Weak Butt Epidemic

There is no shortage of research showing the importance of having a strong and active butt. Many sources of pain and injury can be attributed to poor gluteal strength, endurance or muscle control. I see patients every day with low back1-4, knee5-13, hip14-16 or ankle17-19 pain and many of them have a common contributing factor—they don’t use their butt. In this article I refer to the buttocks as a gluteal complex, rather than speaking about the separate gluteal muscles—gluteus maximus, gluteus medius and gluteus minimus. I use this terminology because the gluteal muscles need to work together and when one muscle isn’t doing its part, the system fails to work effectively. Another reason for this term is that many people misunderstand how to test and train these muscles individually. The gluteus maximus is often a culprit when gluteus medius or minimus is being treated and the ability to detect poor muscle control between gluteus medius and minimus is often a best guess. For those wishing to dive further into the research on this topic, please see the references listed at the end of this article.

I have seen many interesting cases of misdiagnoses when athletes arrive in my clinic for ankle and knee pain. I had one case where a basketball player had been through two ankle surgeries at the age of 19. He went through extensive post-surgical rehabilitation and recovery. His ankles were strong and he had great balance but there was a problem—he still had ankle pain and couldn’t run or cut. When I asked him to squat on one leg he nearly fell to the ground. He looked like one of those air dancers you seen in front of a used car lot. After strength testing his hip we both realized just how weak the gluteal muscles were. 12 weeks later he was playing basketball again with no limitations.

Pictures by: By Beth ohara (raster), Offnfopt (vector), CC BY-SA 3.0,https://commons.wikimedia.org/w/index.php?curid=62915331CC,  BY-SA 3.0,https://commons.wikimedia.org/w/index.php?curid=545381

When the gluteal complex is weak or under poor control the lower body can pay the price. Learning how to train these muscles can make a huge difference in pain and the performance of your core, thighs, legs and ankles. Once you check out the anatomy of these muscles you quickly realize the gluteal complex is a stabilizer of the pelvis, sacrum and hipsPictures by: By Beth ohara (raster), Offnfopt (vector), CC BY-SA 3.0,https://commons.wikimedia.org/w/index.php?curid=62915331CC,  BY-SA 3.0,https://commons.wikimedia.org/w/index.php?curid=545381

Jumping with poor gluteal control can result in the knees collapsing inward. The leads to a significant loss of power generation and excess stress and strain to the neighboring joints and muscles. When the gluteal muscles are poorly utilized, the bones will start to use these muscles as rubber bands to essentially “hang out” on. An easy way to picture this is to imagine yourself standing for a long period of time. What do you do? Do you stand with equal weight in both feet? If you never break from this position, congratulations, you’re a stud! Most of us will stick our hips out to the side and bend one of our knees, placing most of our weight on one leg. When we do this, we are hanging out on our hip and butt! This “Hips out to the side” stance allow two gluteal muscles— gluteus medius and minimus, to take a break and for us to hang on their tendons like rubber bands!

Let’s review this concept of gluteal muscle control. Motor control is largely driven from the nervous system and is essentially the brain to body connection. An important term to understand here is a motor unit—a muscle feeding nerve and all the muscle fibers it activates. You can improve how well your brain activates your muscles by increasing how many motor units are activated and how frequently you activate them.

How do you activate your muscles? There are two things to remember, exercise choice and the type of contraction. To maximize muscle activation in an exercise, research shows isometric—non-moving contractions, are the best. As for the type of exerciser, we have EMG studies that show which exercises allow the most gluteal muscle activation. Combine isometrics with the exercises shown to have good gluteal activation and you have a great combination! Try these exercises to get you started.

  1. Gluteal Bridge (knees past 90 degrees for better gluteal activation)
  2. Fire hydrant
  3. Side lying hip abduction
  4. Front plank with hip extension

Make sure you squeeze to activate the buttock with each exercise and you need to feel this in the buttocks! If you don’t feel it in the right area, you are not performing the exercise correctly and need to adjust your position or drop down to an easier exercise. Start with 2 sets of 15-30 second holds for each exercise, once a day. Progress after 2 days by adding a third set. Then add 5-10 seconds to the hold time for each set, every day. (Example—3 sets of 30 seconds on Monday, 3 sets of 40 seconds on Tuesday, etc) Do this until you reach about a minute for each set, then move on to the harder exercises.

  1. Single leg Gluteal Bridge (knees past 90 degrees for better gluteal activation)
  2. Single-leg squat
  3. Cross-over step-up
  4. Side plank with hip abduction

For the advanced exercises try performing slow reputations rather than isometric(holding) exercises. I mentioned isometric exercises are the best for muscle activation, however, once you improve the ability to activate these muscles with isometrics, it’s time to progress with higher level exercises! Advancing your exercise program beyond isometrics provides a more functional benefit, and lets ne honest, they are less boring. People commonly ask the question, “What is the best exercise.” My answer is simple—The one you will do! I have listed some exercises below and I encourage everyone to try to find a way to integrate these exercises or similar movements into their regular routine. Don’t find yourself performing “Rehab exercise” in addition to “Your routine” as this plan usually doesn’t last.

Notice I used the term, “Muscle activation.” I use this term because there is now a large focus to muscle activation and unfortunately there are providers ready to charge people to activate their muscles for them. The charge is typically per muscle activated and can result in a big bill. My opinion—this is a good example of overutilization in healthcare! Many people are able to do this on their own by using the right positions and exercises. I hope this article was helpful. Please subscribe for more information about common musculoskeletal conditions, injury prevention, athletic performance and injury management. Enjoy the day and share this knowledge with your friends!

Research List

Low Back pain

  1. 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(4):1258-65.
  2. Penney T, Ploughman M, Austin MW, Behm DG, Byrne JM. Determining the activation of gluteus medius and the validity of the single leg stance test in chronic, nonspecific low back pain. Arch Phys Med Rehabil. 2014;95(10):1969-76.
  3. Amabile AH, Bolte JH, Richter SD. Atrophy of gluteus maximus among women with a history of chronic low back pain. PLoS ONE. 2017;12(7):e0177008.
  4. Massoud arab A, Reza nourbakhsh M, Mohammadifar A. The relationship between hamstring length and gluteal muscle strength in individuals with sacroiliac joint dysfunction. J Man Manip Ther. 2011;19(1):5-10.

Knee Pain

  1. Kollock RO, Andrews C, Johnston A, et al. A Meta-Analysis to Determine if Lower Extremity Muscle Strengthening Should Be Included in Military Knee Overuse Injury-Prevention Programs. J Athl Train. 2016;51(11):919-926.
  2. Lack S, Barton C, Sohan O, Crossley K, Morrissey D. Proximal muscle rehabilitation is effective for patellofemoral pain: a systematic review with meta-analysis. Br J Sports Med. 2015;49(21):1365-76.
  3. Thomson C, Krouwel O, Kuisma R, Hebron C. The outcome of hip exercise in patellofemoral pain: A systematic review. Man Ther. 2016;26:1-30.
  4. Alba-martín P, Gallego-izquierdo T, Plaza-manzano G, Romero-franco N, Núñez-nagy S, Pecos-martín D. Effectiveness of therapeutic physical exercise in the treatment of patellofemoral pain syndrome: a systematic review. J Phys Ther Sci. 2015;27(7):2387-90.
  5. Lankhorst NE, Bierma-zeinstra SM, Van middelkoop M. Factors associated with patellofemoral pain syndrome: a systematic review. Br J Sports Med. 2013;47(4):193-206.
  6. Nunes GS, Barton CJ, Serrão FV. Hip rate of force development and strength are impaired in females with patellofemoral pain without signs of altered gluteus medius and maximus morphology. J Sci Med Sport. 2017;
  7. Ramskov D, Barton C, Nielsen RO, Rasmussen S. High eccentric hip abduction strength reduces the risk of developing patellofemoral pain among novice runners initiating a self-structured running program: a 1-year observational study. J Orthop Sports Phys Ther. 2015;45(3):153-61.
  8. Willson JD, Kernozek TW, Arndt RL, Reznichek DA, Scott straker J. Gluteal muscle activation during running in females with and without patellofemoral pain syndrome. Clin Biomech (Bristol, Avon). 2011;26(7):735-40.
  9. Nessler T, Denney L, Sampley J. ACL Injury Prevention: What Does Research Tell Us?. Curr Rev Musculoskelet Med. 2017;10(3):281-288.

Hip Pain

  1. Allison K, Bennell K, Vicenzino B, et al. Hip Abductor Strength In Individuals With Gluteal Tendinopathy: A Cross-sectional Study Br J Sports Med 2014;48:A6-A7.
  2. Allison K, Vicenzino B, Wrigley TV, Grimaldi A, Hodges PW, Bennell KL. Hip Abductor Muscle Weakness in Individuals with Gluteal Tendinopathy. Med Sci Sports Exerc. 2016;48(3):346-52.
  3. Allison K, Bennell KL, Grimaldi A, Vicenzino B, Wrigley TV, Hodges PW. Single leg stance control in individuals with symptomatic gluteal tendinopathy. Gait Posture. 2016;49:108-113.

Ankle Pain

  1. Steinberg N, Dar G, Dunlop M, Gaida JE. The relationship of hip muscle performance to leg, ankle and foot injuries: a systematic review. Phys Sportsmed. 2017;45(1):49-63.
  2. Mucha MD, Caldwell W, Schlueter EL, Walters C, Hassen A. Hip abductor strength and lower extremity running related injury in distance runners: A systematic review. J Sci Med Sport. 2016; 20(4):349-355
  3. Ogbonmwan I, Kumar BD, Paton B. New lower-limb gait biomechanical characteristics in individuals with Achilles tendinopathy: A systematic review update. Gait Posture. 2018;62:146-156.

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