Sunday, December 11, 2016

The Eccentric & Running DPT Injury Prevention Corner: Hip Abductors

As a very dedicated runner and Doctor of Physical Therapy, injury prevention is a major priority. I hate being forced to take time off.  In the past (before DPT school) I suffered from almost chronic Iliotibial Band Syndrome (a big band of connective tissue that runs down the lateral side of each thigh) and many other runners I know suffer from a variety of hip, knee and ankle issues.  I have decided to begin a series of educational posts on how I personally keep myself and my clients as injury free as possible through a variety of prehabilitation exercises (get it?  Exercises you do before or to prevent the need for rehab?).  We all have biomechanical deficits that need continual work and maintenance.

Let's start with one of the more important areas, your hip abductors.

Source: www.denverfitnessjournal.com

Abduction describes movement away from the midline of the body. In relation to the femur/thigh, abduction of the hips involves the femur moving in a lateral based torque away from your center. Your primary abductor muscles Glute Med, TFL, Glute Minimus (and piriformis at many angles).  The gluteus maximus is also a hip abductor, but due to the many incredible things this muscle does (including hip extension, external rotation, abduction and at certain angles hip flexion and internal rotation.  More on that in another post.  The gluteus maximus can and should be activated by all the following exercises), I am going to save that for a special post.  This post will be about the primary hip abductor muscles.  These all work to control the medial, adduction or inward collapse of the femur throughout the gait cycle (usually during stance phase of walking or running).  Running is a series of single leg stances/hops. Having only one foot on the ground means that gravity is attempting to pull your body down or collapse toward the opposite leg (that is off the ground). Without your hip abductor muscles, you would either fall or more commonly, your femur would collapse medially (inward). These muscles are very important to keeping your knees, hips and back stable and in line while you run. Weak hip abductor muscles contribute to collapse of the pelvis, femur, knee and back (and ankle actually due to connections to knee mechanics) with every footstep. Now take in the fact that running is 3-4x the amount of force with each footstrike compared to walking. Now multiply that amount of force combined with collapse of your spine, knees, hips and ankles over 1 mile, 3.1 miles, 6.2 miles, 13.1 miles, 26.2 miles.... now being injured, having knee, ankle or back pain isn't so surprising is it?

So let's talk about these muscles.

Gluteus Medius: The largest and primary hip abductor.  Per Neumann (2010), the gluteus medius makes up 60 % of the cross sectional area of the hip abductors.  So emphasis on the primary hip abductor.  The gluteus medius is a muscle of several tricks too.  The anterior fibers abduct and internally rotate the femur, while the posterior fibers externally rotate and extend the femur.

Gluteus Minimus: A smaller hip abductor that mostly functions to work with the Gluteus Medius.  Per Neumann (2010), the gluteus minimus makes up 22% of the cross sectional area of the hip abductors (down from 60% for the gluteus medius).   It primarily functions to assist the gluteus medius with abduction but also internally rotates the femur 

Tensor Fascia Latae (or Tensor Fascia Latte, but no one wants to drink that): This is the SMALLEST hip abductor.  In addition to hip abduction, the TFL also flexes and internally rotates the hips.  Per Neumann, the TFL makes up 11% of the total abductor cross sectional area.  So this muscle has the least amount of surface area to contribute to hip abduction.  The TFL is interesting as it inserts mainly onto the iliotibial band, which extends down the lateral knee.  Can you understand why this muscle can get so strained when the glutes aren't doing their job and then why IT Band issues arise?  Because it has such a small surface area and is such a minor hip abductor that it becomes it cannot measure up to what the gluteus medius is supposed to do.  So when it does, problems start occurring because it cannot keep up and the structures (TFL and ITB) become overstressed and overworked.  So maybe instead of foam rolling that IT band you should look to where the source of the problem may be (not saying foam rolling is bad, just that you should always seek to treat the source, not the symptoms of the problem).  

So now you know a little more about the anatomy and function of these hip abductor muscles.  They do a little of everything.  Hip abduction (all), hip flexion (TFL), hip extension (gluteus medius), internal rotation (all) and external rotation (gluteus medius).  This also changes depending on the position of the hip when you get past about 60-70 degrees of hip flexion, but that is a post for another time.

So what are some of my favorite exercises for the hip abductors to keep that leg stable during single limb stance?  There is no such thing as the best exercise (I always caution people to be wary of "gurus" who say they have found the best of something.  They tend to be full of it) as it is always best to have a little variety, as evident by the multi-functional aspects of this muscle group.  Here are some of my favorites.

1. Sidelying Hip Abduction or Sidelying Lateral Leg Raise





     This has always been one of my favorite hip abductor exercises, but most people will miss the subtly of how to do this correctly.  This motion is in pure abduction, so it a great way to train the hip abductors (duh).  First of all, adding some hip internal rotation (turn your foot downard) will help hit all three hip abductors (since all three contribute in some way to internal rotation of the hip/femur).  Second of all, DON'T MOVE YOUR TRUNK!  The biggest mistake I see is people using a hip hike and pulling in their lateral back muscles (quadratus lumborum especially) to lift the hip.  Put a hand on your hip and don't let that pelvis move.  The goal is to stabilize the pelvis, so make sure it is stable first!  

If the normal open chain (non-weight bearing) becomes easy, put a towel on the wall and push it up the wall (feet on the wall) to add additional resistance and a weight bearing component.  OR perform hip abduction in standing with a theraband.  Trick of the trade?  In standing when you perform hip abduction, the stance leg (leg not moving) will actually have the most gluteus medius activity as the weight bearing increases joint forces and improves muscle activation.  If you really want to make a muscle stronger, you need to continue to find ways to challenge it.
2. Clamshells and Monster Walks


Honestly this is one of my least favorite hip abductor/external rotator muscle exercises (I am including this one because it is so common).  It is good for initial activation of some of these muscles, but I usually progress patients/clients away from this fairly quickly.  Make sure you keep those hips rolled forward and as always keep the trunk stable to make sure you are emphasizing the gluteus medius.  The external rotation component of this exercise does not make it very functional and generally it only hits the gluteus medius.  However, if you roll your hips backward, you will get the TFL to kick in to assist with the minor hip abduction.  Overall this is a better hip external rotation than hip abductor exercise.  Keep your feet together too and press through that top foot to add a minor weight bearing component (emphasis on minor).

                 

                                               
Now Monster Walks?  These are quality.  Hip abduction in weight bearing?  Oh yeah.  Hip Abduction with resistance?  Even better.  Subtle things to remember with this one?  Keep your trunk stable and upright.  I see a great deal of compensation again with lateral back muscles, which makes the individual look like they are teeter tottering back and forth.  This should look smooth with a straight stable trunk and motion occurring from the hips. 

3.  Side Planks


Another one of my favorites.  Why? Because this really challenges both the core and the hip abductors (and actually makes for a killer shoulder stability exercise too).  Guess what?  Muscles don't work in isolation.  The majority of movements in sport and daily life are combinations of movements.  The problems arise when components start getting lost due to movement dysfunctions, weaknesses, etc (ie where my profession comes in).  There are some subtle things to be aware of to make this exercise truly effective.  As per usual, keep your trunk straight and don't let your hips sag.  And when I say sag, I mean both downward and backward.  This is a fairly challenging exercise and requires extensive preparation to perform correctly.  However, it provides a great challenge to the hip abductors to really work as stabilizers.  Want to make it more challenging?  Do hip abduction/lateral leg raises of the top leg.   


Having a little trouble getting your hip abductors to turn on doing the side plank?  Try doing it from your knees instead of your feet..  That reduces the moment arm and may mean that you need to progress up to the full side plank. 


There are endless other hip abductor exercises but these have been some of my go to for a while.  These are not the be all end all, but they are a good place to start.  The hip is part of what I consider the core of your body.  It functions both to keep the lower leg as well as the lower back stable.  The connections of these muscles to both the pelvis and femur make them importance stabilizers of both as well.  Neglecting these muscles and letting them become weak puts a great many structures at risk and puts even at and even greater risk of compensation with other muscles that do not have the connections or the set up to perform these jobs.  Compensation is rarely a good thing.  Making sure every muscle is contributing in the correct manner to movement is a great way to work toward injury prevention.  When the body has to compensate, it will sacrifice force production for protection.  So you want to run faster?  First you have to have stability.  Trying to generate a great deal of power on an unstable surface is a great way to reduce the amount you actually create.  

Get out there and keep building that running body!

Thanks for reading and don't forget to tack on!  

As always, my views are my own.  My blog should not and does not serve as a replacement for seeking professional medical care.  I have not evaluated you in person, am not aware of your injury history and personal biomechanics, thus am not responsible for any injury that you may incur from th performance of the above.  I have not prescribed any of the above exercises to you and thus again am not responsible for any injury that may occur from the performance of the above.  This blog is meant for educational purposes only.  If you are currently injured or concerned about an injury, please see your local physical therapist.

-Dr. Matthew Klein, PT, DPT

Sources:

Neumann, D. (2010). Kinesiology of the Musculoskeletal System 2nd Edition. St. Louis, Missouri:  Mosby Elsevier, 


Dicharry, J. (2012). Anatomy for Runners.  New York, NY: Skyhorse Publishing.

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