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lower back injuries, lower back exercises, gluteal muscles

Lower back injuries - lower back exercises for strengthening gluteal muscles

These are valuable exercises for strengthening the gluteal muscles

In issue 7 of SIB we discussed 'core stability' of the lumbar spine and its association with lower back pain and recommended exercises to improve the stability of this area. Core-stability programmes tend to focus on the trunk muscles (transversus, multifidus, obliques and paraspinals); however, the gluteal muscles are also very important for core stability and preventing low back pain. This article will explain the functional role of the gluteals in stabilising the lumbar-pelvic area and then describe a series of exercises for them.
The gluteals are a group of muscles that make up the bum area, called the gluteus maximus, medius and minimus. In anatomical terms the gluteus maximus is a hip extensor muscle (pulling the leg back) and the medius and minimus are hip abductor muscles (pulling the leg up to the side). However, for the purposes of injury prevention and improving stability, the function of the gluteals is to stabilise the pelvis and trunk and not to move the legs.

Stabilisers and mobilisers
Hides et al. (1996) and Comerford (1999) have proposed the categorisation system of stabiliser and mobiliser muscles which depicts the key differences in how each set of muscles act during functional movements.
Mobiliser muscles act to move a limb or the trunk. They tend to act at specific times with concentric actions or stretch-shorten cycle (plyometric) actions and the muscle activity tends to be at a high level. For example, during running the hamstrings are one of the main mobiliser muscles which concentrically contract during the latter half of the stance phase at a high level to extend the hip joint to produce a push off.
Stabiliser muscles act to control the motion of a limb or the trunk. They tend to act more continuously either in a 'quasi-static' manner or with a controlling eccentric pull. The muscle activity tends to be at a low level. For example, during running the gluteus maximus acts to maintain upright posture and laterally rotate the femur as the leg pushes off, helping to achieve the toe-off position. The medius and minimus work to maintain a level pelvis when weight-bearing on one leg, preventing the free side from dropping down. They also control the rotation of the pelvis as the free leg swings forward. These are not muscle actions at a specific time which produce a movement but more of a continuous activity to maintain the optimal pelvic position.

Training 'movements' and 'positions'
From the example of running, it can be seen that during any functional task the muscles work in different types of ways to perform different roles. This is true of any activity of daily living (ADL), such as vacuum cleaning or picking up boxes, and athletic movements, such as jumping or swinging a golf club. These different muscles must work together in a co-ordinated fashion, with the strong mobiliser muscles powerfully contracting through the full range of motion and the stabiliser muscles switching on at the right times to control the joint positions.
This is the key difference between functional tasks and exercises where muscle groups work in isolation and explains why the mobiliser/stabiliser system is so important to understand. For effective core stability and injury prevention one must train 'movements' and 'positions' rather than 'muscles'. By this I mean that exercises are more effective when they mirror the demands of ADL's or athletic movements. It is possible to perform exercises which isolate the gluteus maximus (eg leg extensions) and gluteus medius and minimus (eg hip abductions), but this is not how these muscle act in reality.
When designing training programmes to improve muscle function, it is easier to think in terms of the mobiliser/stabiliser system as it guides us into using exercises that will be more functional. The system tells us that stabiliser muscles need to switch on easily at low-load levels, they need to be able to maintain joint position and they need to have good endurance. Stabiliser muscles tend to become inhibited and are not active enough for sufficient duration. Therefore to train stabiliser muscles correctly, exercises should involve positions that mirror ADL or athletic movements, they should be trained with light loads and many repetitions or made to hold the correct position for a prolonged period.
Here are descriptions of how the gluteal muscles fail to act efficiently as stabiliser muscles and the corresponding exercises to improve these dysfunctions. By targeting the lack of stability in this functional manner the results of the training programme will be more effective.

Exercises for common gluteal muscle dysfunction
One of the most common problems with the gluteal muscles is that they are not active enough during trunk flexion and extension movements. This has been shown by Leinonen et al (2000) who found the gluteus maximus was significantly shorter during a forward flexion extension movement (bending over) in back patients compared to healthy controls. This suggests that insufficient recruitment of the gluteus maximus may increase the risk of injury, which makes sense if you consider the role of the gluteus maximus, which is to help maintain an upright posture and extend the trunk.
Two exercises to improve the gluteus maximus's ability to support the extension of the spine are the 'Bridge' and the 'Wood Chop'.

The Bridge
This is a static exercise where the gluteus maximus must work to support the back. Proper technique is essential if the correct stability mechanisms are to be improved.

Level 1
Lie on one's back with knees bent. Draw in the lower abdominals and curl the bum off the floor, lifting the hips until the knees, hips and chest are in line.
Hold this position, purposefully squeezing the glutes to support the bridge position. Start with 10 x 10 seconds, building up to 2 x 60 seconds.
Keep the pelvis level and the lower abdominals drawn in. If you feel a strong contraction in the hamstrings or the lower back is straining, then you are not using your glutes strongly enough. Focus on them to ensure they do the work.

Level 2
Same as above, but once the bridge is achieved lift one knee up in the air and support the bridge on one leg only. Hold for a count of two and then swap sides. Maintain for 60 seconds. Build up to 3 minutes.
Again, ensure the pelvis remains level and the lower abdominals drawn in. If you feel a strong contraction in the hamstrings then you are not using your glutes enough.

The Wood Chop
This is a dynamic exercise where the gluteals must work to extend the trunk from a flexed position.

Level 1
Stand with feet shoulder-width apart, knees slightly bent. Stand up tall and hold a weight in two hands above your head (5kg men, 3kg women).
As if you are wielding an axe to chop wood, bend from the waist and bring the weight down between your legs in a controlled manner. Do not bend your knees any further as you bend forward. At the bottom, draw in your abdominals and squeeze your glutes for support before returning to the start position. When you return upright, ensure it is with the correct sequence, extending your lower back first, then bringing your shoulders up and finally lifting the weight above your head.
Begin with 2-3 sets of 10 reps building up to 20 reps.

Level 2
Same as above, but on one leg.

Improving pelvis stability
The second common gluteal muscle dysfunction is insufficient gluteus medius and minimus activity during walking and running to maintain the correct gluteal position. Norris (1995) discusses how inhibited gluteus medius and minimus leads to poor pelvic stability where insufficient tension during single-leg weight-bearing causes the free-leg hip to drop down.
Two exercises to improve the ability of medius and minimus to maintain pelvis stability are the 'Hip Hitcher' and 'One-Leg Squats'.

The Hip Hitcher
This exercise involves recruiting the gluteals to maintain a level pelvic tilt.
Stand on one leg, bending the free-leg knee slightly so it does not drag on the floor. Stand up with good posture, head looking forward into a mirror.
Tilt the pelvis so the free side drops down. Your stance-leg knee should not have moved nor should your head or back. Then, focusing on the top and outside of your gluteals, pull the pelvis back until the free side is level or even slightly higher. Slowly continue this hitching motion up and down.
Complete 3 sets of 10 building up to 20 reps each side.
Use the mirror to ensure your posture remains aligned and you are using only your gluteal muscles to perform the movement.

One-Leg Squats
This exercise is normally for the legs, but if performed with perfect technique it also works the medius and minimus very hard to maintain pelvic stability.
Stand on one leg in front of the mirror. Ensure your head is up and your shoulders are back, with the lower abdominals drawn in for support. Arch your foot slightly to ensure your knee is not pointing inwards.
Squat down with your bum going back and your knee staying over your laces. Keep the free-leg knee next to the stance knee to ensure you stay aligned. Keep your pelvis level and square as you squat down. Stand back up, ensuring everything remains aligned.
Build up to completing 3 sets of 10 each leg.

Gluteal muscle imbalance and stretching exercises
The gluteals can also be negatively affected by muscle imbalance problems with adjacent muscle groups. Muscle imbalance refers to muscles being shortened and lengthened with respect to each other. Mobiliser muscles have a tendency to shorten (become less flexible) and so are recruited more easily. This is because pre-tension in the muscle increases its excitability. As a consequence, adjacent or antagonistic muscles can become inhibited, impairing their function.
For example, inflexible hip flexors can cause an excessive anterior pelvic tilt which inhibits the gluteus maximus and tight adductors and overactive tensor fascia lata can inhibit gluteus medius and minimus.
Therefore, to ensure correct recruitment of the gluteals the surrounding mobiliser muscles of the hip must be fully flexible. A set of stretching exercises for hip flexors, hamstrings, adductors and tensor fascia lata would be useful to avoid any imbalance problems described above. Here they are.

Hip flexor stretch
Kneel with one foot forward, front knee at right angles and the other leg just behind your hips. Keep your upper body upright. Tilt your pelvis back, tucking in your stomach and squeezing your gluteals. You should feel the stretch strongly in your hip flexor.

Hamstrings stretch
Lie on your back with your knees bent. Pull one leg up towards you and using your quads straighten the knee as much as you can, stretching the hamstring.

Adductor stretch
Sit up with the soles of your feet together. Using your hands push your knees gently apart to the floor stretching the groin area.
Sit up with legs straight out and as wide as you can get them stretching the groin. Support your body with hands behind you.

Tensor fascia lata stretch
Lie on your back with knees bent and arms out wide. Cross your legs and use the top leg to push the bottom leg over to the side. Take your legs over until your opposite shoulder starts to come off the floor; you should feel the stretch on the outer thigh/hip area.


Raphael Brandon


References
Comerford. (1999). Dynamic stabilisation in sport. Presentation notes from NCF High Performance workshop.

Hides et al. (1996). Spine. 21, 2763-2769.

Leinonen et al Arch Phys Med Rehab, 2000, 81: 32-37.
Norris (1995) Physiotherapy 81(3), 127-138.



lower back injuries, lower back exercises, gluteal muscles