Mar
10

Six Must Have Exercises for Hip Stability

Hip Instability Gives New Meaning to Hip-Hop

Six Must Have Exercises for Hip Stability

When our clients tell us about the pain they feel in their lower body when they workout or run it is often very easy for us to concentrate on those parts of the anatomy from the hip joint down.  We typically address hip mobility, knee stability, or ankle mobility because when we visualize the motions associated with these types of movements we think about these parts as fulcrums that allow for these activities. But fundamentally we all know that ideal motion is about stability just as much as it is about mobility. This is precisely why hip stability is an issue that deserves a greater focus.  Of course these other points of consideration are very important because if they are not addressed, lower extremity as well as lower back issues can result. However, this article is intended to identify the impact instability has on the hip in order to bring attention to this less talked about factor in identifying and assisting chronic pain clients and athletes.

Like everything else in life, too much of anything can be bad news.  Such is the case with instability or excessive mobility in the hips. Every joint in our bodies that allows for mobility is equally equipped with stabilizers that allow for controlled motion, the ability to shift our center of gravity, and the handling of various loads. Now consider what will occur if a weak hip is overloaded.  For starters, the body is reactionary. So we know that any deviations will trigger a series of events along the kinetic chain in order to compensate. What you could typically expect to see from a loaded weak hip would be either excessive internal rotation of the hip and/or relative hip adduction.  From there, the domino effect takes over.  Lateral pelvic shift toward the weak hip (actual hip adduction), elevation of the pelvis on the weak side, and lateral torso flexion towards the contra lateral side are all deviations that usually accompany a weak hip.

If the last stated deviations are present, when your client stands on one leg you will potentially observe a valgus stress on the knee which opens the door for the femur to internally rotate on a relatively fixed tibia. The pelvis may also rotate forward following the internal rotation of the hip.  Such being the case, the end of the kinetic chain will reveal a foot and ankle that are everted and pronated respectively.  If corrective measures are not taken, the hip abductor muscles will become strained, the knee can become medially stressed, and ultimately the subtalar joint can become weakened.  This type of instability can result in a whole host of complications including Iliotibial (IT) band syndrome, patellofemoral issues, ligamentous strains, plantar fasciitis, bursitis, hip capsule strains and other lower extremity issues not to mention dysfunctions that often occur above the hip joint as a result. With these circumstances, it is very common to come across lumbar spine complications.  Due to lateral shift and pelvic rotation in the transverse plane, the lumbar spine would not be in the proper position to absorb significant load.  As a result there will likely be a rotational sheering force and unequal loading on one side of the lumbar spine. Over time the discs can weaken, the sacroiliac (SI) joint can become unstable, and the spinous ligaments can become strained.

As previously mentioned our body’s reactive nature will respond to each of these triggers in a manner designed to compensate for the dysfunctions caused by the weak hip.  In other words, excessive mobility in one area can lead to excessive stability in another.  To neutralize these effects it is very important to work on segmental alignment of the hip and pelvis.  The following tests will help identify most hip stability issues that should be addressed.

Simple tests and what to look for:

  1. One legged stance – Have your client stand on one leg and look for hip adduction, excessive internal rotation of hip, lateral shift of pelvis, valgus knee and/or knee flexion, lateral torso flexion, excessive pronation of the subtalar joint, foot eversion or the overall inability to stand on one leg.
  2. One legged reach test – have your client stand on one leg and have them reach down toward the stabilizing foot.  As their knee bends to accommodate the movement, look for the loaded hip to excessively adduct, valgus knee, excessive internal rotation of hip, foot attempting to toe out, excessive pronation of subtalar joint and excessive foot eversion.
  3. Pelvic Tilt : ASIS and PSIS – There is a direct association between asymmetrical pelvic tilt and hip instability.  To check your clients’ pelvic tilt, palpate the ASIS (anterior superior iliac spine) and the PSIS (posterior superior iliac spine). At times the asymmetrical pelvic tilt is the result of hip instability.  However, vice versa can be true. In some instances, hip instability, caused by other factors, can then lead to asymmetrical pelvic tilt.
  4. Calf Stretch test – With their feet pointing straight ahead, have your client stand on either the edge of a stair or a slant board to achieve a sufficient stretch in their calves. Make sure their hips are directly over their ankles and that their shoulders are above their hips.  When our calves are stretched in this manner, our reflex is to flex the torso forward. Because your client is standing vertical versus flexing forward, the hips are forced to extend relatively. From here, note the asymmetries between the internal rotations of both hips.  When the hips extend they are supposed to also externally rotate. Please keep in mind this is relative hip extension and relative external rotation of the hip. The bottom line to this test is to see if one hip has greater internal rotation than the other. The hip that has more internal rotation is usually the weaker, less stable one.
  5. Gait analysis – Look at deviations from what is considered “normal” gait. At swing phase (hip flexion) check for external rotation of the hip for ground clearance. If you note the circumduction of the tibia to substitute for external rotation at the hip, the hip is dysfunctional and impaired. At heel strike with transfer to mid stance the hip should internally rotate slightly. If you see excessive internal rotation then the hip is more than likely unstable. In addition, if you note the loaded hip adducting it too is a sign of hip instability/weakness. At mid stance and prior to toe off the subtalar joint should pronate slightly. If you see excessive pronation with the foot everting, the hip on that side is likely unstable. You can confirm your findings with the previously listed tests or other tests that you currently use to asses hip instability.

The goal with these tests is not to identify specific weak or overactive muscles. Instead look for segmental deviations/weaknesses and how they affect other areas of the body. The entire kinetic chain can be affected but my focus with this article is on the areas closest to the center of gravity. By addressing the deviations closest to the center of gravity you will actually address more dysfunctional issues than you might think including issues in the upper body.

Here are six of my favorite exercises used to help strengthen the pelvic and hip stabilizers. I recommend performing them in this sequence. Before you give them to your clients or athletes try them first. It is important to feel, first hand, how powerful these exercises are at hip and pelvic stabilization/strengthening.

1. FROG PRESSES: Lie on your stomach, resting your chin on your hands.  Spread the legs as far apart as possible. Bend the knees to a 90 degree angle and place the soles of the feet together. Press and release and soles of the feet. Be sure to use both the heels and the balls of the feet equally.  (3 x 20)

Frog Presses

Frog Presses

PURPOSE: To activate and strengthen your deep hip external rotators and glute stabilizers while minimizing adductor and hamstring function. Many times you will not be able to engage the stabilizers bilaterally due to one side being weaker. In time that will change. You can also achieve anterior tilt of the pelvis if your client or athlete has posterior tilt issues with their pelvis. In this case you strengthen the deep hip rotators while the pelvis is anteriorly tilted. If they have anterior pelvic tilt issues have them posterior tilt their pelvis throughout the exercise. They will achieve even greater glute activation.

2. DYNAMIC HIP LIFT: Lie on your back, knees bent and in alignment with the hips. Tie a belt or strap around the knees (knees should be shoulder width apart) and place a 6” pillow between the ankles. Relax the head and shoulders, palms up. Pull the knees apart against the strap and while still applying pressure to the strap squeeze the pillow with the ankles. Relax and repeat. Continue for the desired number of repetitions. (3 x10) To increasethe hip stability demand lift the feet about 6” off the floor while maintaining the pressure of the strap and pillow. (3×10)

Dynamic Hip Lift

Dynamic Hip Lift

Dynamic Hip Lift

Dynamic Hip Lift

PURPOSE: To activate the hip and pelvic stabilizers as you promote external rotation of the hip while the feet are in a neutral position. The lateral hip and pelvis stabilizers will contract as you squeeze and press. The neutral foot position will cause supination and inversion of the foot and ankle. The abdominals will also engage as stabilizers.

The lifting of the feet will activate the psoas which will engage more core stabilization. You may have to cue your client to brace their abs so the lumbar spine does not extend too much. The act of hip flexion will help train the hip and pelvic stabilizers to engage with hip flexion and relative hip extension while the feet are lowering.

3. ROCKING CHAIR: Lie on your back, relax the arms out to the sides, palms to the ceiling. Ankles, knees and hips all in alignment. Place a strap around the knees and roll one foot back onto the heel, at the same time roll one foot up onto the toes. Continue to alternate the feet positions while maintaining the pressure out against the strap. The feet will tend to slide away from the body – that’s okay – bring the feet back to the original position and continue with the exercise for the desired number of repetitions.  (2×20)

Rocking Chair

Rocking Chair

Rocking Chair

Rocking Chair

PURPOSE: To mimic your gait pattern while promoting hip abduction.  This will engage your lateral hip and pelvic stabilizers. You will also get asymmetrical lumbosacral rhythm which occurs with running and walking. The supine position diminishes any pelvic rotation and discourages other muscles from compensating with the exercise. You may have to cue your client on the dorsi/plantar flexion of the feet. Some people have troubles coordinating the movement with both feet.

4. BROOKS CORE PRESS: Place a strap around your ankles a little less than hip width apart. Kneel in front of a wall with knees approximately 6-8 inches from the wall. The knees are directly under the hips. Place the hands on the wall, chest level and slightly wider than the body, fingers pointing to the ceiling. The elbows will be bent, shoulder height and slightly wider than the wrists. Tuck the toes under so that the pads of the toes are in contact with the floor. From this position, press out against the strap with the ankles and then press the toes into the floor as if to push upward. Press against the wall with the hands. This will resist the force created by pressing into the floor with the toes. As you press the abdominals should brace to help the forward motion of the torso and pelvis. The key is to resist any forward movement when you press the balls of the feet in to the floor. Maintain the position of the body directly over the hips and knees.  Repeat for the desired number of repetitions. (3×10)

Brooks Core Press

Brooks Core Press

PURPOSE: To strengthen the lateral pelvic and hip stabilizers as well as the core in a vertical loaded position. The kneeling position will cause an anterior tilt of the pelvis which may or may not be ideal for your client. It depends on your objectives with pelvic tilt. The pressing out on the strap will engage the glutes and the pressing of the feet in to the floor will engage the core (anterior dominant). This includes the quadriceps, abdominals and pecs. You will also activate the low back to help stabilize.

5. BROOKS HIP PRESS: Stand sideways in a doorway, feet straight and knees in line with the hips. Position the side of one foot against the wall. Slightly lift the inside foot off the floor and shift your weight to your outside foot. Press the inside foot against the doorjamb feeling the contraction on the outside of the loaded hip. Keep the knee straight as you push and the body straight up and down. You can also perform with the knees slightly flexed. (3 x 10)

Brooks Hip Press

Brooks Hip Press

PURPOSE: To load/strengthen the outer hip and leg. As you lift the inside foot the outside leg’s glutes will engage (glute med/min). The engagement of the glutes will help pull the outer leg’s pelvis downward. This is an important cue because it helps take the quadratus lumborum out of the picture. As you know many times the quadratus lumborum will engage if the glutes are weak or restricted. When the inside foot presses in to the door jam the outer hip has to prevent adduction of the hip. You can start your client or athlete in the kneeling position if they have extreme instability or a painful hip, knee, foot and ankle issues. If your client has posterior pelvic tilt issues the kneeling position will help the pelvis rotate anteriorly by forcing the quadriceps to lengthen.

6. ONE LEG STANCE with Hip Hikes: Stand against a wall with your heels, mid back and head against the wall. Place one foot on a 14 – 18” block. Make sure the loaded hip does not jutt out to the side. If so the loaded hip will adduct. Hold for (one minute). Next slide or hike the unloaded hip up. Make sure the pelvis stays flush against the wall. Lower the hip and repeat the hike. (2×10)

Hip Hikes

Hip Hikes

Hip Hikes

Hip Hikes

PURPOSE: To dynamically engage the hip stabilizers. This position of your pelvis in this exercise will cause the pelvis to be asymmetrical. (straight leg – anterior tilt, bent leg – posterior tilt)  This fact is important because the pelvic position is more like your pelvis position during movement (gait). As the hip hikes the contra lateral glutes will actively engage. You may have to cue your client to actively engage their glutes. Some clients will only use the QL and obliques to create the movement versus the contra lateral glutes. Make sure this does not happen.

If you note hip instability/weakness issues use these exercises as a starting point or building block. You can also incorporate the exercises at any phase of your client’s training. If you are limited for time you can have your clients perform these exercises at home on a daily basis. Have them continue with the exercises until they have developed the desired hip stability.

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