From my clinical experiences thus far, I have found that many individuals with low back pain lack proper gluteus maximus strength. (This should not be a surprise to you unless you went to physical therapy school when dinosaurs were still roaming). I often find that the gluteals are weak due to a combination of disuse atrophy and muscle inhibition secondary to pain. In the case of disuse atrophy, the individual does not activate their gluts and therefore preferentially activates other muscles to perform the movement. For example, think about the individual who arches his/her back to pick up a box rather than perform a hip hinge and squat OR consider the individual who rests in lumbar extension, locking out the lumbar facets and resting on the anterior hip ligaments. They avoid the gluteals and activate their lumbar paraspinals and hamstrings to perform movements. With pain inhibition, the gluteals are not receiving proper neuromuscular facilitation because pain is overriding the movement. The muscles are temporarily unable to fire because pain is inhibiting the activation. In either situation, properly assessing hip strength and assessing the cause of weakness is a fundamental part of a low back evaluation.
In this post, I want to discuss hamstring dominance is relation to gluteus maximus testing. As I stated in the previous paragraph, poor movement patterns often lead to improper activation of the glut muscles. Since the gluts are not helping perform the movement, a different muscle overcompensates to perform the movement. Clinically, I often find that this other muscle is the hamstrings (or lumbar paraspinals). Individuals that preferentially activate their hamstrings prior to their gluts are called 'hamstring dominant.' This can be problematic because the gluteals are meant to act as a hip stabilizer and extensor. When they do not fire first, the gluteals do not stablize. The hamstrings attempt to act as both a prime mover and stabilizer.
The test for hamstring dominance is similar to the Kendall Glut Max testing position. Place the individual in prone with the tested knee bent to 90 degrees. Ask them to lift their leg off the table. In the normal healthy individual, the glut max engages prior to the hamstrings. Proper activation order: 1. TrA engages, 2. gluteus maximus activates, 3. hamstrings fire as the leg is lifted. If the hamstrings fire before the glut max, the individual drives that motion with the hamstrings.
Do not be fooled by strong gluts in the low back pain population. After assessing the glut max, retest for hamstring dominance to ensure they are not over-activating the hamstrings. Dominance patterns are extremely common. I highly recommend assessing for hamstring dominance in your lumbar patients.
James Heafner PT, DPT, OCS:
Owner and lead physical therapist at Heafner Health, cash-based physical therapy in Boulder, CO. Areas of expertise include orthopedic and manual therapy, functional movement, pain science, and movement science.
In May 2013, I earned my Doctorate in Physical Therapy from Saint Louis University. After graduating from the Harris Health Systems Orthopedic Residency in October 2014, I moved to Boulder, CO. Since living in Boulder, I have started my own cash-based PT practice, earned my OCS certification, and teach for the OPTIM Fellowship and COMT program in Houston TX and Scottsdale, AZ.
Chris Fox PT, DPT, OCS: Physical therapist at Foothills Sports Medicine & Physical Therapy in Scottsdale, AZ and regularly lectures at the Phoenix Campus for NAU's DPT program and for Optim Manual Therapy's COMT program. Completed multiple advanced manual therapy courses implementing aspects of biomechanical analysis. He received his DPT from Saint Louis University in 2013. Completed Scottsdale Healthcare's Orthopaedic Residency (now Honor Health) in July 2014. He became a Board Certified Orthopaedic Specialist in 2015. Level I Expert in FMS and SFMA , Kinetacore FDN Level 1 certification, and IASTM Technique course completion. He would like to pursue further education in McKenzie Technique, Dry Needling, Strength & Conditioning, Orthopaedic and Manual Therapy.
Brian Schwabe PT, DPT, SCS, CSCS:
- Board Certified Sports Physical Therapist (SCS) at Elite OrthoSport in Santa Monica, CA which specializes in treating collegiate/professional athletes and clientele from the Beverly Hills, Hollywood, and Santa Monica areas.
- USC Sports Residency Trained Physical Therapist (<1% of all PT's residency trained)
- DPT from Saint Louis University
- Future plans/interest include:
1. USAW, SFMA & Catapult Systems technology for NBA teams
2. Pursuing a position as a sports physical therapist &/or Strength coach for a Division 1 athletic medicine department or professional sport team.
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