Hip Abductor Weakness
While not a specific diagnosis, hip abductor weakness is a functional diagnosis that is a component of numerous lower extremity and back complaints.
There are 4 muscles that are in charge of abducting the thigh. They are the gluteus maximus, gluteus medius, gluteus minimus, and TFL (or tensor facia lata).
Weakness of the hip abductors, particularly those that assist with external rotation, has the most significant impact on hip and lower extremity stability (5,6).
The gluteus medius is the principal hip abductor. While the main action is hip abduction, it's contribution as a dynamic stabilizer of the hip and pelvis- particularly during single leg stance activities like walking, running, and squatting is of utmost importance. The gluteus medius contributes approximately 70% of the abduction force required to maintain pelvic leveling during single leg stance. The other 30% comes from the the tensor fascia lata and upper gluteus maximus (18).
Incompetent hip abductors and/or external rotators allows for excessive adduction and internal rotation of the thigh during single leg stance activities. This leads to a cascade of biomechanical problems, including pelvic drop, excessive hip adduction, excessive femoral internal rotation, valgus knee stress, and internal tibial rotation (see picture below and to the left) (1,7-12)
Runners with iliotibial band problems frequently demonstrate relative hip abductor weakness on the affected side. (16) Chronic gluteal dysfunction may lead to myofascial trigger points, tendinopathy, and muscle strains (17).
Downstream, hip abductor and external rotator weakness allows for the knees to turn in (called valgus or knock-knee) (22-25).
Hip Abduction and ligaments of the knee
Weak hip abductors causing "knock knees" T stresses the medial collateral (MCL) & anterior cruciate ligaments (ACL) and is a well-recognized contributor to sprains and tears (26,27).
Knee pain and hip abduction weakness
Excessive "knock knee" positioning also causes the knee cap to be pushed to the outside, putting stress the knee cap. This condition is called patellofemoral pain syndrome.
Hip Abductor weakness and shin splints
Hip abductor weakness is known to contribute to problems like shin splints, and foot hyperpronation (flat feet).
Hip Abductor weakness and hyperpronation (flat feet)
Foot hyperpronation and hip abductor weakness are known biomechanical coconspirators. Gluteus medius weakness increased pressure on the inside of the foot, decreasing the typical arch of the foot. In turn, flat feet causes a stretch weakness of the gluteus medius, generating a self-perpetuating cycle.
Who is more likely to have hip abductor weakness, males or females?
Hip abductor weakness seems to be more prevalent in females, particularly athletes (39-45).
Hip Abductor weakness and lower crossed syndrome
Hip abductor weakness is often accompanied by lower crossed syndrome – a larger pattern of biomechanical dysfunction involving weakness of the abdominal wall and hypertonicity in the hip flexors and paraspinal musculature.
Treatment options for hip abductor weakness
Obviously, the primary goal of management is to strengthen the hip abductors, thereby improving function (55).
In patients who have hip pain, hip abductor strength correlates with improvement (16,56). Moreover, athletes with stronger hip abductors are less likely to sustain lower extremity injuries. (39)
The most effective exercises for strengthening the gluteus medius are: side plank abduction with the affected leg on bottom, side plank abduction with the affected leg on top, single leg squat, clam progression #4, and a front plank with hip extension.
Patients with fallen arches and those who hyperpronate may benefit from orthotics or arch supports. Orthotics have been shown to increase activation of the gluteus muscle during single leg stance activities (66) Flexible full-length orthotics have been shown to improve Q angles and may aid in the treatment of secondary biomechanical problems, including foot pain, knee pain, and low back pain (59,60).
At Creekside Chiropractic & Performance Center, we are highly trained to treat hip abductor weakness. We are the only inter-disciplinary clinic providing services to Sheboygan, Sheboygan Falls, Plymouth, and Oostburg including chiropractic, manual therapy, myofascial release, ART (Active Release Technique), massage therapy, acupuncture, physiotherapy, rehabilitative exercise, nutritional counseling, personal training, and golf performance training under one roof. Utilizing these different services, we can help patients and clients reach the best outcomes and the best versions of themselves. Voted Best Chiropractor in Sheboygan by the Sheboygan Press.
Evidence Based-Patient Centered-Outcome Focused
1. Szu-Ping Lee, Powers C. Description of a Weight-Bearing Method to Assess Hip Abductor and External Rotator Muscle Performance. JOSPT. Volume 43, Issue 6
2. Crossley KM, Zhang WJ, Schache AG, Bryant A, Cowan SM. Performance on the single-leg squat task indicates hip abductor muscle function. Am J Sports Med. 2011;39:866-873.
3. Presswood L, Cronin J, Keogh JWL, Whatman C. Gluteus medius: applied anatomy, dysfunction, assessment, and progressive strengthening. Strength Cond J. 2008;30:41-53.
4. Sled EA, Khoja L, Deluzio KJ, Olney SJ, Culham EG. Effect of a home program of hip abductor ex- ercises on knee joint loading, strength, function, and pain in people with knee osteoarthritis: a clinical trial. Phys Ther. 2010;90:895-904.
5. van der Krogt MM, Delp SL, Schwartz MH How robust is human gait to muscle weakness? Gait Posture. 2012 Feb 29.
6. Laurie Stickler, Margaret Finley, Heather Gulgin Relationship between hip and core strength and frontal plane alignment during a single leg squat Physical Therapy in Sport Available online 2 June 2014
7. Ireland ML, Willson JD, Ballantyne BT, DavisIM. Hip strength in females with and without patellofemoral pain. J Orthop Sports Phys Ther. 2003;33:671-676.
8. Noehren B, Davis I, Hamill J. ASB clinical biome- chanics award winner 2006: prospective study of the biomechanical factors associated with iliotib- ial band syndrome. Clin Biomech (Bristol, Avon). 2007;22:951-956.
9. Powers CM. The influence of abnormal hip me- chanics on knee injury: a biomechanical perspec- tive. J Orthop Sports Phys Ther. 2010;40:42-51.
10. Powers CM. The influence of altered lower- extremity kinematics on patellofemoral joint dysfunction: a theoretical perspective. J Orthop Sports Phys Ther. 2003;33:639-646.
11. Sigward SM, Powers CM. Loading characteristics of females exhibiting excessive valgus moments during cutting. Clin Biomech (Bristol, Avon). 2007;22:827-833
12. Souza RB, Powers CM. Differences in hip kine- matics, muscle strength, and muscle activation between subjects with and without patellofemo- ral pain. J Orthop Sports Phys Ther. 2009;39:12- 19.
13. Fetto J, Leali A, Moroz A Evolution of the Koch model of the biomechanics of the hip: clinical perspective. J Orthop Sci. 2002; 7(6):724-30.
14. Becky L. Heinert, Thomas W. Kernozek, John F. Greany, and Dennis C. Fater Hip Abductor Weakness and Lower Extremity Kinematics During Running Journal of Sport Rehabilitation, 2008, 17, 243-256
15. Markley G. Greater Trochanteric Pain Syndrome. Presentation- Illinois Chiropractic Society National Convention. September 2013, Chicago, IL.
16. Fredericson M1, Cookingham CL, Chaudhari AM, Dowdell BC, Oestreicher N, Sahrmann SA. Hip abductor weakness in distance runners with iliotibial band syndrome. Clin J Sport Med. 2000 Jul;10(3):169-75.
17. Bunker T, Esler C, Leach W. Rotator-cuff tear of the hip. J Bone Joint Surg Br. 1997;79:618–620.
18. Grimaldi A. Assessing lateral stability of the hip and pelvis. 3rd International conference on movement dysfunction 2009. Manual Therapy 16 (2011) 26e32
22. Magalhaes E, Fukuda TY, Sacramento SN, et al. A comparison of hip strength between sedentary females with and without patellofemoral pain syndrome. J Orthop Sports Phys Ther. 2010;40(10): 641–647
23. Ireland ML, Willson JD, Ballantyne BT, et al. Hip strength in females with and without patellofemoral pain. J Orthop Sports Phys Ther. 2003;33(11):671–676
24. Souza RB, Powers CM. Predictors of hip internal rotation during running: an evaluation of hip strength and femoral structure in women with and without patellofemoral pain. Am J Sports Med. 2009;37:579–587
25. Zazulak BT, Hewett TE, Reeves NP, et al. Deficits in neuromuscular control of the trunk predict knee injury risk: a prospective biomechanical- epidemiologic study. Am J Sports Med. 2007;35: 1123–1130
26. McLean SG, Huang X, Su A, Van Den Bogert AJ. Sagittal plane biomechanics cannot injure the ACL during sidestep cutting. Clin Biomech 2004;19(8):828-838.
27. Loudon JK, Jenkins W, Loudon KL. The relationship between static posture and ACL injuries in female athletes. J Orthop Sports Phys Ther 1996;24(2):91-97.
28. Lafortune MA, Cavanagh PR, Sommer HJ, Kalenak A. Foot inversion-eversion and knee kinematics during walking. J Orthop Res 1994;12(3):412-420.
29. McKenzie K, Galea V, Wessel J, et al. Lower extremity kinematics of females with patellofemoral pain syndrome while stair stepping. J Orthop and Sports Phys Ther. 2010;40(10):625–632
30. Willson JD, Macleod SB, Davis IS. Lower extremity jumping mechanics of female athletes with and without patellofemoral pain before and after exertion. Am J Sports Med. 2008;36:1587–1596
31. Powers CM The influence of altered lower-extremity kinematics on patellofemoral joint dysfunction: a theoretical perspective. J Orthop Sports Phys Ther. 2003;33:639-46
32. Ireland ML1, Willson JD, Ballantyne BT, Davis IM. Hip strength in females with and without patellofemoral pain. J Orthop Sports Phys Ther. 2003 Nov;33(11):671-6.
33. Cichanowski HR1, Schmitt JS, Johnson RJ, Niemuth PE. Hip strength in collegiate female athletes with patellofemoral pain. Med Sci Sports Exerc. 2007 Aug;39(8):1227-2.
34. S. Grau, I. Krauss, C. Maiwald, R. Best, T. Horstmann Hip Abductor Weakness is not the Cause for Iliotibial Band Syndrome Int J Sports Med 2008; 29(7): 579-583
35. M S Rathleff, C R Rathleff, K M Crossley, C J Barton Is hip strength a risk factor for patellofemoral pain? A systematic review and meta-analysis Br J Sports Med doi:10.1136/bjsports-2013-093305
36. Allen S, Waerlop IF, Lardner R. A Few Words About Pronation Dynamic Chiropractic – February 26, 2008, Vol. 26, Issue 05
37. Oh JS, Cynn HS, Won JH, et al. Effects of performing an abdominal drawing-in maneuver during prone hip extension exercises on hip and back extensor muscle activity and amount of anterior pelvic tilt. J Orthop Sports Phys Ther. 2007;37(6):320–324
38. Princeton University Athletic Medicine Program. Pelvic Stabilization, Lateral Hip and Gluteal Strengthening Program. https://www.princeton.edu/uhs/pdfs/PelStabHip-StrenPro.pdf. Accessed 1/25/14
39. Ferber R, McClay-Davis I, Williams DS. Gender differences in lower extremity mechanics during running. Clin Biomech (Bristol, Avon). 2003;18:350–357.
40. Malinzak RA, Colby SM, Kirkendall B, Yu B, Garnett WE. A comparison of knee joint motion patterns between men and women in selected athletic tasks. Clin Biomech (Bristol, Avon). 2001;16:438–445.
41. Lephart SM, Ferris CM, Riemann BL, Myers JB, Fu FH. Gender differences in strength and lower extremity kinematics during landing. Clin Orthop Relat Res. 2002;401:162–169.
42. Ireland ML. The female ACL: why is it more prone to injury? Orthop Clin North Am. 2002;33:637–651.
43. Ireland ML, Willson JD, Ballantyne BT, Davis IM. Hip strength in females with and without patellofemoral pain. J Orthop Sports Phys Ther. 2003;33:671–676.
44. Zeller BL, McCrory JL, Kibler B, Uhl TL. Differences in kinematics and electromyographic activity between men and women during single leg squat. Am J Sports Med. 2003;31:449–456.
45. Leetun DT, Ireland ML, Willson JD, et al. Core stability measures as risk factors for lower extremity injury in athletes. Medi. Sci. Sports Exerc. 2004;36(6):926–934
46. Bennett JE, Reinking MF, Pluemer B, Pentel A, Seaton M, Killian C. Factors contributing to the development of medial tibial stress syndrome in high school runners. J Orthop Sports Phys Ther. 2001;31:504–510.
47. Messier SP, Davis SE, Curl WW, Lowery RB, Pack RJ. Etiological factors associated with patellofemoral pain in runners. Med Sci Sports. 1991;23:1008–1015.
48. Ferber R, McClay-Davis I, Williams DS. Gender differences in lower extremity mechanics during running. Clin Biomech (Bristol, Avon). 2003;18:350–357.
49. Malinzak RA, Colby SM, Kirkendall B, Yu B, Garnett WE. A comparison of knee joint motion patterns between men and women in selected athletic tasks. Clin Biomech (Bristol, Avon). 2001;16:438–445.
50. Hewett TE, Myer GD, Ford KR, et al. Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes, a prospective study. Am J Sports Med. 2005;33:492–501.
51. Taunton JE, Ryan MB, Clement DB, McKenzie DC, Lloyd-Smith DR, Zumbo BD. A retrospective case-control analysis of 2002 running injuries. Br J Sports Med. 2002;36:95–101.
52. Hardcastle P, Nade S. The significance of the trendelenburg test. Journal of Bone and Joint Surgery British 1985;67B:741e6.
53. Bohannon RW. Reference values for extremity muscle strength obtained by handheld dynamometry from adults aged 20e79 years. Archives of Physical Medicineand Rehabilitation 1997;78:26e32.
54. Sahrmann S. Diagnosis and treatment of movement impairment syndromes. St Louis: Mosby; 2002. 55. Mc Connell J. The physical therapist’s approach to patellofemoral disorders. Clin J Sport Med. 2002;21:363–387.
56. Becky L. Heinert, Thomas W. Kernozek, John F. Greany, and Dennis C. Fater Hip Abductor Weakness and Lower Extremity Kinematics During Running Journal of Sport Rehabilitation, 2008, 17, 243-256
57. Boren K, et al., Electromyographic Analysis Of Gluteus Medius And Gluteus Maximus During Rehabilitation Exercises. The International Journal of Sports Physical Therapy, Volume 6(3) September 2011, 206-23.
58. Pollard TCB. A perspective on fomoroacetabular impingement. SKel Radiology 2011;40:815-818
59. Menz HB, Dufour AB, Riskowski JL, Hillstrom HJ, Hannan MT. Foot posture, foot function and low back pain: the Framingham Foot Study. Rheumatology (Oxford). 2013 Dec;52(12):2275-82. doi: 10.1093/rheumatology/ket298. Epub 2013 Sep 17.
60. Kuhn R, Yochum TR, Anton R. Cherry, and Sean S. Rodgers Immediate Changes in the quadriceps Femoris Angle After Insertion of an Orthotic Device J Manipulative Physiol Ther 2002;25:465 70
61. DiMattia M, Livengood A, Uhl T, Mattaclola C, Malone T. What are the validity of the single-leg-squat test and its relationship to hip-abduction strength? Journal of Sport Rehabilitation 2005;14:108e23.
62. Youdas JW, Mraz ST, Norstad BJ, Schinke JJ, Hollman JH. Determining meaningful changes in hip abductor muscle strength obtained by handheld dynamometry. Physiotherapy Theory and Practice 2008;24(3):215e20.
63. 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.
64. The Gait Guys Hip Biomechanics: Part 6 of 6, The Conclusion http://thegaitguys.tumblr.com/
65. Reinold M. Assessing and Treating Dysfunction of the Gluteus Medius. www.mikereinold.com Accessed 1/25/15.
66. Hertel J, Sloss B, Earl J. Effect of foot orthotics on quadriceps and gluteus medius electromyographic activity during selected exercises. Arch Phys Med Rehabil, 2005;86:26-30.
67. Moreside JM, McGill SM. Improvements in hip flexibility do not transfer to mobility in functional movement patterns. J Strength Cond Res. 2013 Oct;27(10):2635-43.