Lateral hip pain is a fairly common ailment and more often than not, people are resorting to clamshells and glute stretches to deal with it. Sound familiar?
But what if these common fixes for lateral hip pain can actually make it worse?
Lateral hip pain is often associated with poor lateral stability of the pelvis creating excessive hip adduction and resulting in stress on the glute med.
While it makes sense that the target for management of lateral hip pain is often on the glute med, namely stretching and strengthening it,
what if I told you that classic glute, TFL, and piriformis stretches and exercises like clamshells can actually make lateral hip pain worse?
If you are wondering why, make sure to keep reading as I will explain the causes of lateral hip pain, why the common fixes can actually be detrimental, and some more effective choices to help your clients.
WHAT EXACTLY ARE WE TALKING ABOUT?
Individuals with lateral hip pain complain of pain over the greater trochanter and occasionally just below the lateral aspect of the iliac crest.
While this type of pain used to be commonly referred to as trochanteric bursitis, it is now accepted that gluteus medius tendinopathy is the more likely pathology in those with pain and point tenderness over the greater trochanter.
Of course, it is important to note that bursitis and tensor fascia lata enthesopathy (commonly known as IT band syndrome) may also result in lateral hip pain.
But more importantly, the glute med, bursa and TFL are all likely to be irritated by the same mechanics.
WHAT ARE THE MECHANICS OF LATERAL HIP PAIN?
It is important to note that a relatively sudden increase in activity and therefore in load on the tendon alone could be sufficient to create an onset of lateral hip pain.
However, decreased lateral stability of the pelvis can also be a contributive factor.
An inability to stabilize the pelvis in the frontal plane results in excessive hip adduction and increased compression of the distal portion of the gluteus medius tendon against the greater trochanter:
Of course, the glute med may not hold all of the blame for lack of lateral stability of the pelvis. The foot has a large role to play in preventing knee valgus and increased hip adduction.
While compression in itself may have minimal effects on tendons, the combination of compressive and tensile loads is proposed to be particularly damaging to tendons.
As suggested by Cook and Purdham (2012), tendons that have an insertion over a bony prominence are nearly always exposed to both tensile and compressive loads, especially in certain joint positions. For more on that, head to my article Stop Stretching for Tendinopathy.
WHY IS STRETCHING BAD?
I just want to start off by saying that stretching is not bad in itself. Here is my answer to: Is Stretching Good or Bad? if you’re wondering about that.
What I am suggesting here is that the commonly prescribed stretches for the glutes, piriformis and IT band that we most often see are not ideal in the context of avoiding postures that result in compressive load of the tendon.
MAKE SURE YOU WATCH THE MAIN VIDEO OF THIS BLOG TO SEE THESE STRETCHES
That said, whenever we are managing tendinopathy, muscle-tendon unit coordination is an important factor to consider and address.
We need the muscle to function optimally to decelerate and distribute load, and essentially help protect the tendon from excessive stress. If there are myofascial restrictions that are impacting muscle coordination, these are best dealt with using soft-tissue mobilization or self-mobilizations such as foam rolling.
HOW TO ACTIVATE THE GLUTE MED
I make fun of clamshells all the time, as I do band shuffles. If you’re curious as to why, read this article.
However, context is key. From a rehab perspective, there are plenty of good reasons to reactivate the glute med using targeted isolation exercises.
But just like with stretching,
many of the most common glute med exercises are not ideal in the context of avoiding postures that result in compressive load of the tendon
Because clamshells are done in a side lying position, they allow the hip to cross the midline with the added resistance of the band pulling the hip into adduction, creating compressive load.
The good news is, if you just happen to love clamshells, you can have your clients do them from an abducted position and you’re all set!
WATCH THIS VIDEO TO SEE HOW THESE ARE DONE:
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All that said, clamshells are also not HOW your glute med contributes to lateral pelvic stability.
Weight bearing, specifically single-leg weight bearing, paints a better picture of what we want the glute med to be doing. And if your client is not ready for single-leg holds, this single-leg tall kneeling exercise is a great modification:
LOAD MANAGEMENT FOR GAINS
We need to remember that both excessive overload and decreased load, or stress shielding, can contribute to tendinopathy. This is why ensuring strength in the continuum of care is so important.
“Rehab is Training” is my founding vision of Rehab-U | Movement & Performance Therapy. What I mean when I say that is that the same principles that apply for training need to apply for effective rehabilitation programming.
Stress on normal tissue within physiological limits and with sufficient recovery normally leads to tissue adaptation. This is the premise of training periodization.
Rehab is no different, except that the tissue’s tolerance is not at its maximum which makes the starting point different. Understanding the pathomechanics is key in order to be able to identify movements and postures that have the potential to load the injured tissue without exceeding its tolerance.
This is going to be different for each individual you work with, depending on how irritable they are, their training age, and many other factors. But your thinking should be: how can I load this person without creating too much tensile and compressive load?
I know you’re thinking you still need to target the glute med and you’re dying to do squats with a band around the knees.
Don’t.
For many reasons that I discuss here, but namely because most people don’t have the hip abduction strength required to counter the resistance of a band around the knees.
Besides, your glute med focus was in the Activation sequence, now you need to load up! Any acrobatics here only decrease your capacity to overload the movement!
So, how do you do that?
While there is often an over-emphasis on eccentrics for tendinopathy, it can sometimes aggravate pain.
Perhaps the best way to summarize everything I have said above about load management is that the best exercises will be:
high-load, slow speed exercises done with minimal hip adduction or in positions that ensure minimal hip adduction.
For example, I really like lateral step ups for loading up the hip. I think they are an exercise that is often over-looked. You can adjust the height of the box and it is relatively easy to control for adduction.
WATCH THE MAIN VIDEOS OF THIS ARTICLE TO SEE HOW THIS EXERCISE IS DONE.
The bottom line is that it makes absolute sense to target the glute med for lateral hip pain. There just need to be better choices than stretches and clamshells, and for good reason.
What is vehicled as a common fix for lateral hip pain and many other issues and ailments often lacks context and critical thought. Don’t be too quick to assign “go-to” exercises. Rather, build a strategy and then select the appropriate exercises.
REFERENCES
Cook, J., & Purdam, C. (2011). Is compressive load a factor in the development of tendinopathy? British Journal Of Sports Medicine, 46(3), 163-168. doi: 10.1136/bjsports-2011-090414
Grimaldi, A., & Fearon, A. (2015). Gluteal Tendinopathy: Integrating Pathomechanics and Clinical Features in Its Management. Journal Of Orthopaedic & Sports Physical Therapy, 45(11), 910-922. doi: 10.2519/jospt.2015.5829
Mai-Linh Dovan M.SC., CAT(C)
Certified Athletic Therapist
Founder of Rehab-U
Mai-Linh will be coming to Singapore to teach her course Movement and Performance Therapy Specialist on 30-1-2 March/April 2023.
Go here for more details!
She will also be conducting a FREE masterclass for us on Friday 2nd December 2022, 9am (SGT) live on Zoom. Registration is mandatory here