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A literature review of studies evaluating gluteus maximus and gluteus medius activation during rehabilitation exercises

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Recently, clinicians have focused much attention on the importance of hip strength for the rehabilitation of not only patients with low back pain but also lower extremity pathology. Properly designing a rehabilitation program for the gluteal muscles requires careful consideration of biomechanical principles, such as length of the external moment arm, gravity, and subject positioning. Understanding the anatomy and function of these muscles also is essential. Electromyography (EMG) provides a useful means to determine muscle activation levels during specific exercises. Descriptions of specific exercises, as they relate to the gluteal muscles, are described. The specific performance of these exercises, the reliability of such EMG measures, and descriptive figures are also detailed. Of utmost importance to practicing clinicians is the interpretation of such data and how it can be best used in exercise prescription when formulating a treatment plan.
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SYSTEMATIC REVIEW
A literature review of studies evaluating gluteus
maximus and gluteus medius activation during
rehabilitation exercises
Michael P. Reiman, PT, DPT, OCS, SCS, ATC, FAAOMPT, CSCS,
1
Lori A Bolgla, PT,
PhD, ATC,
2
and Janice K. Loudon, PT, PhD, SCS, ATC, CSCS
3
1
Doctor of Physical Therapy Division, Department of Community and Family Medicine, Duke University School of
Medicine, Durham, NC, USA
2
Department of Physical Therapy, Georgia Health Sciences University, Augusta, GA, USA
3
Department of Physical Therapy and Rehabilitation Science, University of Kansas Medical Center, Kansas City,
KS, USA
ABSTRACT
Recently, clinicians have focused much attention on the importance of hip strength for the rehabilitation of not
only patients with low back pain but also lower extremity pathology. Properly designing a rehabilitation program
for the gluteal muscles requires careful consideration of biomechanical principles, such as length of the external
moment arm, gravity, and subject positioning. Understanding the anatomy and function of these muscles also is
essential. Electromyography (EMG) provides a useful means to determine muscle activation levels during
specific exercises. Descriptions of specific exercises, as they relate to the gluteal muscles, are described. The
specific performance of these exercises, the reliability of such EMG measures, and descriptive figures are
also detailed. Of utmost importance to practicing clinicians is the interpretation of such data and how it can be
best used in exercise prescription when formulating a treatment plan.
INTRODUCTION
Strengthening of any muscle group requires careful
planning and a systematic progression from less chal-
lenging to more challenging exercises. The demand
of a particular exercise can be influenced by the
plane of movement, effects of gravity, speed of
motion, base of support, and type of muscle contrac-
tion. Clinicians should consider these factors when
designing and implementing strengthening exercises
for the gluteals. An appreciation of this muscle
groups anatomy and function also deserves
attention.
Gluteal anatomy and function
The gluteus maximus (GMax) is the largest muscle of
the hip accounting for 16% of the total cross-sectional
area (Winter, 2005). It has several anatomical land-
marks, including the ilium, sacrum/coccyx, and sacro-
tuberous ligament as an origin (Kendall, McCreary,
and Provance, 1993). Eighty percent of the GMax
inserts into the ilio tibial band; the remainder inserts
in the distal portion of the femurs gluteal tuberosity.
The GMax is a powerful hip extensor and lateral
rotator (Delp, Hess, Hungerford, and Jones, 1999).
It is often used to accelerate the body upward and
forward from a position of hip flexion ranging from
45° to 60° (e.g., sprinting, squatting, and climbing a
steep hill). In addition, the GMax is active during a
plant and cut maneuver to the opposite side
(Neumann, 2010).
The gluteus medius (GMed) is broad and fan
shaped, attaching to the superior ilium and inserting
Address correspondence to Michael P. Reiman, Doctor of Physical
Therapy Division, Department of Community and Family Medicine,
Duke University School of Medicine, Durham, NC 27710, USA.
E-mail: reiman.michael@gmail.com
Accepted for publication 5 July 2011
Physiotherapy Theory and Practice, 28(4):257268, 2012
Copyright © Informa Healthcare USA, Inc.
ISSN: 0959-3985 print/1532-5040 online
DOI: 10.3109/09593985.2011.604981
257
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on the lateral aspect of greater trochanter (Pfirrmann
et al, 2001). Anatomically, the GMed is divided into
three parts: 1) anterior; 2) middle; and 3) posterior,
each with separate branches from the superior
gluteal nerve.
As a whole, the GMed stabilizes the femur and
pelvis during weight-bearing activities with the great-
est GMed activation observed during the stance
phase of gait (Gottschalk, Kourosh, and Leveau,
1989; Lyons et al, 1983). Functionally, it generates
an exceptional amount of force given its size (Ward,
Winters, and Blemker, 2010).
The GMed a ccounts for 60% of the total hip
abductor muscle cross-sectional area (Clark and
Haynor, 1987). The three anatomical parts phasic
activity is based on fiber orientation (Gottschalk,
Kourosh, and Leveau, 1989). The anterior and middle
portions of the GMed help initiate hip abduction. The
anterior portion singly abducts, medially rotates, assis ts
with hip flexion, and is active when the base of support
is minimal (e.g., bridges, unilater al squat, later al
step-up) (Boudreau et al, 2009). It has been demon-
strated that there is an eightfold increase in medial
rotation leverage at 90° of flexion (Delp, Hess, Hunger-
ford, and Jones 1999). The posterior portion of the
muscle exten ds, abducts, and laterally rotates the hip.
Hip/gluteal weakness and pathology
Hip dysfunction (e.g., weakness and limited range of
motion) is one factor that has been associated with
low back and various lower extremity pathologies. A
moderate relationship currently exists between hip
dysfunction and low back pathology (Reiman,
Bolgla, and Lorenz, 2009), whereas a much stronger
relationship has been identified between hip dysfunc-
tion and knee pathology (Powers, 2010; Reiman,
Bolgla, and Lorenz, 2009).
Hip abduction and lateral rotation weakness has
been associated with patellofemoral pain syndrome
(PFPS). Ireland, Willson, Ballantyne, and Davis
(2003) revealed that females with PFPS demonstrated
26% less hip abductor and 36% less hip lateral
rotation strength than controls. Others have identified
similar trends (Bolgla, Malone, Umberger, and Uhl
2008; Piva, Goodnite, and Childs, 2005; Robinson
and Nee, 2007; Willson and Davis, 2009).
Powers (2003) has theorized that hip abductor and
lateral rotator weakness can lead to knee valgus, hip
adduction, and hip internal rotation, a position that
can place undue stress on lower extremity joints.
Ferber, Kendall, and Farr (2011) found that correct-
ing the hip strength deficits improves lower extremity
pain in runners.
Emerging data support the important role of the
GMax and GMed during athletic endeavors, and a
variety of strengthening exercises have been described.
The purpose of this manuscript is to provide a review
of the current literature regarding GMax and GMed
activation during rehabilitative exercises. It is our
intent that clinicians use this information to facilitate
a systematic approach for the development and
implementation of GMax and GMed strengthening
programs.
METHODS
A literature search was performed for experimental
studies, randomized controlled trials, systematic
reviews, narrative reviews, and meta-analyses using
the Medline (1966 to 05/2010), CINAHL (1982 to
05/2010), and Sports Discus (1975 to 05/2010)
databases. Search terms included hip; strengthening;
exercise; therapy; gluteus maximus; gluteus medius;
gluteal muscles; exertion; testing; electromyography
(EMG); electromyographic analyses; maximum
voluntary isometric contraction (MVIC); and
training, in all possible combinations. Sources also
were located by scanning reference lists from all
relevant articles.
Information from the various sources was com-
pared among authors for relevance of inclusion.
Primary inclusion criteria were studies investigating
EMG activity for either the GMax or GMed. Articles
were excluded if EMG analyses were not performed
for these two muscles. Additional exclusion criteria
for articles investigating EMG analyses were used to
minimize heterogeneity between studies. Additional
exclusion criteria included 1) studies/exercises
that measured EMG activity while adding additional
weight or resistance; 2) studies/exercises that
measured EMG activity while using machines/
equipment to modify the activity; 3) studies/exercises
that measured EMG activity only during the
eccentric phase of an exercise; 4) studies/exercises
that did not normalize EMG activity to a MVIC; 5)
studies/exercises t hat examined gender differences
(separate calculations for males for males and
females); and 6) studies/exercises that lacked detailed
information to discern proper inclusion/exclusion
criteria.
RESULTS
Six studies for the GMax (Ayotte, Stetts, Keenan,
and Greenway 2007; Blanpi ed, 1997; Distefano,
258 Reiman et al.
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Blackburn, Marshall, and Padua 2009; Ekstrom, Do-
natelli, and Carp 2007; Ekstrom, Osborn, and Hauer
2008; Farrokhi et al, 2008) and four studies for the
GMed (Ayotte, Stetts, Keenan, and Greenway 2007;
Bolgla and Uhl, 2005; Distefano, Blackburn, Mar-
shall, and Padua 2009; Ekstrom, Donatelli, and
Carp 2007) met the inclusion criteria. To make mean-
ingful comparisons of EMG activation levels between
studies, we categorized activation into previously de-
scribed levels (low-level muscle activation at 020%
MVIC; moderate-level activation at 2140% MVIC;
high-level activation 4160% activation, and very
high-level activation at greater than 60%) (Escamilla
et al, 2010).
Appendix I lists the exercises included, EMG
activity, and measurement reliability (when available).
Appendix II provides a detailed description of each
study. To make meaningful comparisons of EMG
activity between studies, we summarized EMG data
for the GMax (Figure 1) and GMed (Figure 2)
during exercise from the lowest to highest activation
level. For exercises examined in a single study, we
reported their individual mean and standard
deviation. For exercises examined in more than one
study, we reported the pooled mean and its 90%
confidence interval (CI).
Gluteus maximus activation
Low-level activation (020% MVIC)
Three exercises met the criteria for inclusion in the
category of low-level activation (Figure 1). These exer-
cises included 1) Prone bridge/plank (9% ± 7%
MVIC); 2) Lunge with backward trunk lean (19% ±
12% MVIC); and 3) Bridging on Swiss ball (20% ±
14% MVIC).
Moderate-level activation (2140% MVIC)
Seven exercises met the criteria for inclusion in the
category of moderate-level activation (Figure 1). The ex-
ercises in this category included 1) Side-lying hip
abduction (21% ± 16% MVIC); 2) Lunge with
forward trunk lean (22% ± 12% MVIC); 3) Bridging
on stable surface (25% ± 14% MVIC); 4) Clam
with 30° hip flexion (34% ± 27% MVIC); 5) Lunge-
neutral trunk position (36% MVIC; 90% CI [32, 40]);
FIGURE 1 Gluteus maximus percent maximum voluntary isometric contraction ranking of exercises.
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6) Clam with 60° hip flexion (39% ± 24% MVIC); and
7) Unilateral bridge (40% ± 20% MVIC).
High-level activation (4160% MVIC)
Nine exercises met the criteria for inclusion in the cat-
egory of high-level activation (Figure 1). These exer-
cises were 1) Sideways lunge (41% ± 20% MVIC);
2) Lateral step-up (41% MVIC; 90% CI [36, 46]);
3) Transverse lunge (49% ± 20% MVIC); 4) Quad-
ruped with contralateral arm/leg lift (56% ± 22%
MVIC); 5) Unilateral mini-squat (57% ± 44%
MVIC); 6) Retro step-up (59% ± 35% MVIC); 7)
Wall squat (59% MVIC; 90% CI [51, 67]); 8)
Single-limb squat (59% ± 27% MVIC); and 9)
Single-limb deadlift (59% ± 28% MVIC).
Very high-level activation (>60% MVIC)
One exercise met the criteria for inclusion in the very
high-level activation (Figure 1). This exercise was
Forward step-up (74% ± 43% MVIC).
Gluteus medius activation
Low-level activation (020% MVIC)
None of the included studies had any exercises
that met the criteria for inclusion in the category of
low-level activation.
Moderate-level activation (2140% MVIC)
Eight exercises met the criteria for inclusion in the
category of moderate-level activation (Figure 2).
These exercises were 1) Prone bridge plank (27%
± 11% MVIC); 2) Bridging on stable surface (28%
± 17% MVIC); 3) Lunge-neutral trunk position
(34% MVIC; 90% CI [30, 38]); 4) Unilateral
mini-squat (36% ± 17% MVIC); 5) Retro step-up
(37% ± 18% MVIC); 6) Clam with 60° hip flexion
(38% ± 29% MVIC); 7) Sideways lunge (39% ±
19& MVIC); and 8) Clam with 30° hip flexion
(40% ± 38% MVIC).
FIGURE 2 Gluteus medius percent maximum voluntary isometric contraction ranking of exercises.
260 Reiman et al.
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High-level activation (4160% MVIC)
Nine exercises met the criteria for inclusion in the cat-
egory of high-level activation (Figure 2). The exercises
were 1) Lateral step-up (41% MVIC; 90% CI [37,
45]); 2) Quadruped with contralateral arm and leg
lift (42% ± 17% MVIC); 3) Forward step-up (44%
± 17% MVIC); 4) Unilateral bridge (47% ± 24%
MVIC); 5) Transverse lunge (48% ± 21% MVIC);
6) Wall squat (52% ± 22% MVIC); 7) Side-lying hip
abduction (56% MVIC; 90% CI [49, 63]); 8) Pelvic
drop (57% ± 32% MVIC); and 9) Single-limb deadlift
(58% ± 22% MVIC).
Very high-level activation (>60% MVIC)
Two exercises met criteria for inclusion into the cat-
egory of very-high level activation (Figure 2). These
exercises were 1) Single-limb squat (64% ± 24%
MVIC); and 2) Side-bridge to neutral spine position
(74% ± 30% MVIC).
DISCUSSION
Therapeutic exercise is one of the most important
interventions that clinicians prescribe for the treat-
ment of low back and lower extremity pathology.
Researchers (Ayotte, Stetts, Keenan, and Greenway,
2007; Bolgla and Uhl, 2005; Boudreau et al, 2009;
Distefano, Blackburn, Marshall, and Padua, 2009;
Krause et al, 2009) have used surface EMG to
quantify hip muscle activity during various activities
and exercises. They have theorized that exercises
requiring greater EM G activity will result in strength
gains. Clinicians can use this information because
strength gains of the active muscle(s) are expected
when EMG activity is greater than 40% MVIC
(Ayotte, Stetts, Keenan, and Greenway, 2007; Esca-
milla et al, 2010). The following sections provide an
explanation for the muscle activation levels, as
delineated in Figures 1 and 2, for the GMax and
GMed.
Gluteus maximus activation
Our review identified three low-level exercises, seven
moderate-level exercises, nine high-level exercises, and
one very high-level exercise for GMax activation. The
prone bridge/plank differed from the other exercises in
the low-level activation due to its static nature to main-
tain a neutral hip and spine position during this exercise.
The low activation (9% MVIC) most likely reflected the
GMaxs role as a hip and spine stabilizer.
Data for the five lunges suggested that trunk pos-
ition and movement direction can influence GMax
activity. Farrokhi et al (2008) reported 22% MVIC
GMax activation when subjects performed a forward
lunge with the trunk flexed forward relative to the
hip and pelvis. Compared to the trunk extended
lunge, the trunk flexed forward lunge was more
demanding because it placed the bodys center of
mass more forward relative to the hip joints axis of
rotation. This position change essentially increased
the external moment arm that resulted in an increased
external hip flexion torque. Therefore, subjects gener-
ated greater GMax activity to counteract the higher
hip flexion torque.
Our review included three variations of a bridging
exercise that specifically targeted the GMaxs role as
a dynamic hip extensor. Subjects performed the uni-
lateral and traditional bridges in a hook-lying position,
which effectively shortened the hamstrings to target
GMax activity. The unilateral bridge (40% MVIC)
had greater activation than the traditional bridge
(25% MVIC) because the GMax controlled multiple
planes of hip and pelvis movement when performing
the unilateral bridge. It is interesting that subjects gen-
erated less GMax activity (19% MVIC) during the
bridge on Swiss ball. This exercise differed from the
unilateral and traditional bridge because subjects per-
formed it with the knees extended. This position most
likely allowed for hamstring activation that assisted
with hip extension during the bridge on Swiss ball.
Besides the various lunge and unilateral bridge
exercises, the side-lyi ng hip abduction and clam exer-
cises all generated moderate GMax activity. Although
typically prescribed as exercises to strengthen the
GMed, they also can provide additional benefit for
the GMax. The side-lying hip abduction (21%
MVIC) generated less GMax activation than the
clam with 30° (34% MVIC) and 60° (39% MVIC)
of hip flexion. This relatively lower activation during
side-lying abduction likely reflected the GMaxs role
as a secondary hip abductor. The clam exercises dif-
fered from side-lying hip abduction because both
incorporated dynamic hip lateral rotation, another
important GMax action. As discussed in the GMed
section, both clam exercises generated GMed acti-
vation levels similar to the GMax. Therefore, clini-
cians should consider prescribing clam exercises if
the goal is to equally target the GMax and GMed.
The high-level activation tier of GMax muscle acti-
vation included mostly standing exercises. The side-
ways lunge and lateral step-up both had lower GMax
activation levels (41% MVIC) than the transverse
lunge (49% MVIC). The sideways lunge differed
because subjects performed this maneuver in the
frontal plane, whereas the transverse lunge incorpor-
ated movement in both the frontal and horizontal
planes. These patterns imposed greater demands on
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the GMax to help maintain the pelvis in a level
position (as a hip abductor) and minimize knee
valgus collapse (as a hip lateral rotator). Therefore,
clinicians should consider trunk position relative to
the base of support as well as movement direction
when developing and implementing a progressive
strengthening program.
The quadruped with contralateral arm and leg lift
required 56% MVIC of GMax activity and highlighted
the GMaxs role as both a hip stabilizer and hip exten-
sor. Subjects were further challenged because the
GMax had to control multiple planes of movement
via the contralateral arm and leg lift. While clinicians
prescribe this exercise as part of a progressive spinal
stability program, patients with marked hip weakness
also may benefit from this exercise.
The remaining single-leg squats (single-limb dead-
lift, single-limb squat, wall squat, retro step-up, unilat-
eral mini-squat) generated relatively higher GMax
activity (5759% MVIC) than the lateral step-up
because they incorporated a greater excursion of the
bodys center of mass away from the base of support
and movements in multiple planes. The front step-
up had the highest level of GMax activity (74%
MVIC), which most likely reflected an even greater
amount of body excursion to and from the base of
the support.
Gluteus medius activation
Our review identified eight moderate-level exercises,
nine high-level exercises, and two very high-level exer-
cises for GMed activation. The prone bridge/plank
again demonstrated the lowest level of GMed acti-
vation (27% MVIC) . Similar to the GMax, the static
nature to maintain a neutral hip and spine position
likely reflected the GMeds role as a hip and spine
stabilizer.
Bridging on a stable surface (28% MVIC), lunge in
neutral trunk position (34% MVIC), unilateral
mini-squat (36% MVIC), and retro step-up (37%
MVIC) generated moderate-level GMed activation.
Subjects performed these exercises primarily in the
sagittal plane that required the GMed to maintain a
level pelvis. These findings suggest an important stabi-
lizing effect afforded by the GMed and the use of the
above listed exercises early in the rehabilitation
process to strengthen the GMed.
Other exercises in the moderate-level tier included
the clam exercises at 30° (40% MVIC) and 60° (38%
MVIC) of hip flexion as well as the sideways lunge
(39% MVIC). GMed activity generated during both
clam exercises was similar to that of the GMax
(34% and 39% MVIC at 30° and 60° of hip
flexion, respectively) during these exercises. It was
noteworthy that the clam exercises incorporated a
combination of hip abduction and lateral rotation.
Although the GMed is primarily responsible for hip
abduction, its posterior fibers also assist with hip
lateral rotation.
GMed activity during the lunges ranged from
34% to 48% MVIC. Subjects performed the
forward lunge in the sagittal plane, which would
explain its relatively lower amount of activity (34%
MVIC). However, GMed activation increased when
performing lunges in the frontal (39% MVIC for
the sideways lunge) and horizontal (48% MVIC
during the transverse lunge) planes. These exercises
were more dynamic than the front lunge and most
likely required greater GMed activity to maintain a
level pelvis position (as a hip abductor) and mini-
mize knee valgus collapse (as a hip lateral rotator).
It is interesting that subjects generated similar
GMax activity during the sideways (41% MVIC)
and transverse (49% MVIC) lunges as the GMed.
These findings further highlighted the synergistic
role that the GMax and GMed play during these
exercises. In summary, clinicians should ensure
that a patient with GMed weakness can correctly
perform a forward lunge before prescribing the side-
ways and transverse lunges.
The quadruped with contralateral arm and leg lift
(42% MVIC) and unilateral bridge (47% MVIC)
required high GMed activation. The increased chal-
lenge of controlling multiple planes of movement
most likely accounted for the relatively higher GMed
activity during these exercises. The clinician should
consider these exercises as a logical progression from
the clam exercises.
Except for the full single-leg squat, the wall squat
required the next highest GMed activity (52%
MVIC). This exercise differed from the unilateral
mini-squat, retro step-up, lateral step-up, and
forward step-up because subjects began the squat by
positioning the trunk against the wall and the stance
limb 15.2 cm away from the wall. This position effec-
tively placed the bodys center of mass posterior to the
base of support. Movement of the pelvis away from the
base of support would require greater activity of all
muscles around the hip, including the GMed, to
stabilize the pelvis (Ayotte, Stetts, Keenan, and
Greenway, 2007). These findings highlighted move-
ment of the bodys center of mass away from the
base of support as a logical exercise progression.
Side-lying hip abduction generated GMed
activation equal to 56% MVIC, which most likely
reflected this muscles role as a primary hip abductor.
While this exercise was in the high-level activation
tier, other standing exercises demonstrated similar
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GMed muscl e activation levels (5258% MVIC).
The standing exercises highlighted the GMeds
importance in providing multi-planar stabilization
for the trunk/pelvis. These findings were clinically rel-
evant because subjects who cannot perform GMed
weight bear ing exercises may get similar benefit by
performing the side-lying exercise (Bolgla and Uhl
2005).
The pelvic drop and single-limb deadlift exercises
(57% and 58% MVIC, respectively) had the highest
relative activation in this exercise tier. The pelvic
drop exercise specifically targeted the GMeds ability
to control pelvis-on-femur adduction and abduction,
which incorporated a combination of eccentric and
concentric muscle actions. The single-limb dead lift
task differed in that the GMed worked in an isometric
manner. Subjects performed this exercise by flexing
the hip enough to touch the long finger of one hand
on the ground. Like posterior displacement of the
bodys center of mass relative to the base of support,
anterior displacement from the stance limb would
require greater overall hip muscle activity. In
summary, these exercises would provide similar
strengthening effects as the others described above
and would provide clinicians another way for targeting
the GMed.
The very high-level tier of GMed activation
included the single-limb squat and the side-bri dge to
neutral spine position. Although the single-limb
squat is similar in some respects to exercises previously
described, subjects who performed the lunge, unilat-
eral mini-squat, and step-up exercises did so with
the trunk in a more vertical alignment over the
stance limb. This position differed from the single-
leg squat described by DiStefa no, Blackburn, Mar-
shall, and Padua (2009), who reported greater
GMed activity (64% MVIC) during a full single-leg
squat. Subjects in their study squatted low enough to
touch the long finger of one hand on the ground.
This larger excursion of the bodys center of mass
toward the ground would explain the relatively
higher GMed activity needed to stabilize the pelvis
and knee.
The side-bridge to neutral spine position exhibited
the highest GMed muscle activation (74% MVIC) of
all the exercises included in our review. Typically,
the lateral side-bridge exercise has represented a
more demanding spinal stabilization exercise targeting
the lateral abdominal muscles (Ekstrom, Donatelli,
and Carp, 2007; Ekstrom, Osborn, and Hauer,
2008). However, findings from this review further
highlight the stabilizing role of the GMed. The clini-
cian should carefully consider the prescription of this
and other high- to very-high level tier exercises later
in the rehabilitation process.
CONCLUSION
The purpose of this review was to analyze studies that
have evaluated activation of the GMax and GMed
during rehabilitation exercises. Our findings showed
how changes in the trunk position, movement
direction, and base of support can affect EMG
activity. EMG activity for these muscles ranged from
9% to 74% MVIC. It is noteworthy that strength
gains are expected for activation levels equal to or
greater than 40% MVIC (Ayotte, Stetts, Keenan,
and Greenway, 2007; Escamilla et al, 2010).
However, clinicians can still use the lower-level acti-
vation exercises to facilitate neuromuscular activation
(Ayotte, Stetts, Keenan, and Greenway, 2007) and
progress patients with marked GMax and GMed
weakness to more demanding tasks. Finally, the
clinician should note that subjects who performed
exercises included in this review were healthy. It
remains elusive if similar findings would result in
patients with pathology.
Declaration of interest: The authors report no
conflicts of interest. The authors alone are responsible
for the content and writing of the article.
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264 Reiman et al.
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Appendix I. EMG (%MVIC) for Gluteal Strengthening Exercises.
Physiotherapy Theory and Practice 265
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266 Reiman et al.
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Appendix II. Details of evaluated studies.
Study Exercise Included in Review Subjects
Ayotte et al. 2007 Gluteus Maximus
Unilateral mini-squat
Twenty-three physically active Department of Defense beneficiaries (16 males, 7
females; mean ± SD age, 31.2 ± 5.8 years; mean ± SD height, 173.1 ± 10.1
cm; mean ± SD body mass, 77.0 ± 13.9 kg) volunteered for this study.
Inclusion
-Age range, 1865 years
-Bilateral lower extremity range of motion within normal limits
-Bilateral lower extremity strength with manual muscle testing 5/5
-Able to perform single-limb balance with eyes open for 30 seconds
-Department of Defense beneficiary
Exclusion
-History of surgery for spine or lower extremities
-History of disease affecting the spine or lower extremities, such as diabetes,
peripheral neuropathy, stroke, arthritis, or fibromyalgia
-Unresolved lower extremity pathology or current pain in the spine or lower
extremities
-Taking any medications
Continued
Physiotherapy Theory and Practice 267
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Appendix II. Details of evaluated studies. Continued
Study Exercise Included in Review Subjects
Blanpied 1999 Gluteus Maximus
Wall squat
Twenty asymptomatic women (age = 31.3 ± 6.9 years, height = 160.9 ± 4.1 cm,
mass = 58.1 ± 8.7 kg) subjects.
Inclusion/exclusion criteria: No pathology, subjects over 170 cm tall were
excluded due to equipment size limitations.
Bolgla & Uhl, 2005 Gluteus Medius
Pelvic drop
Sixteen healthy subjects (8 men, 8 women; mean ± SD age, 27 ± 5 years; mean ±
SD height, 1.7 ± 0.2 m; mean ± SD body mass, 76 ± 15 kg) volunteers.
Inclusion/exclusion criteria: No lower extremity dysfunction and could safely
perform a single-leg stance on each lower extremity. Subjects were excluded if
they had a history of significant lower extremity injury or surgery in the
preceding year.
DiStefano et al, 2009 Gluteus Maximus
Side-lying hip abduction
Clam with 30° hip flexion
Clam with 60° hip flexion
Lunge
Sideways lunge
Transverse lunge
Gluteus Medius
Side-lying hip abduction
Clam with 30° hip flexion
Clam with 60° hip flexion
Lunge
Sideways lunge
Transverse lunge
Twenty-one healthy subjects (9 males, 12 females; mean ± SD age, 22 ± 3 years;
height, 171 ± 11 cm; mass, 70.4 ± 15.3 kg) volunteered to participate in this
study.
Inclusion/exclusion criteria: Subjects were recreationally active individuals
who participated in physical activity for at least 60 minutes, 3 days per week.
Ekstrom, Donatelli &
Carp, 2007
Gluteus Maximus
Prone plank
Unilateral bridge
Quadruped with
contralateral arm and leg lift
Lunge
Lateral step-up
Gluteus Medius
Side-lying hip abduction
Prone plank
Unilateral bridge
Bridging on stable surface
Quadruped with
contralateral arm and
leg lift
Side-bridge to neutral spine
position
Lunge
Thirty healthy subjects (19 males and 11 females; mean ± SD age 27 ± 8 years;
height,176 ± 8 cm; body mass, 74 ± 11 kg), participated in the study.
Inclusion/exclusion criteria:
Subjects were accepted for the study if they were in good health, with no
current or previous lower extremity or back problems. They were excluded if
they had low back or lower extremity pain, or any recent surgery.
Ekstrom, Osborn, &
Hauer, 2008
Gluteus Maximus
Bridge on stable surface
Bridging on Swiss ball
In group 1 there were 30 subjects (23 females, 7 males; mean ± SD height, 170 ±
6 cm; body mass, 64 ± 9 kg; age, 24 ± 4 years). Group 2 consisted of 29
subjects (12 females, 17 males; mean ± SD height, 175 ± 8 cm; body mass, 73
± 10 kg; age, 27 ± 8 years). In group 3 there were 30 subjects (20 females, 10
males; mean ± SD height, 171 ± 7 cm; body mass, 68 ± 9 kg; age, 26 ± 7
years).
Inclusion/exclusion criteria: Subjects were accepted for the study if they were
in good health, with no current back or lower extremity problems. Subjects
were excluded if they had any previous back surgery.
Farrokhi et al, 2008 Gluteus Maximus
Lunge
Lunge with forward trunk
lean
Lunge with backward trunk
lean
Ten healthy adults (5 males and 5 females) without a history of lower extremity
pain or pathology participated in this study (mean ± SD age, 26.7± 3.2 years).
Inclusion/exclusion criteria: Subjects were excluded from participation if they
reported having any of the following: (1) previous history of knee surgery, (2)
history of traumatic patellar dislocation, or (3) neurological involvement that
would influence performing the required exercises. The average ± SD height
and mass of the subjects were 1.73 ± 0.07 m and 62.5 ± 9.8 kg, respectively.
268 Reiman et al.
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... Various exercises such as single-limb squat, side-bridge, and www.nature.com/scientificreports/ forward step-up have been reported as exercises for strengthening the gluteus muscle 23 . However, it is crucial that the choice of exercise takes into account patient factors such as functional status, overall muscular strength, and postoperative health 23 . ...
... forward step-up have been reported as exercises for strengthening the gluteus muscle 23 . However, it is crucial that the choice of exercise takes into account patient factors such as functional status, overall muscular strength, and postoperative health 23 . As patients with ASD generally show degeneration and atrophy of the paraspinal muscle, and as they undergo the long-level spinal construct and fusion, the gluteal muscle exercise is based on the following protocol that modifies known exercises, while maximally preserving the neutral position of the lumbar spine: ...
... The known strengthening exercises for the gluteus muscle include lunge, bridging, squats, deadlifts, clams, leg presses, and step-ups. Reiman et al. 23 reported that, during rehabilitative exercises, a very high-level activation on the electromyography (EMG) was observed for the gluteus maximus muscle in the forward step-up and for the gluteus medius muscle in single-limb squat and side-bridge to neutral spine position. Neto et al. 30 also found that the step-up exercise and its variations presented the highest levels of gluteus maximus muscle activation. ...
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This study aimed to investigate the changes in gluteal muscle volume and the effects of such changes in spinal alignment as a result of postoperative gluteal muscle strengthening exercise (GMSE) in patients following long-segment fixation for adult spinal deformity (ASD). Eighty-three consecutive patients (average age, 70.1 years) were analyzed. Three-dimensional CT scans were conducted to obtain serial axial gluteus muscle image slices. The size of each muscle area in every image slice was measured by Computer Aided Design and the sum of each muscle area was calculated. At the last follow-up, the sagittal vertical axis was significantly greater in the basic postoperative exercise group (1.49 mm vs. 17.94 mm), and the percentage of optimal sagittal alignment was significantly higher in the GMSE group (97.8% vs. 84.2%). At the last follow-up, the gluteus maximus volume was significantly higher in the GMSE group (900,107.1 cm3 vs. 825,714.2 cm3, p = 0.036). For the increase in muscle volume after 1 year, gluteus maximus and medius volumes showed a significant intergroup difference (+ 6.8% vs. + 2.4% and + 6.9% vs. + 3.6%). The GMSE protocol developed in this study could effectively increase gluteal muscle volume and maintain the optimal sagittal balance in patients with ASD.
... A weak gluteus medius (Gmed) could disrupt movement and may lead to adverse alterations in lower extremity kinematics that increase the injury risk in players and result in deterioration in sports performance (Stastny et al. 2016). Gmed acts primarily by producing abduction at the hip joint and is critical for pelvic and lower limb (femur) stability during weight-bearing movements, such as the different actions required in field hockey (Ebert et al. 2017;Reiman, Bolgla & Loudon 2012;Stegeman & Hermens 2014;Van Putte et al. 2014). ...
... Weakness of Gmax and Gmed will result in compensatory movements of the lower back, hip and knee, notably a pelvic drop, excessive hip adduction, femoral internal rotation and an exaggerated knee valgus angle (Distefano et al. 2009;Macadam, Cronin & Contreras 2015;Reiman et al. 2012). Against this background, the hip extensors and abductors that support the lumbar spine structures of high-performance female field hockey players warrant investigation. ...
... Exercises that involve hip abduction are typically prescribed for strengthening Gmed, with the most common version being side-lying hip abduction (Distefano et al. 2009;Ebert et al. 2017;Reiman et al. 2012). However, we examined a side-plank version of hip abduction, because Boren et al. (2011) found that this version generated the highest %MVIC activation of the primary function of Gmed, namely hip abduction. ...
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Background: Field hockey, a team sport played by both men and women at both recreational and professional levels, requires maintaining a forward flexed posture putting stress on the lumbar spine. Hence, it is necessary to assess the muscles supporting the lumbar spine, especially those surrounding the hip, to inform strengthening exercises for this population. Objectives: To establish the best body weight rehabilitation exercises shown to produce high muscle activation (≥ 61%MVIC – maximal voluntary isometric contraction) for both the gluteus maximus (Gmax) and medius (Gmed) muscles. Four exercises fell into this category. Method: Surface electromyography (sEMG) was used to record the muscle activation of Gmax and Gmed of four body weight rehabilitation exercises in 26 high-performance female field hockey players. The %MVIC activation data of both Gmax and Gmed were analysed using a three-way ANOVA. Results: The single-leg squat generated the highest %MVIC activation of both Gmax (125.65%MVIC) and Gmed (126.30%MVIC). The only statistically significant difference for Gmax was between the single-leg squat and plank with hip extension (p = 0.0487). No statistically significant difference was observed for Gmed between the four body weight rehabilitation exercises (p = 0.6285). Conclusion: The four exercises generated similar %MVIC activation levels. The single-leg squat produced the highest observed %MVIC of Gmax and Gmed in high-performance female field hockey players and is, therefore, recommended. Clinical implications: Implementation of the findings could result in benefits during prehabilitation, injury prevention programmes and the later stages of rehabilitation for high-performance female field hockey players.
... EMG, kinematic, and kinetic data were collected during a double-leg squat and single-leg squat. These exercises were selected since they are commonly prescribed exercises in lower extremity rehabilitation programs (Boren et al., 2011;McCurdy et al., 2018;Reiman et al., 2012). The double-leg squat was performed with the feet pelvis width apart, parallel to one another, with one foot on each force plate. ...
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Given its tri-planar action at the hip, strengthening of gluteus maximus (GMAX) has been advocated as part of rehabilitation and injury prevention protocols for various musculoskeletal conditions. However, recruitment of GMAX during weight-bearing strengthening exercises can be challenging owing to the muscular redundancy at the hip for a given joint motion. The current study sought to determine if a 1-week activation program could result in greater GMAX recruitment during functional strengthening exercises. Pre- and post-training surface electromyography were collected from 12 healthy participants as they performed double- and single-leg squats. Between testing sessions, participants completed a GMAX activation training program consisting of isometric exercises with band resistance (twice per day for 7 days). Following the 1-week activation program, GMAX recruitment was found to increase by 57% during the double-leg squat (p = 0.005, Cohen’s r = 0.73) and 53% during the single-leg squat (p = 0.006, Cohen’s r = 0.70). Implementation of an initial GMAX activation program should be considered to facilitate neuromuscular adaptations that facilitate utilization of GMAX during hip strengthening exercises.
... Bir derlemede; öne doğru merdiven çıkma egzersizinin gluteus maximusun, tek bacak çömelme ve yan köp-rü pozisyonundan omurganın nötral pozisyona gelmesini sağlayan egzersizlerin ise gluteus mediusun güçlendirilmesinde en etkili olduğu raporlanmıştır. 36 Hasta egzersizler sırasında uygun pozisyonlamayla konumlandırılmalı ve bu pozisyonun korunmasına özen gösterilmelidir. Özellikle gluteus mediusun kalça fleksiyondayken sadece iç rotasyona destek verdiği bilinmektedir. ...
... Bir derlemede; öne doğru merdiven çıkma egzersizinin gluteus maximusun, tek bacak çömelme ve yan köp-rü pozisyonundan omurganın nötral pozisyona gelmesini sağlayan egzersizlerin ise gluteus mediusun güçlendirilmesinde en etkili olduğu raporlanmıştır. 36 Hasta egzersizler sırasında uygun pozisyonlamayla konumlandırılmalı ve bu pozisyonun korunmasına özen gösterilmelidir. Özellikle gluteus mediusun kalça fleksiyondayken sadece iç rotasyona destek verdiği bilinmektedir. ...
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... The STG and SPTG programs will be based on the training principles recommended by the American College of Sport Medicine (ACSM) [32]. The exercises were chosen based on a study that successfully applied the protocol to people with PFP [30] and other strength training studies [22,[42][43][44][45]. ...
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The organization of fibers within a muscle (architecture) defines the performance capacity of that muscle. In the current commentary, basic architectural terms are reviewed in the context of the major hip muscles and then specific illustrative examples relevant to lower extremity rehabilitation are presented. These data demonstrate the architectural and functional specialization of the hip muscles, and highlight the importance of muscle physiology and joint mechanics when evaluating and treating musculoskeletal disorders.
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Excessive flexion and internal rotation of the hip is a common gait abnormality among individuals with cerebral palsy. The purpose of this study was to examine the influence of hip flexion on the rotational moment arms of the hip muscles. We hypothesized that flexion of the hip would increase internal rotation moment arms and decrease external rotation moment arms of the primary hip rotators. To test this hypothesis we measured rotational moment arms of the gluteus maximus (six compartments), gluteus medius (four compartments), gluteus minimus (three compartments) iliopsoas, piriformis, quadratus femoris, obturator internus, and obturator externus. Moment arms were measured at hip flexion angles of 0, 20, 45, 60, and 90° in four cadavers. A three-dimensional computer model of the hip muscles was developed and compared to the experimental measurements. The experimental results and the computer model showed that the internal rotation moment arms of some muscles increase with flexion; the external rotation moment arms of other muscles decrease, and some muscles switch from external rotation to internal rotation as the hip is flexed. This trend toward internal rotation with hip flexion was apparent in 15 of the 18 muscle compartments we examined, suggesting that excessive hip flexion may exacerbate internal rotation of the hip. The gluteus maximus was found to have a large capacity for external rotation. Enhancing the activation of the gluteus maximus, a muscle that is frequently underactive in persons with cerebral palsy, may help correct excessive flexion and internal rotation of the hip.
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Controlled laboratory study using a repeated-measures, counterbalanced design. To test the ability of 8 Swiss ball exercises (roll-out, pike, knee-up, skier, hip extension right, hip extension left, decline push-up, and sitting march right) and 2 traditional abdominal exercises (crunch and bent-knee sit-up) on activating core (lumbopelvic hip complex) musculature. Numerous Swiss ball abdominal exercises are employed for core muscle strengthening during training and rehabilitation, but there are minimal data to substantiate the ability of these exercises to recruit core muscles. It is also unknown how core muscle recruitment in many of these Swiss ball exercises compares to core muscle recruitment in traditional abdominal exercises such as the crunch and bent-knee sit-up. A convenience sample of 18 subjects performed 5 repetitions for each exercise. Electromyographic (EMG) data were recorded on the right side for upper and lower rectus abdominis, external and internal oblique, latissimus dorsi, lumbar paraspinals, and rectus femoris, and then normalized using maximum voluntary isometric contractions (MVICs). EMG signals during the roll-out and pike exercises for the upper rectus abdominis (63% and 46% MVIC, respectively), lower rectus abdominis (53% and 55% MVIC, respectively), external oblique (46% and 84% MVIC, respectively), and internal oblique (46% and 56% MVIC, respectively) were significantly greater compared to most other exercises, where EMG signals ranged between 7% to 53% MVIC for the upper rectus abdominis, 7% to 44% MVIC for the lower rectus abdominis, 14% to 73% MVIC for the external oblique, and 16% to 47% MVIC for the internal oblique. The lowest EMG signals were consistently found in the sitting march right exercise. Latissimus dorsi EMG signals were greatest in the pike, knee-up, skier, hip extension right and left, and decline push-up (17%-25% MVIC), and least with the sitting march right, crunch, and bent-knee sit-up exercises (7%-8% MVIC). Rectus femoris EMG signal was greatest with the hip extension left exercise (35% MVIC), and least with the crunch, roll-out, hip extension right, and decline push-up exercises (6%-10% MVIC). Lumbar paraspinal EMG signal was relative low (less than 10% MVIC) for all exercises. The roll-out and pike were the most effective exercises in activating upper and lower rectus abdominis, external and internal obliques, and latissimus dorsi muscles, while minimizing lumbar paraspinals and rectus femoris activity. J Orthop Sports Phys Ther 2010;40(5):265-276, Epub 22 April 2010. doi:10.2519/jospt.2010.3073.
Article
To investigate whether females seeking physical therapy treatment for unilateral patellofemoral pain syndrome (PFPS) exhibit deficiencies in hip strength compared to a control group.
Article
Unlabelled: During the last decade, there has been a growing body of literature suggesting that proximal factors may play a contributory role with respect to knee injuries. A review of the biomechanical and clinical studies in this area indicated that impaired muscular control of the hip, pelvis, and trunk can affect tibiofemoral and patellofemoral joint kinematics and kinetics in multiple planes. In particular, there is evidence that motion impairments at the hip may underlie injuries such as anterior cruciate ligament tears, iliotibial band syndrome, and patellofemoral joint pain. In addition, the literature suggests that females may be more disposed to proximal influences than males. Based on the evidence presented as part of this clinical commentary, it can be argued that interventions which address proximal impairments may be beneficial for patients who present with various knee conditions. More specifically, a biomechanical argument can be made for the incorporation of pelvis and trunk stability, as well as dynamic hip joint control, into the design of knee rehabilitation programs. Level of evidence: Aetiology/therapy, level 5.
Article
The 21 muscles that cross the hip provide both triplanar movement and stability between the femur and acetabulum. The primary intent of this clinical commentary is to review and discuss the current understanding of the specific actions of the hip muscles. Analysis of their actions is based primarily on the spatial orientation of the muscles relative to the axes of rotation at the hip. The discussion of muscle actions is organized according to the 3 cardinal planes of motion. Actions are considered from both femoral-on-pelvic and pelvic-on-femoral perspectives, with particular attention to the role of coactivation of trunk muscles. Additional attention is paid to the biomechanical variables that alter the effectiveness, force, and torque of a given muscle action. The role of certain muscles in generating compression force at the hip is also presented. Throughout the commentary, the kinesiology of the muscles of the hip are considered primarily from normal but also pathological perspectives, supplemented with several clinically relevant scenarios. This overview should serve as a foundation for understanding the assessment and treatment of musculoskeletal impairments that involve not only the hip, but also the adjacent low back and knee regions.
Article
Weight-bearing exercises are frequently used to train and strengthen muscles of the hip. These exercises have been advocated in the rehabilitation of a variety of hip and knee dysfunctions. Limited evidence is available to describe the level of muscle activation occurring with specific weight-bearing exercises. The purpose of this study was to investigate the level of activation of the gluteus medius muscle as measured by electromyographic (EMG) signal amplitude in 5 weight-bearing exercises. Twenty healthy subjects aged 21 to 30 years participated in the study. The EMG surface electrodes were positioned over the muscle belly of the gluteus medius. Subjects performed 5 exercises that consisted of bilateral stance, single limb stance, single limb stance on both a firm surface and an Airex cushion, and single limb squat on a firm surface and an Airex cushion. Statistical differences (rho < 0.05) in gluteus medius EMG values were found between single limb stance as compared with double limb stance, and single limb squat as compared with single limb stance. Single limb stance places more demands on the gluteus medius than double limb stance, whereas single limb squats are more demanding than single limb stance. Although exercises performed on an Airex cushion produced greater EMG values as compared with a firm surface, the difference was not statistically significant. The results, however, suggest that if the goal is to increase the challenge to the gluteus medius, dynamic, single limb exercises performed on unstable surfaces, such as a balance cushion, may place greater demands on the gluteus medius than similar exercises performed on stable surfaces.