Should We Stop Blaming the Glutes for Everything?

Today’s guest post comes from John Snyder, PT, DPT, CSCS.  John, who is a physical therapist in Pittsburgh, has a blog that has been honored as the “Best Student Blog” by Therapydia the past two years.  He’s a good writer and has many great thoughts on his website.  John discusses some of our common beliefs in regard to the role of the proximal hip on knee pain.  I’ll add some comments at the end as well, so be sure to read the whole article and my notes at the end.  Thanks John!

 

Should We Stop Blaming the Glutes for Everything?

should we stop blaming the glutes

Anterior cruciate ligament (ACL) rupture1,2 and patellofemoral pain syndrome (PFPS)3,4,5 are two of the most common lower extremity complaints that physicians or physical therapists will encounter. In addition to the high incidence of these pathologies, with regards to ACL injury, very high ipsilateral re-injury and contralateral injury have also been reported6,7,8.

With the importance of treating and/or preventing these injuries, several researchers have taken it upon themselves to determine what movement patterns predispose athletes to developing these conditions. This research indicates that greater knee abduction moments9,10, peak hip internal rotation11, and hip adduction motion12 are risk factors for PFPS development. Whereas, for ACL injury, Hewett and colleagues13 conducted a prospective cohort study identifying increased knee abduction angle at landing as predictive of injury status with 73% specificity and 78% sensitivity. Furthermore, as the risk factors for developing both disorders are eerily similar, Myer et al performed a similar prospective cohort study finding that athletes demonstrating >25 Nm of knee abduction load during landing are at increased risk for both PFPS and ACL injury14.

 

Does Weak Hip Strength Correlate to Knee Pain?

With a fairly robust amount of research supporting a hip etiology in the development of these injuries, it would make sense that weakness of the hip musculature would also be a risk factor, right?

A recent systematic review found very conflicting findings on the topic. With regards to cross-sectional research, the findings were very favorable with moderate level evidence indicating lower isometric hip abduction strength with a small and lower hip extension strength with a small effect size (ES)15. Additionally, there was a trend toward lower isometric hip external rotation and moderate evidence indicates lower eccentric hip external rotation strength with a medium ES in individuals with PFPS15. Unfortunately, the often more influential prospective evidence told a different story. Moderate-to-strong evidence from three high quality studies found no association between lower isometric strength of the hip abductors, extensors, external rotators, or internal rotators and the risk of developing PFPS15. The findings of this systematic review indicated hip weakness might be a potential consequence of PFPS, rather than the cause. This may be due to disuse or fear avoidance behaviors secondary to the presence of anterior knee pain.

 

Does Hip Strengthening Improve Hip Biomechanics?

Regardless of its place as a cause or consequence, hip strengthening has proved beneficial in patients with both PFPS16,17,18 and following ACL Reconstruction19, but does it actually help to change the faulty movement patterns?

Gluteal strengthening can cause several favorable outcomes, from improved quality of life to decreased pain, unfortunately however marked changes in biomechanics is not one of the benefits. Ferber and colleagues20 performed a cohort study analyzing the impact of proximal muscle strengthening on lower extremity biomechanics and found no significant effect on two dimensional peak knee abduction angle. In slight contrast however, Earl and Hoch21 found a reduction in peak internal knee abduction moment following a rehabilitation program including proximal strengthening, but no significant change in knee abduction range of motion was found. It should be noted that this study included strengthening of all proximal musculature and balance training, so it is hard to conclude that the results were due to the strengthening program and not the other components.

 

Does Glute Endurance Influence Hip Biomechanics?

All this being said, it is possible that gluteal endurance may be more influential than strength itself, so it would make sense that following isolated fatigue of this musculature, lower extremity movement patterns would deteriorate.

Once again, this belief is in contrast to the available evidence. While fatigue itself most definitely has an impact on lower extremity quality of movement, isolated fatigue of the gluteal musculature tells a different story. Following a hip abductor fatigue protocol, patients only demonstrated less than a one degree increase in hip-abduction angle at initial contact and knee-abduction angle at 60 milliseconds after contact during single-leg landings22. In agreement with these findings, Geiser and colleagues performed a similar hip abductor fatigue protocol and found very small alterations in frontal plane knee mechanics, which would likely have very little impact on injury risk23.

 

Can We Really Blame the Glutes?

The biomechanical explanation for why weakness or motor control deficits in the gluteal musculature SHOULD cause diminished movement quality makes complete sense, but unfortunately, the evidence at this time does not agree.

While the evidence itself does not allow the gluteal musculature to shoulder all of the blame, this does not mean we should abandon addressing these deficits in our patients. As previously stated, posterolateral hip strengthening has multiple benefits, but it is not the end-all-be-all for rehabilitation or injury prevention of lower extremity conditions. Proximal strength deficits should be assessed through validated functional testing in order to see its actual impact on lower extremity biomechanics on a patient-by-patient basis. Following this assessment, interventions should be focused on improving proximal stability, movement re-education, proprioception, fear avoidance beliefs, graded exposure, and the patient’s own values, beliefs, and expectations.

 

John SnyderJohn Snyder, PT, DPT, CSCS received his Doctor of Physical Therapy degree from the University of Pittsburgh in 2014. He created and frequently contributes to SnyderPhysicalTherapy.com (Formerly OrthopedicManualPT.com), which is a blog devoted to evidence-based management of orthopedic conditions.  

 

Mike’s Thoughts

John provides an excellent review of many common beliefs in regard to the influence of the hip on knee pain.  While it is easy to draw immediate conclusions from the result of one study or meta-analysis, one must be careful with how they interpret date.

I think “anterior knee pain,” or even PFPS, is just too broad of a term to design accurate research studies.  It’s going to be hard to find prospective correlations with such vague terminology.  Think of it as watering down the results.  Including a large sample of people, including men, women, and adolescents and attempting to correlate findings to “anterior knee pain” is a daunting task.

Imagine if we followed a group of adolescents from one school system for several years.  Variations in gender, sport participation, recreational activity, sedentary level, and many more factors would all have to be considered.  Imagine comparing the development of knee pain in a 13 year old sedentary female that decided she wanted to run cross country for the first time with an 18 year old male basketball player that is playing in 3 leagues simultaneously.  Two different types of subjects with different activities and injury mechanisms.  But, these two would be grouped together with “anterior knee pain.”

What do we currently know?  We know hip weakness is present in people with PFPS and strengthening the hips reduces symptoms.  As rehabilitation specialists, that is great, we have a plan.  I’m not sure we can definitely say that hip weakness will cause knee pain, but I’m also not sure we can say it won’t.  Designing a prospective study to determine may never happen, there are just too many variables to control.

John does a great job presenting studies that require us to keep an open mind.  I’m not sure we can make definitive statements from these results, but realize that there are likely many more variables involved with the development of knee pain.  Hip strength and biomechanics may just be some of them.  Thanks for sharing John and helping us to remember that it’s not always the glutes to blame!

 

 

Updated Strategies for Anterior Pelvic Tilt

The latest Inner Circle webinar recording on the Strategies for Anterior Pelvic Tilt is now available.

Updated Strategies for Anterior Pelvic Tilt

strategies for anterior pelvic tiltThis month’s Inner Circle webinar was on Strategies for Anterior Pelvic Tilt.  This is actually an update on one of my most popular webinars in the past.  I am doing a couple new things and wanted to assure everyone has my newest thoughts.  In this webinar I go through my system of how I integrate manual therapy, self-myofascial release, stretching, and correcting exercises.  To me, it’s all how you put the program together.  My system builds off each step to maximize the effectiveness of your programs.

Anterior Pelvic Tilt Influences Hip Range of Motion and Impingement

One of the most common postural adaptations that I see on a day to day basis is anterior pelvic tilt.  In fact, it’s getting more rare to find someone that isn’t in a large amount of anterior pelvic tilt.

I blame it on our seated culture.  The human body is excellent at adapting, and the seated posture produces an anterior pelvic tilt.

 

Anterior Pelvic Tilt Influences Hip Range of Motion and Impingement

Anterior Pelvic Tilt Hip Range of Motion ImpingementA recent research study published in the American Journal of Sports Medicine looked at the effect of changes in pelvic tilt on range of motion and impingement of the hip.

The authors looked at CT scans of the hips of  50 subjects with femoroacetabular impingement and simulated range of motion using 3D-generated models.

A 10 degree increase in anterior pelvic tilt, which I would say is something we see clinically, resulted in a significant loss of 6-9 degrees of hip internal rotation and increase in FAI.  This increase in anterior pelvic also resulted in a loss of 10 degrees of hip flexion.  Subsequently, an increase in posterior pelvic tilt resulted in greater hip internal rotation, less impingement, and more hip flexion.

 

Clinical Implications

The results of the study have several implications

  • Assessment of hip ROM should take pelvic position into consideration.
  • FAI symptoms may be reduced by decreasing anterior pelvic tilt.
  • People with limited hip internal rotation or hip flexion may have too much anterior pelvic tilt.  Focus on alignment before starting to torque the joint.  This is a fundamental principle I talk about in Functional Stability Training of the Lower Body.
  • People with poor squat mechanics, especially in the deeper positions, may have an underlying pelvic position issue.  People with excessibve anterior pelvic tilt that are squatting deep maybe impinging and beating up their hips.

 

I talk a lot about reverse posturing, my terminology for focusing on reversing the posture that you assume for the majority of your day.  But there is a big difference between reducing static anterior pelvic tilt posture and dynamic anterior pelvic tilt control.  You have to emphasize both with dynamic control being arguably more important.

Keep these findings in mind next time you see someone with a large amount of anterior pelvic tilt.

If you are interested in learning more about how I work with anterior pelvic tilt, I recently outlining my integrated system of manual therapy and corrective exercise in my Inner Circle webinar on Strategies to Reduce Anterior Pelvic Tilt.

 

 

Is Perfect Squat Form a Myth?

Over the years I have helped 1000’s of people squat better.  As a physical therapist, my career has evolved over the years from working with injured people to working with healthy people looking to optimize their body and maximize their performance.  In fact, I’m starting to refer to it more as “performance therapy” than “physical therapy.”

Lately, I’ve seen more and more people come to me to learn how to improve their squat.  Often times it’s one of two reasons why they can’t quite get find perfect squat form:

  • Something hurts when I squat
  • I can’t squat with perfect form

After going through a full body assessment, I always assess their squat form.  I don’t mean a rigid deep squat test, such as the one within the FMS of SFMA assessments, but an actual loaded squat.  I don’t say a word, I just observe.  Well, I actually record a video of it, but the point is I don’t want to cue the squat at all so I can see how the set up and how they perform their squat without my coaching.

What I often find is that many people are trying to squat with perfect form, or least what they believe is “perfect form.”  Perhaps they just picked up a copy of Starting Strength, or just attended their level 1 weekend certification, or just went through a foundations course at their box.  The quest for “perfect squat form” probably isn’t that simple.

I’m starting to wonder if there really is a such thing as perfect squat form.

 

Is Perfect Squat Form a Myth?

Don’t get me wrong, you have to start somewhere.  I personally recommend people read Mike Robertson’s article on How to Squat and the book Starting Strength is worth every penny.  My point isn’t that you should throw away any attempt to squat with perfect form, there are good ways and bad ways to squat, you have to start somewhere.

But I almost feel like we are over-coaching and using the same coaching cues during the squat with everyone.  Yes, there are many faults the can occur during squatting that should be avoided.  Bret Contreras has a nice article about solving 7 squat dilemmas.    But there is a big difference between correcting faults and overcorrecting people without faults.

Here is a good example, imagine you are squatting with your knees caving in towards each other, or tracking medially into a valgus knee position.  This would be a great time to cue someone to force their knees out.  However, it is possible to force your knees out too far and I’m not sure I want to cue someone that is squatting with decent form to aggressively force their knees out.  It’s a good thought to prevent knee cave in, but don’t go too far in the opposite direction.

But more importantly, I’m not sure there is a textbook way to squat, simply because we are all built different and have different daily habits.  There is a textbook perfect squat form for YOUR body, but it may be different for the person next to you.

This is why proper coaching and an individualized program built for you is the best way to succeed at perfecting your squat form.  There are several limitations that we all have that may be limiting our ability to achieve a perfect squat form.

 

Anatomical Limitations

The first thing we need to understand is that everyone’s anatomy is unique.  Bret Contreras does a nice job discussing our how our anatomical differences impact our squat mechanics and Ryan DeBall has a great article as well.  In fact, our pelvis and femurs are completely and vastly unique.

Look at these photos of several different pelvis and femur bones by Paul Grilley:

Femur neck variations

Femur Torsion Variations

Acetabular pelvic bone variations

Looking at these photos, it is striking how different we all really are on the inside.  The angles of how the femur bone forms as well as how it sits in the socket can be dramatically different between people.

This is what I find to be the biggest factor impacting why people can’t perform a squat with perfect form.  How can you say there is one way to squat when you look at these photos?  The spectrum of variation is so wide.

Unfortunately there isn’t a quick fix for anatomical limitations.  Rather, a detailed biomechanical assessment can be used to determine what may be the best squat mechanics based on your anatomy.  Sometimes this means that you will need to limit depth.  People never want to hear this, but sometimes you just simple run out of anatomy and can’t physically flex your hips enough to achieve deep squat form, at least without significant low back compensation.

 

Mobility Limitations

Luckily, not everyone has significant underlying anatomical variations.  Some just have mobility restrictions of their joint capsules and muscle tissue.  This is common in the person that assumes a frequent postural position over several years, such as sitting.  Most adults will have postural and mobility limitations that can be improved and subsequently improve their squat performance.

So, keep this in mind if you are a coach at a gym with adult fitness clients that are looking to start squatting.  Chances are they won’t be immediately able to perform a squat well until you clean up some of their movement patterns.  Rushing this process is how newbie adult fitness clients tend to hurt themselves while squatting.  They don’t have the mobility to squat with proper mechanics, and without this mobility, you are just going to compensate and put extra stress somewhere else, like this guy, who probably doesn’t have the mobility to be squatting:

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A detailed assessment process can accurately determine if you have an anatomical or simple mobility limitation.

I also want to briefly comment on squatting like a baby.  I know many people have commented that if babies can squat perfectly, why can’t adults?  Dean Somerset wrote about this recently, but this concept is really ridiculous.  There are many factors that make babies able to squat well, including their head to body size ratio, femur height, acetabular position, but most importantly the simple fact that their bones aren’t fused!  Adults will never have the mobility of a baby, this has nothing to do with motor control.

 

Motor Control Limitations

perfect squat formAnother possible area of limitation that can be negatively impacting your squat performance is poor motor control.  I again tend to see this in adults that have been sitting for the majority of the day the last 10-30 years.  When you sit all day, you don’t need abdominal control, lumbopelvic control, or posterior chain activity.  The chair simply does all of this for you.  You essentially learn how to turn all of these off!

This can be seen in someone that has poor movement patterns, however during my clinical assessment have no real mobility restrictions of their joints or muscles.

Sadly, however, I also see this often in my younger athletes.  I’m amazed at how poor our high school students move.  I blame it on sitting and staring at the TV, Xbox, or iPhone all day, but kids can’t even touch their toes anymore!

We have close to 100 high school athletes training with us at Champion Physical Therapy and Performance, and a large portion of them are performing corrective exercises and goblet squats until their motor control improves!

 

Your Perfect Squat Form

It’s always going to be in your best interest to work on your mobility and motor control limitations to improve your squat form.  However, realize that we all have different anatomical factors that may also be limiting your squat form.  This is why getting a proper assessment and individualized program is important if you are serious about enhancing your squat performance and reducing your chance for beating yourself up.

A custom program of mobility drills, corrective exercises, and individualized squat mechanics can really help you.   Sometimes you have to work within your own unique anatomical limitations.  Perhaps you just need to toe out a little more or widen your stance by an inch.  That may mean that you don’t perform the textbook perfect squat mechanics, but that may be OK, it’s your perfect squat form.

 

Base of Support and Core Stability

I work with with a lot of youth athletes, especially baseball players.  I am often amazed at how some of our younger athletes have such poor movement skills.  Many are 6 inches away from touching their toes!  I’m sure this is a trend this is not going away as our society spends more and more time staring at our iPhones and less on long term athletic development.

The body is great at compensating and finding the path of least resistance.  Here is a quick tip that you can apply to many different exercises to enhance core stability.

 

Base of Support

When the core and entire lumbopelvic region has poor motor control and stability, especially in the transverse and frontal planes, a way the body likes to compensate is by widening the base of support.  Here is an example of a young athlete performing a medicine ball chest pass.  Notice his base of support in the first photo.  This was his natural set up position.

Base of Support

 

By widening his base of support, he can likely generate more power during the exercise by making it more stable in general.  However, in a training environment, I want to assure that we develop both power and control.

By narrowing his base of support, as you can see in the second photo, he has to stabilize his core during the exercise and work on developing power while controlling the force of the ball.  This is going to have a more functional carry over into his sport.

Building athletes isn’t always just about strength and power, it’s also about movement quality and control.  Watch for compensations at the base of support for signs of poor lumbopelvic and core stability.

 

 

Yoga Stability Push Up

yoga stability push upI’ve recently been playing around with a variation of the yoga push up on an unstable surface.  The yoga push up exercise integrates a push up with a plus with the downward dog yoga position.  You can also perform this exercise on an unstable surface, such as a stability ball.

 

How to Perform the Yoga Stability Push Up

Here are a few of my coaching cues during the yoga stability push up:

  • Place the stability ball up against a wall.  The instability provided the ball is plenty, having the ball mobile isn’t needed and may not be safe.  Also, don’t perform this on turf as it is sometimes hard to keep the feet from slipping.
  • Start at the beginning plank position at the top of the push up.  In this position prep you body by finding neutral spine and performing a mild abdominal brace.  Keeping the core stable with enhance the mobility benefits at both the shoulders and hips.
  • Perform a push up but on the push back up focus on your hands pushing up and out above your head to drive your hips up high.  Protract your shoulders to perform a “push up with a plus.”  Be sure to keep your core stable and hinge at your hips.  You should feel both your abdominal area and glutes engage.

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Benefits of the Yoga Stability Push Up

There are many benefits of incorporating the yoga stability push up into your routine.  The three big things I am looking to improve with this exercise are:

  • Shoulder and scapular stability.  Performing a push up on an unstable surface has been shown to enhance scapular muscle activity compared to a traditional push up.  This can also be said for the rotator cuff muscles.
  • Serratus anterior activity.  The push up with a plus includes both upward rotation and protraction of the scapula, the two motions of the serratus anterior that when performing together have been shown to enhance serratus activity.
  • Hip mobility.  By adding the downward dog yoga hip hinge portion of the exercise, you drive more elevation of the arms, but also help facilitate a hip hinge pattern.

 

 

 

Strategies for Anterior Pelvic Tilt

The latest Inner Circle webinar recording on the Strategies for Anterior Pelvic Tilt is now available.

Strategis for Anterior Pelvic Tilt

strategies for anterior pelvic tiltThis month’s Inner Circle webinar was on Strategies for Anterior Pelvic Tilt.  I go through my system of how I integrate manual therapy, self-myofascial release, stretching, and correcting exercises.  To me, it’s all how you put the program together.  My system builds off each step to maximize the effectiveness of your programs.

 

To access the webinar, please be sure you are logged in and are a member 0f the Inner Circle program.

The True Hip Flexor Stretch

The hip flexor stretch has become a very popular stretch in the fitness and sports performance world, and rightly so considering how many people live their lives in anterior pelvic tilt.  However, this seems to be one of those stretches that I see a lot of people either performing incorrectly or too aggressively.  I talked about this in a recent Inner Circle webinar on 5 common stretches we probably shouldn’t be using, but I wanted to expand on the hip flexor stretch as I feel this is pretty important.

I’ve started teaching what I call the “true hip flexor stretch.”  I call it the true hip flexor stretch as I want you to truly work on stretching the hip flexor and not just torque your body into hip and lumbar extension.  When performing, most people say they never felt a stretch like that before, hence the name “true hip flexor stretch.”

 

True Hip Flexor Stretch

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Key Points

  • There is a difference between a quadriceps stretch and a hip flexor stretch.  When your rationale for performing the stretch is to work on stretching your hip flexor, focus on the psoas and not the rectus femoris.
  • Keep it a one joint stretch.  Many people want to jump right to performing a hip flexor stretch while flexing the knee.  This incorporates the rectus and the psoas, but I find far too many people can not appropriately perform this stretch.  They will compensate, usually by stretching their anterior capsule too much or hyperextending their lumbar spine.
  • Stay tall.  Resist the urge to lean into the stretch and really extend your hip.  Most people are too tight for this, trust me.  You’ll end up stretch out the anterior hip joint and abdominals more than the hip flexor.
  • Make sure you incorporate a posterior pelvic tilt.  Contract your abdominals and your glutes to perform a posterior pelvic tilt.  This will give your the “true” stretch we are looking for.  Many people wont even need to lean in a little, they’ll feel it immediately in the front of their hip.
  • If you don’t feel it, squeeze your glutes harder.  Many people have a hard time turing on their glutes while performing this stretch, but it is key.
  • Guide your hips with your hands.  I usually start this stretch with your hands on your hips so I can teach you to feel posterior pelvic tilt.  Place your fingers in the front and thumbs in the back and cue them to posterior tilt and make their thumbs move down.

true hip flexor stretch

  • Progress to add core engagement.  Once they can master the posterior pelvic tilt, I usually progress to assist by curing core engagement.  You can do this by pacing both hands together on top of your front knee and push straight down, or by holding a massage stick or dowel in front of you and pushing down into the ground.  Key here is to have arms straight and to push down with you core, not your triceps.

 

I use this for people that really present in an anterior pelvic tilt, or with people that appear to have too loose of an anterior hip capsule.  This works great for people with low back pain, hip pain, and postural and biomechanical issues related to too much of an anterior pelvic tilt.  Give the true hip flexor stretch a try and let me know what you think.