The myth of gluteus and how reasoning errors lead to such beliefs Introduction: A look at how we and our

colleagues practice offer a glimpse into the trends and fads of physiotherapy. One common practice in rehabilitation is the retraining of the gluteal muscle complex. The gluteals have been touted to be the reason for the onset of multiple lower limb pathologies, including hip and knee osteoarthritis, tendinopathies, patellofemoral pain syndrome, ITB friction syndrome, ankle sprains and impingements etc. In short, name a lower limb condition and the gluteals will inadvertently come to mind. Is the gluteals the magic bullet for all conditions, or are therapists seriously misled into the belief that what they are doing is working? I am attempting to identify the scientific basis of our everyday reasoning. Only the highest available evidence will be cited. Challenge to my citations may be made, yet they should be countered by higher quality evidence. If I cannot identify any credible basis to the gluteal-is-important reasoning, then the conclusion that it is a fad may be made. Part 1: If gluteals are the panacea, than epidemiologically, it should be easy to identify that the gluteals are a risk factor for future injuries, a prognostic factor, and mediating factor in why symptoms improve. Are they true?

Commonly cited reasoning: 1. Subnormal gluteal neuromuscular function is a strong and consistent predictor of future lower limb injuries [pardon me, I am only going to touch on ankle sprains, PFPS, knee OA, hip OA]. Is it true? Ankle sprain Gluteals have not be evaluated as a predictor of future ankle sprains. The following are all associated with an increased risk of ankle injury: higher postural sway, being in the lower postural stability group, lower inversion proprioception, higher concentric plantar flexion strength at faster speeds and lower eccentric eversion strength at slower speeds.
Witchalls et al. Intrinsic functional deficits associated with increased risk of ankle injuries: a systematic review with meta-analysis. Br J Sports Med. 2012 Jun;46(7):515-23. doi: 10.1136/bjsports-2011-090137. Epub 2011 Dec 14.

PFPS Gluteals does not predict future PFPS. Weaker knee extension strength, expressed by peak torque, appears to be a risk factor for PFPS. This was supported by two independent systematic reviews.
Lankhorst et al. Risk factors for patellofemoral pain syndrome: a systematic review. J Orthop Sports Phys Ther. 2012 Feb;42(2):81-94. doi: 10.2519/jospt.2012.3803. Epub 2011 Oct 25. Pappas E, Wong-Tom WM. Prospective Predictors of Patellofemoral Pain Syndrome: A Systematic Review With Meta-analysis. Sports Health. 2012 Mar;4(2):115-20. Thijs et al. Is hip muscle weakness a predisposing factor for patellofemoral pain in female novice runners? A prospective study. Am J Sports Med. 2011 Sep;39(9):1877-82. doi: 10.1177/0363546511407617. Epub 2011 Jun 1.

Knee OA:

Obviously there are more important risk factors then neuromuscular reasons. However, with regards to what muscle deficits predict increased risk of knee OA, no studies have evaluated the gluteals. Weak quadriceps predict the onset of incident knee OA.
Segal et al. The longitudinal relationship between thigh muscle mass and the development of knee osteoarthritis. Osteoarthritis Cartilage. 2012 Dec;20(12):1534-40. doi: 10.1016/j.joca.2012.08.019. Epub 2012 Sep 3.

Hip OA: No prospective studies have evaluated if poor gluteals function increase the risk of future hip OA

2. Subnormal gluteal neuromuscular function is a strong and consistent prognostic factor for persistent symptoms in lower limb injuries [pardon me, I am only going to touch on ankle sprains, PFPS, knee OA, hip OA]. Is it true? Ankle sprain: I can find no prospective cohort studies nor any lesser quality studies on such a thinking. PFPS: Surprisingly, no prospective cohort studies nor any lesser quality studies were found to support such a thinking. The only predictors were pain duration and pain intensity.
Collins et al. Prognostic factors for patellofemoral pain: a multicentre observational analysis. Br J Sports Med. 2013 Mar;47(4):227-33. doi: 10.1136/bjsports-2012-091696. Epub 2012 Dec 13.

Knee OA: No evidence was found for the prognostic influence of gluteals in structural or symptom progression. In fact, the only evidence for the influence of muscle factors on prognosis is in the area of quadriceps neuromuscular function and morphology.
Dannhauer et al. Longitudinal sensitivity to change of MRI-based muscle cross-sectional area versus isometric strength analysis in osteoarthritic knees with and without structural progression: pilot data from the Osteoarthritis Initiative. MAGMA. 2013 Nov 22. [Epub ahead of print] Eckstein et al. Baseline and longitudinal change in isometric muscle strength prior to radiographic progression in osteoarthritic and preosteoarthritic knees--data from the Osteoarthritis Initiative. Osteoarthritis Cartilage. 2013 May;21(5):682-90. doi: 10.1016/j.joca.2013.02.658. Epub 2013 Mar 6. Segal et al. Quadriceps weakness predicts risk for knee joint space narrowing in women in the MOST cohort. Osteoarthritis Cartilage. 2010 Jun;18(6):769-75. doi: 10.1016/j.joca.2010.02.002. Epub 2010 Feb 11.

Hip OA: No neuromuscular prognostic factors have been evaluated. 3. Treating the gluteals is more effective (reduce more pain and improve function to a greater level) than treating any other muscles within the kinetic chain. Ankle sprain: No studies have been performed to evaluate the effectiveness of gluteal training. PFPS: Gluteal rehabilitation on the average reduces pain by 3.671.96 on a 0-10 VAS scale. Yet, studies on quadriceps based training reveal a benefit of 2/10 pain reduction. However, hip strengthening prior to functional training improves pain faster, not more, than quadriceps based training prior to functional training.
Peters JS, Tyson NL. Proximal exercises are effective in treating patellofemoral pain syndrome: a systematic review. Int J Sports Phys Ther. 2013 Oct;8(5):689-700. Syme G, Rowe P, Martin D, Daly G. Disability in patients with chronic patellofemoral pain syndrome: a randomised controlled trial of VMO selective training versus general quadriceps strengthening. Manual Therapy 2009 Jun;14(3):252-263

Dolak et al. Hip strengthening prior to functional exercises reduces pain sooner than quadriceps strengthening in females with patellofemoral pain syndrome: a randomized clinical trial. J Orthop Sports Phys Ther. 2011 Aug;41(8):560-70. doi: 10.2519/jospt.2011.3499. Epub 2011 Jun 7.

Knee OA: Hip strengthening reduces pain but not knee joint loads compared to no therapy in people with varus aligned knee OA. Yet, when a head to head comparison was made with quadriceps based exercise, both were equally effective in reducing pain and improving function.
Bennell et al. Hip strengthening reduces symptoms but not knee load in people with medial knee osteoarthritis and varus malalignment: a randomised controlled trial. Osteoarthritis Cartilage. 2010 May;18(5):621-8. doi: 10.1016/j.joca.2010.01.010. Epub 2010 Feb 6. Bennell et al. Neuromuscular versus quadriceps strengthening exercise in people with medial knee osteoarthritis and varus malalignment: A randomised controlled trial. Arthritis Rheum. 2013 Dec 24. doi: 10.1002/art.38317. [Epub ahead of print]

Hip OA: No studies that have compared hip based training versus any other muscle based training.

4. The reason why this patients pain and function improved is due to improvement in gluteals neuromuscular function and no other muscles. Ankle sprain: I can find no evidence. PFPS: The only study to have directly evaluated changes in physiological parameters to patient outcomes points to an improvement in quadriceps cross sectional area as a predictor of improvement in the short term.
Pattyn et al. What predicts functional outcome after treatment for patellofemoral pain? Med Sci Sports Exerc. 2012 Oct;44(10):1827-33.

Knee OA: This very recent review identified that quadriceps specific rehabilitation is one the key ingredients for improvement. An interesting point was that hip based training compared to doing nothing, improved not only hip abduction but also quadriceps strength.
Juhl et al. Impact of exercise type and dose on pain and disability in knee osteoarthritis: A systematic review and meta-regression analysis of randomized controlled trials. Arthritis Rheum. 2013 Dec 18. doi: 10.1002/art.38290. [Epub ahead of print] Bennell et al. Hip strengthening reduces symptoms but not knee load in people with medial knee osteoarthritis and varus malalignment: a randomised controlled trial. Osteoarthritis Cartilage. 2010 May;18(5):621-8. doi: 10.1016/j.joca.2010.01.010. Epub 2010 Feb 6.

Hip OA: I can find no evidence.

Part 2: I have attempted to establish the aberrant thinking of how gluteals are more important than any other muscles in the kinetic chain from an epidemiological sense. However, individuals can still argue about the importance of gluteals from a physiological/mechanistic sense. In this section, I will demonstrate that one does not need the gluteals to explain what we see. I will also demonstrate that clinicians have double standards when it comes to mechanistic explanations in practice.

Argument 1: Lean forward, feel the gluts, does it feel easier and lighter?

What therapist think: The person squatting on the left is undesirable. Comparing that to the right, there is increased anterior pelvic tilt, greater recruitment of the gluteus, hence reducing knee joint loads. What could also be happening: When you lean forward to a greater extent, you reduce the lever arm of the body weight to the fulcrum (knee). This reduced lever arm, means the quadriceps work less to support the same body weight!! People can feel easier based on this very simple fact. No gluteus required. Argument 2: The evidence states gluteus neuromuscular deficits are present in people with PFPS. Counter argument: I do not doubt that gluteus neuromuscular deficits are present in this cohort, as nicely summarised by Barton et al (2013). The implicit reasoning or thinking is that gluteus neuromuscular deficits are MORE IMPORTANT or MORE PREVALENT than another other neuromuscular deficits, making it the MORE IMPORTANT muscle to target. This is blatantly inaccurate as many studies report on quadriceps and ankle neuromuscular deficits in people with PFPS. No research has been done to justify why gluteus impairments are inherently more important than any other impairments.
Barton et al. Gluteal muscle activity and patellofemoral pain syndrome: a systematic review Br J Sports Med 2013;47:207-214 doi:10.1136/bjsports-2012-090953 V Fagan, E Delahunt. Patellofemoral pain syndrome: a review on the associated neuromuscular deficits and current treatment options. Br J Sports Med 2008;42:10 789-795 Published Online First: 18 April 2008 doi:10.1136/bjsm.2008.046623 Giles et al. Does Quadriceps Atrophy Exist In Individuals With Patellofemoral Pain? A Systematic Literature Review With Meta-Analysis. Journal of Orthopaedic & Sports Physical Therapy, 2013, Volume: 43 Issue: 11 Pages: 766-776 doi:10.2519/jospt.2013.4833

Argument 3: The reason why I do not target quadriceps ever is that I belief that pain inhibition is the primary reason for its deficit. Thats why I target the hip. Counter argument. I believe that I do not even need evidence to proof that argument 3 is untenable. How? If quadriceps deficits are a result of pain in the knee, than one should never treat muscles that crosses a painful joint. BUT, do you treat the hip in people with hip OA or hip FAI or hip labral

tears? I bet you do. But gluteus deficits in people with hip injury must surely be due to inhibition? Why do you still treat it then? Hence, this line of reasoning is flawed partially because you do not consistently believe it. The proper counter argument is that muscle impairments are not always due to inhibition, which is an EXTREMELY dated model of motor control. Also, quadriceps impairments are present way before pain occurs, and this predict the onset of pain. The resolution of pain does not guarantee the return of normal muscle physiology.
Lankhorst et al. Risk factors for patellofemoral pain syndrome: a systematic review. J Orthop Sports Phys Ther. 2012 Feb;42(2):81-94. doi: 10.2519/jospt.2012.3803. Epub 2011 Oct 25. Pappas E, Wong-Tom WM. Prospective Predictors of Patellofemoral Pain Syndrome: A Systematic Review With Meta-analysis. Sports Health. 2012 Mar;4(2):115-20. Van Tiggelen et al. Delayed vastus medialis obliquus to vastus lateralis onset timing contributes to the development of patellofemoral pain in previously healthy men: a prospective study. Am J Sports Med. 2009 Jun;37(6):1099-105. doi: 10.1177/0363546508331135. Epub 2009 Mar 12. Hodges PW, Tucker K. Moving differently in pain: a new theory to explain the adaptation to pain. Pain. 2011 Mar;152(3 Suppl):S90-8. doi: 10.1016/j.pain.2010.10.020. Epub 2010 Nov 18.

Argument 4: I ask my patients to squeeze the gluts during walking, as the gluts are very important for walking.

The gluteus are adapted for running. Its role in walking is minimal. In fact, the argument is not that gluteus are important or not. The argument is whether it is more important than any other muscles

of the body in walking for it to deserve such prominence. The answer graphically is NO!!! ALL MUSCLES ARE IMPORTANT at different stage for different functions. Moreover, the gluteals act in a phasic manner. Asking someone to tighten the butt whilst walking is promoting an unnatural pattern. I can understand this if you are doing it for running.
Lieberman et al. The human gluteus maximus and its role in running. J Exp Biol. 2006 Jun;209(Pt 11):2143-55. Pandy and Andriacchi. Muscle and Joint Function in Human Locomotion. Annual Review of Biomedical Engineering. Vol. 12: 401-433 (Volume publication date August 2010)

Now I too would like to counter argue this point not using evidence, but using inconsistent reasoning. Everyone is saying the brain does not control muscles but control movement. This is borne out Ledermans paper. Lets assume that this statement is right (although Henry Tsao and Paul Hodges works clearly demonstrate that the brain controls both movement and muscles). It would explain why we do not perform isolationist training such as VMO and TrA retraining anymore. Why then do we ask patients to tighten the butt in isolation? Surely the brain controls movement not muscles. Therapists who adopts such a reasoning are surely shooting themselves in the foot.
Lederman E. The myth of core stability. J Bodyw Mov Ther. 2010 Jan;14(1):84-98. doi: 10.1016/j.jbmt.2009.08.001.

Where do we go? Clearly, we have jumped onto the bandwagon of eternal gluteal retraining without much thought. This thinking is clearly driven by fad and fashion rather than science. What we should do is to perform a thorough assessment and treat deficits that have been shown consistently to reduce symptoms and improve function. We should also have a sophisticated understanding of typical motor control and biomechanics, to assist us in deciding if a certain deficit is important or not.