Ebert JR, Edwards PK, Fick DP, Janes GC. A systematic review of rehabilitation exercises to progressively load gluteus medius. J Sport Rehabil. 2017;26:418–436.
Clinical Question: How should clinicians correctly develop and implement a progressed therapeutic exercise program for gluteus medius activation?
Data Sources: Reviewers performed a comprehensive search of the following electronic databases: Medline, SPORTDiscus, Scopus, CINHAL, and EMBASE. The literature search included combined words and truncated forms of words. The search terms were glut*, medius, hip abduct*, exercis*, resist*, rehab*, physical therapy, strength*, load*, training, electromyo*, and EMG.
Study Selection: The initial literature search included 2,074 articles. After removing duplicate articles, the number was reduced to 435. A total of 41 articles were selected for full-text review. Following review, 20 were selected based on inclusion/exclusion criteria.
Data Extraction: One reviewer completed data extraction. This information included subject demographics, standardization and collection methods for electromyography, limb evaluation, protocol for each subject evaluation, and the evaluation of rehabilitative exercises. Finally, rehabilitation exercises were categorized by exercise and percent of maximal volitional isometric contraction (MVIC) low (0% to 20%), moderate (21% to 40%), high (41% to 60%), and very high (> 61%).
Main Results: The authors identified 20 articles that evaluated 33 rehabilitation exercises for gluteus medius activation. In general, exercises specific to prone, quadruped, and bilateral bridging produced low to moderate muscle activation. Moderate, high, or very high muscle activation was produced by hip rotation and abduction exercises. Rehabilitative exercises that focused on unilateral stances and incorporated contralateral limb movements produced the highest gluteus medius activation most often. Moreover, functional weight-bearing exercises produced the most variability across levels of gluteus medius activation.
Conclusions: Exercises commonly implemented for the rehabilitation of the gluteus medius are outlined in this systemic review. The review will assist clinicians who are helping patients through a rehabilitative program targeted at the loading progression of the gluteus medius.
Summary: The gluteus medius plays a key role in the functional stability of the pelvis and lower extremities.1 Weakness or neuromuscular inhibition of the gluteus medius can result in detrimental effects for physically active populations. These deficits can predispose patients to lower extremity injuries and lower back pain.2 The risks of acute, lower extremity injuries can be reduced by using prevention programs that focus on strengthening or neuromuscular facilitation of the gluteus medius. Moreover, the same goals can be applied to patient cases in which a chronic injury of the lower back or extremity may be linked to poor pelvic stability, which negatively affects the kinetic chain.
Clinicians routinely use a graduated series of therapeutic exercises. Literature supports using varied sub-maximal loads to achieve different therapeutic goals. Loading at levels of less than 25% MVIC can help to enhance endurance capacity or stability maintenance, and loading at levels of 40% or greater may improve muscular strength. Proper development of the intervention plan allows clinicians to achieve their clinical goals using a systematic approach.3 To aid in the developmental process, previous studies categorized therapeutic exercises into four different muscle loading groups: low (0% to 20% MVIC), moderate (21% to 40% MVIC), high (41% to 60% MVIC), and very high (> 61% MVIC).4,5
A variety of factors affect the loading activity of the gluteus medius, including the type and complexity of exercise, patient position, surface, and limb support. Current clinical practice involves the manipulation of these variables to achieve specific therapeutic goals, challenge the patient, and establish functional or activity-specific components to progress through the intervention plan. However, if the exercise selection does not consider gluteus medius activation, then therapeutic goals such as neuromuscular facilitation with low muscle activation exercises (0% to 20% MVIC) may not be accomplished. This phenomenon is attributed to deactivation following injury or inhibition from chronic overuse. Following the reestablishment of neuromuscular control, the patient should progress to exercises that produce moderate (21% to 40% MVIC) and high (41% to 60% MVIC) muscle activity. In the latter, patients begin to accomplish the therapeutic goal of strength gain. The continuation of therapeutic progression allows patients to perform exercises that require a significant activation of the gluteus medius.3
The systematic review included 20 original research articles and evaluated 33 rehabilitative exercises. A quality assessment tool was not applicable to this review. The research articles included participants who were injury free and focused on gluteus medius activation by means of electromyography (EMG). Case reports, non-peer reviewed studies, and general reviews were excluded. Following data analysis, the authors grouped exercises according to type. Five groups were established: prone and quadruped, bridging, hip abduction/rotation, weight-bearing (standing), and weight-bearing (functional). Using EMG results from each included study, the authors determined the level of muscle activation produced from each exercise.
Of the five prone and quadruped exercises, the majority of results demonstrated moderate muscle activation. Bilateral bridge exercises reported moderate muscle activation and single-legged bridge exercises reported high to very high muscle activation. Adding hip movement to the non–weight-bearing extremity increased the level of muscle activation to very high. Exercises that focused on hip abduction provided the patient with moderate to high muscle activation of the gluteus medius.
Finally, the authors looked at static and functional weight-bearing exercises. Static exercises required moderate to high muscle activation. Muscle activation increased when the non–weight-bearing extremity moved out of neutral position. Functional weight-bearing exercises provided the greatest degree of variance for muscle activity. The variability in gluteus medius activation for functional weight-bearing exercises is likely due to the number of variables that affect the difficulty of the exercises.
Examples of exercise variables with variance in gluteus medius activation included unilateral versus bilateral stance, stable versus unstable surface, freestanding squat versus ball-assisted squat, directional plane of lunges, hops, and banded walks. The majority of exercises observed in this category ranged from moderate (frontal plane banded walk) to high (unilateral squat on unstable surface) muscle activity with a few patients who reported low (bilateral ball-assisted wall squat) and very high (lateral step-ups) muscle activity.3
The results of this systematic review provide multiple areas of clinical knowledge pertaining to the aforementioned clinical question. First, the type of exercise and exercise variables are the most significant factors influencing gluteus medius activation. Variables to consider for static weight-bearing exercises include bilateral versus unilateral stance and stable versus unstable surface. For prone, quadruped, and bridging exercises, clinicians should consider hip and knee positioning (flexion versus extension) and bilateral versus unilateral stance. Related to hip abduction or rotation exercises, hip positioning is the sole variable (neutral versus flexion). Pertaining to specific exercises, unilateral bridges, unilateral freestanding squats, band walks, step-ups, and hops produce the greatest amount of muscle activation. Interestingly, single-legged bridges required more gluteus medius muscle activation than the majority of functional weight-bearing exercises. Athletic trainers traditionally integrate functional exercises, which mimic activity-specific demands, into the final stage of therapeutic progression. In this systematic review, functional weight-bearing exercises seldom produced the most gluteus medius muscle activation.
Clinicians must understand the level of gluteus medius muscle activation during each therapeutic exercise to develop an injury prevention protocol or therapeutic intervention plan that best aligns with the patient's impairment, functional limitations, and disability-related goals. The injuries to lower extremities associated with gluteus medius weakness include patellofemoral pain, lower back pain, and medial tibial stress syndrome. As clinicians seek to provide care to patients for pathologies distal to the hip, such as the knee, lower leg, and ankle, it is important to consider a graduated progression of therapeutic exercises for the gluteus medius to reduce the risk of hip abductor weakness. Examples of this progression include bilateral supine bridges, prone hip extensions with the knee flexed at 90°, unilateral squats on an unstable surface, and lateral step-ups.
- Leetun DT, Ireland ML, Willson JD, Ballantyne BT, Davis IM. Core stability measures as risk factors for lower extremity injury in athletes. Med Sci Sports Exerc. 2004;36:926–934. doi:10.1249/01.MSS.0000128145.75199.C3 [CrossRef]
- Cooper NA, Scavo KM, Strickland KJ, et al. Prevalence of gluteus medius weakness in people with chronic low back pain compared to healthy controls. Eur Spine J. 2016;25:1258–1265. doi:10.1007/s00586-015-4027-6 [CrossRef]
- Ebert JR, Edwards PK, Fick DP, Janes GC. A systematic review of rehabilitation exercises to progressively load gluteus medius. J Sport Rehabil. 2017;26:418–436. doi:10.1123/jsr.2016-0088 [CrossRef]
- Reiman MP, Bolgla LA, Loudon JK. A literature review of studies evaluating gluteus maximus and gluteus medius activation during rehabilitation exercises. Physiother Theory Pract. 2012;28:257–268. doi:10.3109/09593985.2011.604981 [CrossRef]
- Philippon MJ, Decker MJ, Giphart JE, Torry MR, Wahoff MS, LaPrade RF. Rehabilitation exercise progression for the gluteus medius muscle with consideration for iliopsoas tendinitis: an in vivo electromyography study. Am J Sports Med. 2011;39:1777–1785. doi:10.1177/0363546511406848 [CrossRef]