FAI, hip dysplasia and femoral retroversion. Because this was all missed/ignored for so long, and because I tried to "play through" the pain, my labrum (both sides) is starting to ossify.

    Get thee to a hip surgeon! A specialist in sports med and labral tears! MRI with dye will help them see labral tears. Don't live with this pain.

    for more info, I've appreciated Facebook's Understanding FAI group and http://www.hipchicks.ning.com

  28. Use bands. Stand on a band and pull it over your head to have it rest on the back of your neck and in front of your shoulders. Whilst maintaining correct posture do side shuffles (like a crab walks- from side to side). The hip can be maintained in varying degree's of flexion/internal rotation and extension/external rotation during the movement to stress all parts of glute med/min/tfl and glute max. Plenty of athletes no longer have to do foam rolling/trigger point work through much of the gluteal area after becoming stronger in glute med.
    Enjoy the burn!

  29. MIke,
    Great info on the Gmed.
    I agree with your comments on the mini-band use for some CKC exercises.
    I also try to pretty much add the use of the bands into all types of simple exercises to try and always increase your bang for buck value and time spent with each athlete or patient.
    Try adding them to simple bridges, prone planks, side planks, SB planks, SB Hamstring curls, wall sits, wall squats, and all types of various TrA activation exercises.

  30. Good review, I enjoyed the read. What about the ankle joint and shoulder joint as it relates to maintaining the overall health of the glut medius? A dysfunctional ankle or shoulder joint will hinder any process forward in allowing the glut medius work to positive. Remember to treat the body as a unit and not a singular piece.

  31. Mike, love this site, it is a wealth of information, information like this is at the heart of true continuing education for strength coaches and trainers.

    Regarding this glute medius work, I find lying clamshells and other abduction exercises extremely ineffective for activation of this muscle. Since its primary role is stabilization of the pelvis, is that alone not adequate as an activation/strengthening start point? Or is it assumed the glute medius when dysfunctional lacks the strength to stabilize the pelvis even when consciously attempting to do so?

    Regarding the abduction exercises to work the glute medius, it seems many people already improperly recruit tfl to the point where it may almost impossible to overcome, since that improper movement pattern is so deeply ingrained. I could be teaching clamshells incorrectly but I thought I’d ask your opinion.

  32. Mike, thanks for all the great PT knowledge you give.

    I agree Domenic. Most patients tend to incorporate the TFL if given a chance that is why proper cueing is so essential. During clams when patients get fatigued they generally lean there pelvis backwards which negates proper GMed activation. I will generally try to stretch/massage a tight TFL/ITB before doing GMed strengthening to help loosen the generally tight TFL and allow the GMed to work. Any thoughts?

  33. Interesting.. I will give that a whirl and see how it goes.. what do you think about locking the hip in place manually to force the glute med to abduct the the femur properly?

  34. For patients who need that extra help I will lock or hold their hips a little forward. This makes them contract the GMed successfully.

  35. Does the Gluteus Medius have anything to do with my hip snapping after sitting for decent periods of time, and that my right hip bone feels tender/sore when I press down on it?

    Abducting my right leg also feels like it’s a little bit more sore than when doing with my left.

  36. The Gluteus Medius will become inhibited when the SI joint is hypermobile or when there is trauma to the SI ligaments. Depending on the length of injury the whole extremity will become destabilized leading to knee ligament sprain and ankle pronation as well as various soft tissue symptoms. When I see significant GM dysfunction I always check the SI joint as well as leg length symmetry.

  37. Mike,

    I have an ongoing issue which was one step further into debilitation during what I thought was sore muscles from zumba during Jan of this year (2012) – I have had a ‘sore hip” which i thought was sciatica for years, and about a year ago experienced ankle swelling, an now also have knee pain, all on my right side… anyway, with the zumba thing…I kept thinking that the soreness would heal, but even now… March 27th 2012 – my gluteus minimus/medius is still tense and very sore, sometimes I can hardly stand up from sitting, or get out of the car without doubling over. I have difficulty working out too! Yoga, regular stretching… ibuprofen, flexeril, heat… ice… none of this (all having been tried frequently over the past 3 mo) have helped, and seems to get worse with exercise. What could be causing this? OR do you have any recommendations on doctors or chiropractors in my area (ZIP: 25302) who KNOW how to discover this??

  38. Hi Mike,

    About a year ago I injured my lower left back and now my QL seems to always tighten up especially while walking and standing for period of time. My concern is my left hip has been hiked just as your article states and I’ve been doing all kinds of stretches and exercise to try to correct problem. My stretches concentrate on the QL and psoas which is difficult to stretch.

    Do you suggest that I focus more on exercising the gluteas Medius? I’ve always had a weak muscles in that area so it’s starting to make sense.

    Please let me know your thoughts.

    Thanks,
    Brandon

  39. Hi, a great post, and very informative.
    Can these exercises for strengthening glutes or ‘retraining’ described here, be done with tears? I have partial tears 1/3 width in glute medius and minimus at insertion point. I’ve been told surgery is the only option, but I can’t have it as can’t have ‘down time’ on crutches as I am a carer of someone in a wheelchair, and I can’t push a chair if I’m on crutches, physically impossible! IHave been to physiotherapist but the elbow in the buttox ‘massage’ and ‘clamshell’ and pulling my leg behind me stretching really really hurt. Is cycling bad? if it is mechanical, as i was told, does that mean i should not walk, or swim or do anything? thanks. Has lasted four years now, progressed from pain to limp. cortison just killed the pain so i cycled and made it all worse.

  40. Hi Mike,

    Kendall’s research into gluteus medius weakness illustrates general weakness in healthy and LBP populations in their right gluteus medius whereas all populations have a strong left gluteus medius. Have you found this unilateral discrepancy in your own experience?

    This study is found in Muscles, Testing and function by Kendall p.8

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