Recently I had the opportunity to observe Michael Vadiveloo, a Specialist Sports Physiotherapist, as awarded by the Australian College of Physiotherapists in 2011. Michael is the owner of City Baths Spinal & Sports Medicine Clinic and Energise Physiotherapy & Clinical Pilates Studio in Oakleigh. He worked for St Kilda football club from 1991 to 2005 and travelled with various Australian AFL representative teams. His area of specialisation is the knee with a particular interest in rehabilitation of the lower limb kinetic chain.

One unique experience Michael shared with me was an overview of his functional assessment of the kinetic chain. Performing this assessment is a regular component of my clinical practice, but what I realised is that I have been too focussed on gluteal activation and neglected the rest of the lower limb. This blog is therefore an overview of what new tips I learnt in retraining a single leg squat, lunge & bulgarian lunge.

In a previous blog I wanted to explore what exercises promote gluteus maximus activation while minimising TFL activation. The reason being that there is a large amount of evidence supporting that hip abduction, external rotation, and extension weakness is associated with increased hip adduction, internal rotation and dynamic knee valgus. In clinical practice I was searching for the answers about what exercises are great for independent home rehab programs. What I found was an article by Selkowitz published in 2013 that looked at the EMG activity of the hip muscles during a clam, single leg bridge, 4PK hip extension with bent/straight knee, and sidestepping with theraband around knees. The outcome of this study was so applicable to my daily practice.

To preferentially target GMED, side lying hip abduction and hip hitching off the edge of the step provide the greatest activation. This activation pattern however, is greater than that of TFL but not in isolation to TFL.
Sup-Gmax is maximally recruited during a clam and secondly during a unilateral bridge.
Clam, side step, unilateral bridge, 4PK hip extension (straight knee), 4PK hip extension (bent knee), bilateral bridge and squat all showed statistically significant higher normalised electromyographic signal amplitude of gluteus maximus than the TFL. All of these exercises have 50% more activation in the gluteal muscles compared to TFL.

So over the past 2 years I've continued to incorporate the results of this study into my method for rehabilitating lower limb injuries that displayed poor gluteal strength and motor control of the kinetic chain. However..... Michael's technique takes these exercises one step further and uses foot and knee positioning to promote VMO activity and optimal arch control at the foot.

Lets begin with exercises that are easy to complete at home without equipment and promote gluteus maximus activation: clams, side lying hip abduction, 4PK hip extension and supine bridge.

Clams are a great exercise to teach isolated upper gluteus maximus activation. Aim to feel the muscles along the back upper of the buttock contract as the top leg opens at the knee, while the heels squeeze firmly together. Start with feet flat. Then… — Clams are a great exercise to teach isolated upper gluteus maximus activation. Aim to feel the muscles along the back upper of the buttock contract as the top leg opens at the knee, while the heels squeeze firmly together. Start with feet flat. Then raise feet & hover. Then you can wrap a theraband around the knees.

Side lying hip abduction is a progression after clam. The leg should be straight and toes facing forward. Aim to raise the hip to 11.30 on a clock face i.e. up & back as this helps to promote a better gluteal activation. I use my hand to palpate… — Side lying hip abduction is a progression after clam. The leg should be straight and toes facing forward. Aim to raise the hip to 11.30 on a clock face i.e. up & back as this helps to promote a better gluteal activation. I use my hand to palpate muscles around the hip and ensure there isn't too much TFL to quadriceps activation kicking in.

4PK hip extension aka donkey kick (when the knee is bent) is another hip extension exercise. I use this exercise to teach patients about their naturally movement compensations using the mirror. Try to extend the hip beyond horizontal without droppin… — 4PK hip extension aka donkey kick (when the knee is bent) is another hip extension exercise. I use this exercise to teach patients about their naturally movement compensations using the mirror. Try to extend the hip beyond horizontal without dropping & rotating the pelvis & avoid arching & twisting through the lower back. Aiming to keep the weight bearing hip centred over the knee helps to stop the weight shift. Then drive the heel of the kicking leg to the ceiling to promote gluteal activation. This is a good example of not great technique :) due to my limited hip strength.

Below there are four progressions of a supine bridge for gluteal strength:

Feet are level.
Feet are split to load one side with more body weight prior to single leg loading.
Single leg bridge with leg bent (a short lever).
Single leg bridge with straight leg (a longer lever).

Common mistakes are to use the hamstrings and lower back to lift the hips off the floor. Strategies for correction include placing arms by side as a base for support, keeping both ASIS level to limit pelvic rotation and to drive down through the heel to squeeze the buttocks before and during the bridge.

A benefit for using the bridge over clam, abduction and 4PK hip extension is that the foot is anchored and therefore you can commence training the entire leg. E.g. keep the body weight through the medial aspect of the heel, then externally rotate the knee (through the hip) which lifts the arch and activates VMO and external rotator fibres of gluteus maximus, and finally drive down through the heel to lift the hips activating the extensor component of gluteus maximus.

Once the client has increased awareness of correct activation patterns and muscle endurance, the exercises are transferred to a standing lunge, single leg squat and bulgarian lunge.

If standing balance is an issue and clients are struggling to keep their awareness of foot, knee and hip posture, a loaded leg press can help with the transition. It is sitting (less functional) but can allow for less body weight and therefore better technique. Weight through the medial aspect of the heel, then externally rotate the knees from the hip to lift the arches (keeping 1st toe down) and realign the knees, and finally drive through the heel to extend the legs feeling muscles contract around the inner knee and buttock (not anterior hip, groin, lateral quad and hamstring).

In standing there are lots of variations exercises including single leg, lunges, and bulgarian lunges. My advice is to select an exercise you can do well and hold on for balance if you can't get the best trunk, pelvis, hip and knee alignment.

I prefer to start with a lunge for more balance. Try keep the knee centred over the ankle (shin vertical), trunk parallel to the shin, gap between the knees and the hips level.

Lower the lunge down by bending the knee and keeping your weight back over your heel, without putting too much weight through the back leg. You can add weights, perform the entire lunge, hold isometric mid-range lunges, place your back foot on a swiss ball etc. It depends what functional demands you are trying to replicate.

And finally, the Bulgarian Lunge (a lunge with the back leg up on a step or bench). The great aspect of this exercise is the knees are a level height and you can accurately see the gap needed between them to keep the hips and pelvis level. Being critical, my balance is not good enough to stand up straighter or lunger lower down, both of which would be a more ideal representation of the exercise.

Michael used the same exercise and the same progression of exercises that I love to use, but he was focussed on the entire lower limb. After watching Michael apply and adapt this assessment to patients with knee pain, following knee surgery, and for chronic hip pain, I realised that although the principles of exercise progression can be generalised across these injuries, each patient must be specifically and carefully trained at a level they can achieve the best contraction. You'll be surprised how many clients are limited at the level of a bridge or clam to begin with and need to develop a lot more strength, control and endurance before standing exercises are completed well.

It was a great opportunity to watch a very experienced Physiotherapist adapt and change his verbal cues and exercise progressions. It made me appreciate how specifically we need to train functional movements.

Thanks Michael for sharing these great tips for clinical practice.

Sian

References:
Selkowitz, D. M., Beneck, G. J., & Powers, C. M. (2013). Which Exercises Target the Gluteal Muscles While Minimizing Activation of the Tensor Fascia Lata? Electromyographic Assessment Using Fine-Wire Electrodes. J Orthop Sports Phys Ther, 43(2), 54-64.