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DrAlisonGrimaldi

Dynamic Stabilisation of the Hip & Pelvis Lesson 4

Topics for Discussion

Normal function
Gluteus maximus & joint pathology
Lesson 4
Gluteus Maximus: Gluteus maximus & unloading
Function & Dysfunction
Implications for therapeutic exercise

Dr Alison Grimaldi PhD, MPhtySt(Sports), BPhty

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PhysioTec www.physiotec.com.au
www.DrAlisonGrimaldi.com

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Picture © Primal Pictures Ltd

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Normal function
ald Glut Max EMG in gait
Adapted from Stern, Pare & Schwarz 1980
Upper Glut Max:
im
Heel Strike STANCE SWING

1° Abductor function UGM


WALK
Also ER
LGM
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UGM
Lower Glut Max: JOG
1° Extensor function LGM

Also Add & ER Picture © Primal Pictures Ltd UGM

RUN
ni

LGM
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Ali

Glut max in other WB function Topics for Discussion

Lower glut max will be maximally recruited in a lunge in the Normal function
Dr

trunk forward position (Farrokhi et al 2008)


Gluteus maximus & joint pathology
Always consider gravitational loading in therapeutic exercise
prescription Gluteus maximus & unloading
Implications for therapeutic exercise

Picture © Primal Pictures Ltd

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DrAlisonGrimaldi
Dynamic Stabilisation of the Hip & Pelvis Lesson 4

Hip Extensor Strength & OA Glut Max Size & Hip OA

Rasch et al 2007: Associated with loss of strength, loss of muscle size has
19% less isometric hip extensor strength on the side of pathology been demonstrated in GM in those with hip OA
in patients with unilateral OA Rasch et al 2007:
13% smaller in GMax CSA on the side of pathology in
Arokoski et al 2002: patients with unilateral OA
22% less isometric extensor strength & Arokoski et al 2002:
13-14% less isokinetic extensor strength on the side with worst 9% smaller lower GMax CSA on side of worse pathology in
hip OA subjects with hip OA

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Grimaldi et al 2009:
Use it or lose it! Antalgic unloading will ultimately result in
Measured muscle volume of UGM and LGM separately in

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reduced strength in antigravity extensors, but could this loss
have preceded the OA? subjects with unilateral hip OA – mild or advanced, and
age & sex matched controls

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Mild unilateral hip OA
ald Advanced unilateral hip OA
ANTERIOR ANTERIOR
im
ANTERIOR ANTERIOR
Gr

Affected Side Affected Side


Affected Side Affected Side UGM TFL & LGM
UGM TFL & LGM UGM & LGM: Significantly smaller on affected side (p=0.00;p< 0.05)
UGM significantly larger (mean 24.6%) on unaffected side compared
Differences between sides were not great enough to reach
statistical significance but changes in size and quality observable with normal control subjects (p<0.05). TFL NSD in size
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Grimaldi et al 2009
Grimaldi et al 2009
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Ali

Implications Glut Max Fibre Type & Hip OA

LGM demonstrates atrophy, more evident in advanced Selective loss of fast twitch fibres in gluteus maximus has
Dr

stages of pathology been demonstrated in patients with hip OA


(Sirca & Susec Micheli, 1980)
UGM, like TFL does NOT readily atrophy in the presence of
degenerative hip pathology
UGM & LGM should be considered functionally separate Implications:
muscles & may require differing approaches in targeted Poorer capacity for strength development & shock
management of muscle dysfunction. absorption - increased joint forces
UGM is more functionally similar to TFL. Excessive bulk and Potential to shift towards more tonic function
activity in the upper portion of the gluteus maximus may
not be healthy for the underlying joint. Assess & target Important to address fast twitch fibre function & to ensure
UGM & LGM as 2 separate muscles. avoidance of excessive tonic activation strategies for GM in
functional retraining & therapeutic exercise

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DrAlisonGrimaldi
Dynamic Stabilisation of the Hip & Pelvis Lesson 4

Hip extensor exercise & joint forces Topics for Discussion

Lewis et al 2009 Normal function


Measured joint forces in a simulated biomechanical Gluteus maximus & joint pathology
modelling study. Looked at ranges between 10° flexion
and 20° extension in a prone hip extension model. Gluteus maximus & unloading
Highest hip joint forces (*ant), occur in hip extension esp if Implications for therapeutic exercise
gluts are weak.

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Picture © Primal Pictures Ltd

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Unloading: Insights for Aetiology?
ald Berlin Bed Rest Study

Muscle deficits in OA – chicken or the egg? Young healthy males restricted to bed for
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Muscle deficits have been linked to the development and
8 weeks
progression of OA at the knee (Slemender et al 1998, Hurley 1999) MRI’s were taken at baseline, every 2
and hip (Hootman et al 2004) weeks during bed rest, & 5 times during
the ambulant recovery period – 180
Lack of appropriate loading of the musculoskeletal system is days
Gr

thought to be one of the factors leading to the development of


muscle deficits (Richardson 2004) Countermeasure group performed
exercises in bed on a bed mounted
Microgravity research provides the opportunity to observe whole body vibration platform
patterns of muscle change during unloading in healthy subjects
- squats
Unloading studies have shown preferential atrophy of antigravity
muscles, slow twitch muscle fibres, and intrinsic stabilisers at - jumps
the Lx & knee (Fitts et al 2000, Hides et al 2007, Musacchia 1992) - heel raises Straps provided 1.8 x BW
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axial compression onto the


- toe raises plate
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Ali

GMax/TFL during BR & recovery Implications

LGM & UGM demonstrated differing patterns of response to


Dr

unloading
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While LGM was significantly affected by unloading
Percentage change in average cross-sectional area

10 (7.3%± 7.2% atrophy by 8 weeks), the UGM was not, like


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the other superficial hip abductor TFL

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* ** UGM This reflects the patterns seen in the presence of
* LGM degenerative joint pathology and implies that it is possible
-5 TFL
that loss of hip extensor bulk may precede and contribute
-10 to the development of hip OA.
**
-15
BR001 BR014 BR028 BR042 BR056 R014 RO28 RO90 R180

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DrAlisonGrimaldi
Dynamic Stabilisation of the Hip & Pelvis Lesson 4

Topics for Discussion Implication for Therapeutic Exercise

Normal function Considering:

Gluteus maximus & joint pathology 1. LGM is an antigravity extensor, negatively impacted upon
by unloading &
Gluteus maximus & unloading 2. Joint forces (*Ant) are increased in hip extension,
Implications for therapeutic exercise particularly if gluteals are weak (Lewis et al 2009), leading
these authors to state that hip extension past neutral is
not recommended for patients with hip OA to limit
compressive loading across joint

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Which exercises will be most functionally consistent for this

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muscle, and safest for the underlying joint?
Picture © Primal Pictures Ltd

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Therapeutic Exercise for Lower Glut Max
ald Use gravity to your advantage
im
?
Gr

?
ni
so
Ali

Use gravity to your advantage GMax in gait & posture

Considering:
Dr

1. GM is not tonically active during quiet standing or gait &


2. GM experiences a selective loss of fast twitch fibres in hip OA,
therefore a shift towards a slower phenotype

Cues given for posture & gait should be consistent with the
natural function of this muscle
- GM should not be held tight during quiet bilateral standing
- GM should be phasically active during gait- to prepare for and
absorb ground reaction forces at heel strike, and additionally in
TWS Slider, PhysioTec running to rapidly extend the hip to bring the foot back to the
ground.

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