Guest Writer #3 ‘(Lateral) Hips Dont Lie'
Back in 2005 when Strength and Conditioning was really still in its infancy, a wise woman once said “my hips don’t lie” and just over 15 years later, I think she may still have a very valid point.
Unlike Shakira whose career path is somewhat different to my own, like most who work in a rehab setting, a common phrase I hear is “my last *insert physio/S&C/therapist etc* also said I have weak hips/glutes”. I also hear this across a wide variety of injury complaints, particularly in athletic groin pain, low back pain and knee related pain/injuries. I think what this means (generally speaking) is it is therefore fairly common that this area is undertrained in the rehab/training process. In simple terms, I don’t think this area is trained hard enough. Shakira FC 1 – Rehab and Training Principles United 0.
The three main principles I’d say drives the success of the rehab/training process, regardless of injury status, are assessment, anatomy and adaptation. The “3 As’ if you will.
In this article, I am going to focus on anatomy and adaptation of the lateral hip and glute musculature. This is mainly because every assessment should be unique to the athlete/patient based on how they present and the information they provide, which will drive your assessment process to determine potential pathologies/diagnosis which ultimately guides your training/rehabilitation process.
Anatomy
The main muscular structures this article will discuss are the gluteus maximus (GMax), gluteus medius (GMed) and gluteus minimus (GMin). Together, they help allow the femur to be moved through all three planes of motion (sagittal, frontal and transverse), which means that the hip musculature contributes in all lower limb movements such as running, moving side-to-side and changing direction. These global movements will require a variety of hip flexion, extension, internal/external rotation, abduction and adduction dependent on the task. This will often lead to rapid transitions between two positions, for example hip extension in to hip flexion whilst sprinting and as such, the hip musculature has to allow strength and stability in these positions, whilst transitioning to the other.
GMax is the largest of the hip muscles that are being discussed. It primarily contributes to hip extension. It also provides stabilisation to the knee laterally, via the formation of the iliotibial tract/band (for those with knee pain, you may have been told your “IT Band is tight”!).
GMed and GMin primarily act as abductors (moving the leg away from the body). When running, as the foot makes contact with the ground these muscles work to resist adduction (moving the leg towards the body) and have to work eccentrically and rapidly to stabilise the pelvis. When this is less efficient, you can see the opposite hip drop, which is known as contralateral hip drop. I would again typically see this as a common issue across general public and athletic populations and is often exacerbated in those who have low back and lower limb injuries who demonstrated reduced strength levels in the lateral and posterior hip in their assessment. As a side note, it is important to know that GMin is more anterior anatomically in relation to GMed – the importance of this will be touched on more later.
Adaptation
Now we have a general overview of lateral hip and glute anatomy, the focus has now shifted on to what adaptations we are looking to influence in these muscles. The biggest clue that I can give is that 3x10 bodyweight clam type exercises are not the answer!
That’s not to say that that exercise does not have its place for a different person, my point is that past a certain point, this alone will not stress these muscles enough to lead to a positive and continued adaptation – particularly in athletic populations. I’m not sure why, but I find the principle of progressive overload is often overlooked when it comes to lateral hip and glute exercises – we wouldn’t get an individual to squat the same amount of weight, for the same amount of sets and reps, at the same speed multiple times a week month after month and I think lateral hip and glute training should be treated exactly the same!
Broadly speaking, the adaptation we are looking to target is an increase in strength, or perhaps more importantly the speed at which this strength is recruited. Its important to understand that strength development/training is on a continuum and to an extent the “type of strength” we need to develop may vary slightly depending on the individual – for example an elderly person following a total hip replacement does not need the same level nor type of hip strength that a high level team sport athlete does but they both need some form of strength training nonetheless.
In layman’s terms I tend to explain these types of strength adaptations in two main areas for patient/athlete education. Simply put, I usually explain that I am looking to improve the overall amount of strength that that muscle(s) can produce (motor unit recruitment e.g. a near-maximal to maximal effort squat) or that I am trying to improve how fast that muscle(s) can access the strength it needs for a given task (rate coding e.g. bodyweight jump squat). I think a good analogy is that increasing motor unit recruitment is like putting a bigger engine in your car. Rate coding is like how fast your car accelerates. A bigger engine will naturally mean you have more potential to accelerate faster, but this doesn’t matter if you don’t practise driving fast! I think training should reflect this. If you want to be strong, train strong. If you want to be fast, train fast. Of course and more often than not, some people will need a bit of both.
N.B. I’m aware this is a massive oversimplification of strength training but I feel this approach helps define clear outcomes with the patients/athletes I work with and improves their understanding of the “why”!
Exercise Prescription/Selection
For the final part of this article, I am going to give some examples of exercise I have found to be of great benefit to a wide range of patients/athletes, along with the prescription and a bit about why I feel that prescription matches the targeted adaptation.
Banded Clam
This is one that always divides opinion. The marmite of glute/lateral hip training. I’ll stick my neck on the block and say I like it – like anything it has a time and a place as long as it is progressively overloaded and fits the individual’s needs/programme!
My preferred method for this exercise is high levels of time under tension. This should allow strength adaptations focused on motor unit recruitment. A prescription I like to use is a 10 second isometric hold followed by 10 reps, one full set would see this repeated 2-3 times. I’d then have a patient completed 2-4 sets of that, potentially biasing one side more if there is any asymmetry. See the video below!
Note: the isometric hold should be an active pulling against the band for the duration prescribed – not just holding the leg up waiting for it to end like a dog marking it’s territory!
Hip Hitch
One that is harder than it looks… if done correctly and made difficult! When done correctly, this should bias GMin more. This goes back to understanding anatomy of the lateral hip. GMin inserts in to the anterolateral aspect of the greater trochanter, meaning it sits more anteriorly than GMed. The anterior fibres of GMin act as an internal rotator of the hip. As a combination of the insertion point and the action of the anterior fibres, the Hip Hitch should be completed in internal rotation of the hip – to help cue this with patients/athletes, I normally ask them to keep their hips facing 12 o’clock and when working the right hip, the foot should be turned towards 10/11 o’clock and when working the left hip, the foot should be turned in towards 1/2 o’clock.
My preferred method is working to fatigue on hip hitch variations, again increasing the amount of time spent under tension – a nice way to view GMin is similar to the posterior rotator cuff of the shoulder – it primarily acts as a stabiliser and is more resistant to fatigue than larger torque producing musculature and should be trained accordingly.
Single Leg Hip Thrust
Along with a single leg RDL, this is probably one of my favourite unilateral strength exercises. It is also one that I often see being done poorly and more often than not, the issue I mainly see is the exercise being lumbar dominant. Key thing for this is to keep the ribs down and to set the pelvis in posterior tilt before extending through the hip. On this, I like to use cues that get the patient/athlete to focus on closing the gap between their hips and ribs as they extend the hip to the ceiling. With the correct pelvis position maintained throughout extension, the patient/athlete should not feel this in their lower back – once the position is set, I will often borrow a cue from our Head of Performance at the Sports Surgery Clinic, Enda King, which is to “keep your belt buckle up” and this should help maintain the lumbopelvic position throughout the movement. I also like this exercise as the lateral hip has to work hard to avoid the contralateral hip dropping which would lead to external rotation of the working hip – as such the hip musculature has to facilitate internal rotation of the hip to resist this movement and as discussed above, we know GMin acts as an internal rotator, as do the anterior fibres of GMed.
Switch Step
This is great one for coordination/patterning, hip lock and rate of force development. This goes back to my early comment on how I phrase the “why” to patients/athletes. The focus on this is on how fast we can get to that position, as opposed to training their maximal amount of strength/force required – for example a Switch Step compared to a heavy single leg press. Specifically at the lateral hip, I’m looking for the patient/athlete to be able maintain their position as they strike the floor, meaning they would be locking the hip quickly to resist contralateral hip drop and adduction of the ipsilateral hip (same side/working hip). I think these are a great place to start before advancing on to more complex running mechanics drills such A Skips and Bounding as it should provide a solid foundation for pelvic stability and allow greater absorption and transference of the forces we are exposed to whilst running.
Finally, thanks for reading my ramblings on the lateral hip and thanks to Paul for inviting me to share my thoughts. I guess to summarise, I find this is a misunderstood and often under appreciated part of rehab and training, for both general and athletic populations and shouldn’t be left by the way side. The key is to remember that it should be progressively overloaded, as should any other component of rehab or athletic performance and this should be constantly guided by our understanding of anatomy, adaptation and our assessment process. I’ve also given some examples on exercises I have used and continue to use for a wide range of injury complaints, along with what adaptations I am aiming to develop. Like anything, it is also important to remember this is one part of the rehab/athletic performance puzzle and naturally there are other important considerations across individuals and their rehab/training needs, which is beyond the scope and focus of this article; but if in doubt just remember, “(Lateral) Hips Don’t Lie”!
Cheers,
