Best Exercises for the Gluteus Medius

The gluteal musculature has been implicated in many different pathologies due to its potential impact on lower extremity biomechanics. Because during weight bearing the femur moves about a fixed patella, excessive femoral internal rotation (IR) and adduction results in increased contact primarily at the lateral facet of the patella.¹

Just 10° of IR can lead to a substantial decrease in PFJ contract area and a 50% increase in joint stress. Coinciding with these findings:

• Souza et al.² found that females with patellofemoral pain syndrome (PFPS) demonstrated greater peak hip internal rotation compared to the control group during running, drop jump, and step down. The PFPS group also demonstrated 14% weaker hip abductor strength and 17% weaker hip extensor strength.
• Wilson et al.,³ Noehren et al.,⁴ and Nakagawa et al.⁵ found that individuals presenting with PFPS demonstrated increased hip adduction during running, jumping, and single-leg squats. This excess femoral adduction creates an increased valgus force about the knee joint, which in turn causes increased loading of the lateral patellofemoral joint.

In addition to patellofemoral pain, a hip etiology or influence has also been implicated in iliotibial band syndrome,⁶ anterior cruciate ligament rupture,⁷ and achilles tendinopathy.⁸

Gluteal Strengthening and Rehabilitation

In support of a gluteal etiology, several studies have found the effectiveness of gluteal strengthening in the treatment of lower extremity disorders. A recent systematic review conducted by Santos and colleagues⁹ found gluteal strengthening to have the following effects amongst individuals diagnosed with PFPS.

1. Decreased highest intensity of pain experienced during the previous week
2. Decreased pain when ascending and descending stairs
3. Decreased pain while squatting or sitting for prolonged periods

Additionally, with regards to rehabilitation following anterior cruciate ligament reconstruction, the inclusion of hip strengthening appears to improve sagittal plane dynamic balance at three months post ACLR as compared to traditional rehabilitation.¹⁰

EMG Activity and Exercise Goals

According to Reiman et al.¹¹ and Escamilla et al.,¹² moderate electromyographic activity (EMG) activation (21-40% MVIC) is best used to facilitate endurance and neuromuscular re-education, and high activation (41-60+% MVIC) to promote strength gains.

From Biomechanics to Exercises

Origin: External surface of Ilium between anterior and posterior gluteal lines

Insertion: Lateral surface of greater trochanter

Primary Function: Abduction of the hip joint

The anterior fibers contribute to hip flexion and hip internal rotation, and the posterior fibers to hip extension and hip external rotation. Additionally, the gluteus medius is responsible for preventing the opposite side of the pelvis from dropping during the stance phase of gait and plays a major role in providing frontal plane stability for the entire pelvis during walking and other functional activities.

During the early stages of rehabilitation or when attempting to selectively activate the gluteus medius, the following demonstrate the highest EMG levels: ^13-14

1. Side-lying plank with hip abduction
2. Reverse clamshell with hip abduction and extension
3. Prone plank with hip extension
4. Reverse clamshell with hip abduction
5. Single-leg bridge

[Table] MVIC of the Gluteus Medius during Therapeutic Exercise

Additionally, you must consider the interaction of other muscles acting with or against the gluteus medius when determining exercise prescription. It has been proposed that individuals who demonstrate excessive femoral internal rotation during functional tasks may be relying too heavily on the tensor fasciae latae to control their pelvis in the presence of weak or inhibited gluteus medius musculature.

Selkowitz and colleagues determined that the following exercises achieved the best Gluteal to Tensor Fasciae Latae Activation Ratio:¹⁵

1. Clamshell
2. Side-step with resistance band
3. Single-leg bridge
4. Quadruped hip extension with knee extended
5. Quadruped hip extension with knee flexed

[Table] Gluteal-to-TFL Index during Therapeutic Exercise (Selkowitz et al., 2013)

Finally, when progressing your patient towards more functional closed kinetic chain and sport/activity-specific exercises, the following exercises achieve the highest gluteus medius activation:^{13, 16-18}

1. Walking lunge with dumbbell in contralateral hand
2. Lateral band walk
3. Unilateral mini-squat
4. Skater squat
5. Unilateral deadlift

[Table] MVIC of Gluteus Medius during Closed Kinetic Chain Exercise