Hip Abduction

Introduction

Hip abduction is much more than a sideward movement of the thigh at the hip joint. It is an essential movement pattern indispensable for standing and moving on two feet. Good hip abduction (and hip extension) patterns keep the lateral and posterior hip muscles toned and shaped, staving off the saddlebag problem so prevalent in a populace that is overweight and sedentary.

There are two major problems that arise with a poor hip abduction pattern. The functional fallout is low endurance during standing/walking, poor balance on one foot and poor grounding. The aesthetic fallout is the "saddlebag" shape often found in the female thigh. The saddlebag is the thickened fascia and deposited fat at the top of the lateral thigh typically seen in pear-shaped physiques. Excess body fat is partly to blame for the shape, but even when normal weight is achieved, the saddlebag often remains. Unfortunately, conventional side-leg raising exercises and seated hip abduction resistance machines are inadequate solutions for either problem, as I will explain.

Ninety percent of my clients present with poor hip abduction function. They get around because other muscles provide compensation. The built-in redundancy of the body's neuromusculature provides for substitute muscle involvement but the result is not optimal or even normal. When clients tell us that standing for long periods gives them low back pain or that walking through a shopping mall is fatiguing, the reason is often due to poor support on one leg and the strain of maintaining a level pelvis during the gait cycle. Clients are seldom aware of hip pain but instead will complain of low back or sacroiliac problems. Since most of our clients walk into our fitness settings, we often assume they have adequate hip abduction patterns. Nothing could be further from the truth.

Before getting to solutions for saddlebags and endurance, I will describe this essential movement pattern and ways to work with it. I will explain hip abduction as a first order pattern and problems associated with poor patterns. This article will also cover the anatomy of the muscles involved, tests to assess the problem and exercises to correct both the pattern and the saddlebags. I will also discuss the problems of conventional exercises used for hip abduction.

A pattern of the first order

All movement is patterned which means there is a particular sequence or order of muscle recruitment that produces any optimal, functional movement. A “first order” pattern is one that must be in place before other patterns and is foundational to other movements. The process of standing and moving on two feet depends on good hip abduction--a first order pattern.1 Specific muscles—gluteus medius and minimus--must initiate and carry out the movement. This pattern of muscular action is anatomically fixed (stereotypical) and cannot be changed (Lewis, 1990).

During the gait cycle, we must stand and dynamically balance on one foot for up to 85% of the time (Janda, 1984). Humans can do this because of the action of the hip abductors. By keeping the pelvis level, they allow us to stand on one foot while the other swings through in the sagittal plane. The hip abductors make it possible to smoothly move the center of gravity over the standing leg (transverse shift) and then forward (sagittal shift) with every step we take. If the ipsilateral gluteus medius/minimus is weak, the pelvis will not remain level (see Trendelenberg sign in Hoppenfeld, 1976) and the gait cycle will be dysfunctional. Even a minor weakness in these muscles puts a strain on the lumbar, sacroiliac, hip, knee or ankle joints.

Anatomy

The principle muscles involved in hip abduction are the gluteus medius and minimus, both located on the lateral side of the ilium and crossing the lateral hip joint. All of the gluteal muscles are phasic muscles. This means they are (or should be) available on demand but do not answer to the pull of gravity as do postural or tonic muscles.

Gluteus minimus, the smaller and deeper of the two, originates on the anterior portion of the lateral ilium and inserts on the superior part of the greater trochanter. It is an abductor of the hip but also an internal rotator and assists in flexion. The larger gluteus medius overlies most of the minimus. It originates in a broad patch on the lateral ilium and inserts on the posterior/lateral aspect of the greater trochanter. Its posterior fibers are covered by the gluteus maximus. Medius functions in abduction of the hip joint and assists in flexion and extension.

Observing and testing the movement pattern

These tests put the gluteus medius and minimus in a position to respond to the direction of resistance providing a useful and valid test.

Test #1: Gait.

Position yourself to observe the client walk away and toward you and then across your field of vision. If the hip abduction is normal, the client should be able to walk slowly and evenly, in a straight line, with the legs moving in their own sagittal planes; the torso and shoulders will be relaxed. Watch for quick, wobbly gait and tight, held shoulders indicating poor support from the hip abductors.

Test #2: One-legged stance.

Ask your client to pick up one foot and stand on the remaining leg, first with eyes open and then with eyes closed. Let the client do several trials before you judge the movement. In a normal test, there will be a small amount of lateral weight shift over the standing leg; the torso and arms will remain relaxed and steady, the pelvis level. Compare the stability of each side and note which is least stable.

Test #3: Step-up.

This test stresses the system a little more than the above tests. Place a step stool opposite a wall so that the client can touch the wall for balance. Ask your client to step up one foot at a time. Note whether the client can simultaneously raise the body weight while shifting the center of gravity forward and sideward onto one leg with a level pelvis. Watch for any instability on the standing leg, difficulty raising the body weight and any report of pain or discomfort. Compare the two sides.

Test #4: Side-lying leg raise (Fig. A).

This side-lying test is more complex, but very valuable because it tests the gluteus medius/minimus against maximal gravitational pull.

The client is in a side-lying position on a table or mat without shoes; the supporting leg is flexed 90° at hip and knee joints for stability; head rests on arm or small pillow. The working hip joint is extended 10-15°, the knee is extended; the ankle and foot are relaxed. The leg is not stretched nor are the toes pointed. Ask the client to exhale and slowly raise (abduct) the whole leg toward the ceiling but no higher than hip level.2 Ask the client to initiate the movement from the lateral malleolus; briefly touch the bone to cue the client. The client lowers the leg slowly and rests in between trials, of which there should be two or three.

Watch for these common errors, which indicate poor recruitment of the gluteus medius and minimus:

• Problems in taking the test position such as lying on the supporting hip, keeping the hips stacked or extending the hip joint (due to tightness in the hip flexor muscles)
• Any flexion or external rotation of the hip joint (substitutes for the weaker abductor function)
• Any raising/hiking of the pelvis toward the ribs
• Any recruitment of the quadratus lumborum or abdominals (substitutes for the weaker abductor function)
• Any appearance or sensation of weightiness of the leg
• Any wobble or tremor of the leg during any part of the movement

This is a long list of potential errors found in a poor hip abduction pattern. When the pattern is functional, the client can smoothly raise and lower the leg in its own plane (just behind the frontal plane). The leg will feel nearly weightless and the movement will be effortless. As the femur abducts on the pelvis, the shortening of the gluteus medius and the lateral fibers of the maximus will create a dimple just above and behind the greater trochanter showing that the correct muscles are in use (see Fig. E).

What is the cause of poor hip abduction?

Many people of the third world live on their feet with little evidence of low back or sacroiliac pain (Fahrni, 1966). These people travel on foot and sit or squat on the earth. It is my view that we in the developed world have poor hip abduction due to too much sitting in chairs. When standing and walking become uncomfortable or tiring, we sit even more, adding to the problem. The muscles become deconditioned or may simply exhibit pseudoparesis (false paralysis) through lack of use. Trauma is also a frequent cause of dysfunction. Other clients trace problems back to the birth of a child.

Coincident with poor hip abduction, at least in many females, is the saddlebag problem. Tissue that is unused or misused lacks the appearance of optimal tone and shape. Readers will learn that the solution for a poor pattern is also a saddlebag solution.

Facilitating the Tissue

If one or more of the tests indicates a problem in the pattern, I verify the visual impression with palpation and/or postural muscle testing (Woodruff, 2002). The soft tissues of the hip abductors typically present with layers of hypertonic fibers tender to moderate pressure. Such tenderness is frequently a surprise to the client who usually feels pain elsewhere such as the lumbar spine or sacroiliac joint(s). Myofascial and patterning techniques may be required to normalize the tissue but often a gentle patting or rubbing of the lateral hip area will serve to facilitate, i.e., "wake up" the dormant tissue. Clients can do this on themselves before doing their exercises. Failing that, professional treatment by a qualified therapist is needed.

Conventional Exercises and Their Limitations

The conventional side-lying leg raise is generally performed with a slightly flexed hip and a large range of motion (Fig. B). This movement uses only the anterior fibers of the lateral gluteals; most of the work is performed by the tensor fasciae latae, rectus femoris and iliopsoas. These are hip flexors, not abductors. Such large, kicking actions or small, repeated leg lifts may exhaust some portions of the muscle but does nothing for the hip abduction pattern. A pure hip abduction is a very small leg raising movement, no higher than the pelvis (see Test #4 above).

The seated resistance machine in which the client presses the lateral thigh outward against pads also uses the wrong muscles. Hittner’s research shows that in the seated position, the piriformis and the tensor fasciae latae are being loaded and that “gluteus medius and minimus are in a poor position to abduct the hip” (Hittner, 2003). These lateral gluteals along with the gluteus maximus, are the muscles that need to be toned and conditioned to address the saddlebag problem.

Working with stability devices such as balls and balance boards can tune up an already functional hip abduction pattern but cannot restore it if the tissue is not available, i.e., inactive for any reason. Restoring the pattern means putting new information into the CNS through manual facilitation, specific exercises and maintenance of the pattern.

Roll into Position (Figs. C,D,E)

Begin by teaching your client to roll into the side-lying position as follows. Ask your client to lie supine, in sock feet, with legs straight and feet spread wider than shoulder width; hands rest on abdomen. Roll onto the left side, flexing left hip and knee and anchoring the right foot to the floor. Arrange right arm under the head for comfort. Leaving the right foot "behind" puts the right hip into extension--the correct position to activate the lateral gluteals. Repeat this rolling sequence until the client is comfortable with it. The client is now ready to do side-lying leg raises.

Hip Abduction Exercise (Figs. A and E).

Give the client these instructions: Inhale, exhale and lift your leg toward the ceiling to hip level. Lower and rest. Repeat. Keep the hip in extension. Repeat four or five times. Change sides by rolling into position and repeat the exercise on the new side. Review the criteria in Test #4 to check whether your client is exercising correctly.

Working with patterns is not the same as resistance training. Do not overwork; stop and change sides when the movement starts to deteriorate. If you exhaust the correct muscles, the CNS will find substitutes. This creates a poor pattern. Do not add ankle weights or leg circles to the movement. The weight of the leg is sufficient to stimulate the muscles needed for a good pattern.

Standing Lateral Weight-Shift.

This weight-bearing sequence using a sideward shift of weight cultivates a stable one-legged stance (supported by lateral gluteals), activates the center of gravity and improves grounding. The client stands with feet parallel, hip width apart. Place the heel of the hand on each iliac crest, letting the fingers drape down over the gluteus medius. Shift the whole torso sideward to support on one leg keeping the other foot on the floor. Rest and exhale into the standing leg and foot. Shift back to center, pause, and then to the other side.3 Repeat four or five more times. Avoid sinking the weight into the hip joint or rotating the pelvis or shoulders.4

Integrating the Changes Through Movement

When we change a pattern it must be integrated into the CNS. Movement sends a message to the brain that there are new choices available to it. These new choices must be integrated; a whole series of biomechanical relationships will change as this process occurs. Patterns are not about isolated strengthening or volitional "commands" to the muscles, but are complex activities of the sub-cortex that can be stimulated only with intentional movement.

The side-lying leg raises described above are non weight-bearing and should be integrated with movement such as the lateral weight shift, walking and/or the step-up movement described in Test #3. Clients may feel a little unstable when they first get to their feet so they should walk slowly and deliberately for about a minute until the body re-organizes itself.

The Saddlebag Solution

Trainers should perform a regular assessment and measurements including the hip girth. Observe your client’s gait. Test for hip abduction pattern dysfunction. Teach the exercises I have described and check to see they are done properly and routinely. Clients should do the side-lying leg raise at least three times a week. If there is a saddlebag problem, the exercise should be done daily in combination with a weight-loss program to reduce overall body fat. I am not suggesting that spot reduction is possible but that sculpting the tissue by using it properly is, in my experience, routinely successful. With improved hip abduction, clients will be able to walk longer and further with less fatigue and more enjoyment. They will sit less, use more calories and enjoy a body shape change they may have sought for years.

Notes

1. Hip extension and shoulder abduction are the other two first order patterns identified by Dr. Janda. My article on Hip Extension and Back Pain can be found on PTontheNet.com.
2. In pure hip abduction, the femur abducts until the greater trochanter meets the acetabulum. No further range of movement is necessary or helpful in getting a valid test.
3. This exercise is shown on my videotape, 3-D WORKOUT, vol. 1, the Basics (2001).
4. I use a number of other exercises in my hip abduction protocol. They are most effective when learned in a face-to-face setting. My course: Muscles in Patterned Action covers the concepts discussed in this article. Visit my web site for details: www.body-in-motion.com.

References

• Hittner, N (2003). Avoiding the Traditional Pitfalls of Training Part I: Seated Hip Ab/adduction Machines. PTontheNet.com.
• Hoppenfeld, S (1976). Physical examination of the spine and extremities.
• Fahrni, HW (1966). Reference in Janda, V (1984). Low back pain: trends, controversies, community rehabilitation approach. WHO.
• Janda, V (1984). Pain in the locomotor system: a broad approach. In Aspects of manipulative therapy. Melbourne: Churchill Livingstone.
• Lewis, G (1990). Lecture notes on Janda’s principles of therapeutic exercise.
• Woodruff, DL (2001). 3-D WORKOUT, vol. 1, the Basics. Oakville, ON: Body-in-Motion. 48-minute VHS videotape.
• Woodruff, DL (2002). Postural and Phasic Muscles. PTontheNet.com.
• Woodruff, DL (2003) Hip extension and Back Pain. PTontheNet.com.