Facebook Pixel
Brookbush Institute Logo

Tuesday, June 6, 2023

Effect of Mobilization of the Anterior Hip Capsule on Gluteus Maximus Strength

Brent Brookbush

Brent Brookbush

DPT, PT, MS, CPT, HMS, IMT

Research Review: Posteroanterior Hip Joint Mobilizations Improve Gluteus Maximus Strength

By Nicholas Rolnick PT, DPT, MS, CSCS

Edited by Brent Brookbush DPT, PT, COMT, MS, PES, CES, CSCS, ACSM H/FS

Original Citation: Yerys S, Makofsky H, Byrd C, Pennachio J, Cinkay J. (2002). Effect of mobilization of the anterior hip capsule on gluteus maximus strength. Journal of Manual and Manipulative Therapy. 10(4): 218-224. ABSTRACT

Why the Study is Relevant: Altered gluteus maximus activity has been correlated with pain and dysfunction of the low back, sacroiliac joint (SIJ), hip , knee and ankle (1 - 13). A growing body of literature suggests that joint mobilizations may have a positive impact on posterior hip and thigh muscle activity and recruitment (14-17). This 2002 study investigated the influence of posteroanterior hip joint mobilizations on gluteus maximus strength in 20 healthy participants. Results support the use of posteroanterior hip joint mobilizations to aid in optimal activity and recruitment of the gluteus maximus .

Study Summary

Study Design Randomized controlled trial
Level of Evidence
  • IB Evidence from at least one randomized controlled trial
Participant CharacteristicsDemographics
  • Age: 19-39
  • Gender: Not specified
  • Number of participants: 40
    • 20 in experimental group (EG)
    • 20 in control group (CG)

Inclusion Criteria:

  • N/A

Exclusion Criteria:

  • Hip joint hypomobility (defined as hip extension < 0°) or hypermobility (defined as hip extension > 20°) measured by goniometry
  • Presence of hip pathology, a history of trauma, low back pain and/or past surgery of the hip
MethodologyPrior to data collection, a blinded examiner took baseline gluteus maximus strength measurements from participants with an isokinetic dynamometry machine (Cybex Norm Testing and Rehabilitation System). This helped reduce the learning effects of testing on hip extension strength.
  • Participants were positioned prone at a predetermined motion barrier between 10°-20° hip extension, with the measured leg bent to 90° knee flexion.
  • Participants performed five maximum isometric contractions against the dynamometry machine with the right hip into extension.

To reduce the influence of fatigue, participants observed a 5-minute rest interval between the familiarization trial and the intervention.

Following familiarization, participants were randomly placed in the EG or the CG using a table of random numbers.

Joint Mobilization Procedure:

All participants were positioned in prone, with the left hip flexed to 110° off the plinth to maximize reliability between trials.

The right hip was positioned between 10°-20° hip extension at the first motion barrier.

A member of the research team administered all joint mobilizations. Each intervention was performed for 3 1-minute sets with 30-seconds of rest intervals between sets.

Following joint mobilization, each participant immediately underwent gluteus maximus strength testing using the same protocol performed during baseline testing and the blinded researcher. The blinded researcher was not aware of each participant's group allocation.

Data Collection and Analysis
  • Strength measures of the gluteus maximus were calculated and expressed as peak torque (in foot-pounds) by a computer connected to the dynamometry machine.
  • An independent group t-test compared the mean change in pre- and post-test strength values between the two groups. Significance was set at p < 0.05.
Outcome Measures
ResultsPre-intervention strength (in foot-pounds):
  • CG - 29.10 ± 1.87
  • EG - 30.65 ± 3.53

Post-intervention strength (in foot-pounds):

  • CG - 30.65 ± 2.02
  • EG - 34.85 ± 3.54

Gluteus maximus strength improved 14% in the EG following grade IV mobilizations but improved only 4% following grade I mobilizations to the CG (p = 0.002)

  • The following were calculated by Dr. Rolnick:
    • Cohen's d - 0.938 (Strong effect size)

Our ConclusionsThe findings reinforce the Brookbush Institute's practice of using joint mobilizations to improve muscle activation and strength prior to isolated activation and integration exercises.  Specifically, this study supports use of posteroanterior hip joint mobilizations to improve gluteus maximus strength.
Researchers' Conclusions

A 3-minute grade IV posteroanterior hip joint mobilization intervention improved gluteus maximus strength in asymptomatic participants. Benefits may extend to clinical populations with reduced hip extension mobility and/or strength.

Labelling of the structures of the hip joint. The anterior capsule is being stressed with postero-anterior hip joint mobilizations. Image courtesy of https://commons.wikimedia.org/wiki/File:Slide2DAD.JPG
Caption: Labelling of the structures of the hip joint. The anterior capsule is being stressed with postero-anterior hip joint mobilizations. Image courtesy of https://commons.wikimedia.org/wiki/File:Slide2DAD.JPG

The structures of the hip joint. The anterior capsule is being stressed with posteroanterior hip joint mobilizations. [Image courtesy of https://commons.wikimedia.org/wiki/File:Slide2DAD.JPG]Review & Commentary:

To our knowledge, this study was the first to investigate the immediate effects of posterior-to-anterior (PA) hip  joint mobilizations on gluteus maximus muscle strength. The findings add to a growing body of research on the acute effects of joint mobilization/manipulation on muscle activity/strength (14-17). This study demonstrated an immediate improvement in gluteus maximus muscle strength post PA hip  joint mobilizations.

The study had many methodological strengths, including:

  • The findings filled a gap in the research. Prior to this study, it was unknown whether posteroanterior hip joint mobilizations could improve gluteus maximus strength.
  • The double-blinded, randomized-controlled research design minimized observer bias and improved confidence in outcomes.
  • The posteroanterior hip joint mobilization is frequently performed in clinical practice, increasing the practicality of the study.

Weaknesses that should be noted prior to clinical integration of the findings include:

  • The reliability of the clinician’s grading (applied force) during joint mobilizations was not determined.
  • The determination of maximum isometric voluntary contraction of the gluteus maximus  post-intervention may have improved due to participants’ familiarity of the testing procedure. Future studies should include electromyography to help differentiate muscle strength and muscle activation levels following joint mobilizations. A control condition in which joint mobilizations are not received may also help to rule out bias from familiarity of the testing procedure.
  • The lack of follow-up and the design of the study do not permit speculation on the long-term effects of posteroanterior hip joint mobilizations on gluteus maximus strength.
  • The participants were asymptomatic. It is unknown whether individuals with pain would exhibit similar effects.

How This Study is Important:

This study adds to a growing body of research that suggests joint mobilizations affect muscle recruitment, activity and strength. Specifically, this study adds that performing (PA) hip  joint mobilizations may result in an increase in gluteus maximus  strength. Further research will be needed to determine the changes in muscle strength/activity that can be expected from mobilizations at other joints and in other directions. This study does support an integrated approach to practice by demonstrating a relationship between muscle function and joint mobilization.

How the Findings Apply to Practice:

Human movement professionals should consider incorporating hip joint mobilization (when assessment implies stiffness) into a program with a goal of increased gluteus maximus muscle strength. Based on the findings of this study, and of additional studies on other body regions (14-17), the use of joint mobilizations should extend beyond arthrokinematic hypomobility and potentially be included to alter muscle activity and recruitment strategies.

How does it relate to Brookbush Institute Content?

The findings of this study support the Brookbush Institute’s (BI) integrated approach and order of treatment for individuals exhibiting lower extremity dysfunction (LED) . In LED , gluteus maximus is classified as long/underactive. As suggested by this study, mobilizing the hip joint prior to gluteus maximus activation techniques  may enhance hip gluteus maximus force production. In addition the BI recommends release (and potentially lengthening) techniques performed on the biceps femoris , adductor magnus and erector spinae  before hip joint mobilization  to further contribute to optimal recruitment of the gluteus maximus  during functional activities.

While the self-administered and manual hip  joint mobilizations recommended by the BI do not resemble the one performed in this study, all of these techniques are likely to improve arthrokinematics in those exhibiting hypomobility. The following videos illustrate techniques related to hip mobilization and gluteus maximus  activation:

Brookbush Institute Videos

Hip Joint Self-Administered Lateral Mobilization

Self-Administered Hip Joint Anterior-to-Posterior Mobilization

Hip Joint Lateral Manual Mobilization

Gluteus Maximus Isolated Activation

Bibliography:

  1. Cooper, N., Scavo, K., Strickland, K., Tipayamongkol, N., Nicholson, J., Bewyer, D., Sluka, K. Prevalence of gluteus medius weakness in people with chronic low back pain compared to healthy controls. J Euro Spine. 26 May 2015
  2. Grimaldi, A, Richardson, C, Stanton, W., Durbridge, G, Donnelly, W. and Hides, J. (2009) The association between degenerative hip joint pathology and size of the gluteus medius, gluteus minimus and piriformis muscles. (2009). Manual Therapy 14. 605-610
  3. Hungerford, B., Gilleard, W., Hodges, P. (2003) Evidence of altered lumbopelvic muscle recruitment in the presence of sacroiliac joint pain. Spine 28(14), 1593-1600
  4. Ireland, ML., Wilson, JD., Ballantyne, BT., Davis, IM. (2003). Hip Strength in Females With and Without Patellofemoral Pain. J Orthop Sports Phys Ther 2003. 33: 671-676
  5. Noehren B, Hamill J, Davis I. Prospective Evidence for a Hip Etiology in Patellofemoral Pain. Medicine & Science in Sports & Exercise. 2013;45(6):1120–1124.
  6. Franettovich, S. M., Honeywill, C. O. N. O. R., Wyndow, N., Crossley, K. M., & Creaby, M. W. (2014). Neuromotor control of gluteal muscles in runners with achilles tendinopathy. Medicine and science in sports and exercise, 46(3), 594-599.
  7. Smith, J. A., Popovich, J. M., & Kulig, K. (2014). The influence of hip strength on lower limb, pelvis, and trunk kinematics and coordination patterns during walking and hopping in healthy women. Journal of Orthopaedic & Sports Physical Therapy, (Early Access), 1-23.
  8. Mauntel, T., Begalle, R., Cram, T., Frank, B., Hirth, C., Blackburn, T., & Padua, D. (2013). The effects of lower extremity muscle activation and passive range of motion on single leg squat performance. Journal Of Strength And Conditioning Research / National Strength & Conditioning Association, 27(7), 1813-1823.
  9. Padua, D. A., Bell, D. R., & Clark, M. A. (2012). Neuromuscular characteristics of individuals displaying excessive medial knee displacement. Journal of Athletic Training, 47(5), 525
  10. Bell, D. R., Oates, D. C., Clark, M. A., & Padua, D. A. (2013). Two-and 3-dimensional knee valgus are reduced after an exercise intervention in young adults with demonstrable valgus during squatting. Journal of athletic training,48(4), 442-449.
  11. Ramskov, D., Barton, C., Nielsen, R. O., & Rasmussen, S. (2015). High Eccentric Hip Abduction Strength Reduces the Risk of Developing Patellofemoral Pain Among Novice Runners Initiating a Self-Structured Running Program: A 1-Year Observational Study. Journal of Orthopaedic & Sports Physical Therapy, 45(3), 153-161
  12. Snyder, K. R., Earl, J. E., O’Connor, K. M., & Ebersole, K. T. (2009). Resistance training is accompanied by increases in hip strength and changes in lower extremity biomechanics during running. Clinical Biomechanics, 24(1), 26-34
  13. Hewett, T. E., Myer, G. D., Ford, K. R., Heidt, R. S., Colosimo, A. J., McLean, S. G., & Succop, P. (2005). Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes A prospective study. The American Journal of Sports Medicine, 33(4), 492-501.
  14. Liebler EJ, Tufano-Coors L, Douris P, Makofsky HW, McKenna R, Michels C, Rattray S. The effect on thoracic spine mobilization on lower trapezius strength testing. J Manual manipulative Ther. 2001; 9(4): 207-212.
  15. Cleland J, Selleck B, Stowell T, Brown L, Alberini S, St. Cyr H, Caron T. Short-term effects of thoracic manipulation on lower trapezius muscle strength. Journal of Manual & Manipulative Therapy. 2004; 12(2): 82-90.
  16. Ghanbari A. and Kamalgharibi S. (2013). Effect of knee joint mobilization on quadriceps muscle strength. International Journal of Health and Rehabilitation Sciences. 2(4): 186-191.
  17. Makofsky, H., Panicker, S., Abbruzzese, J., Aridas, C., Camp, M., Drakes, J., … & Sileo, R. (2007). Immediate effect of grade IV inferior hip joint mobilization on hip abductor torque: a pilot study. Journal of Manual & Manipulative Therapy, 15(2), 103-110.

© 2017 Brent Brookbush

Questions, comments, and criticisms are welcomed and encouraged -

Comments

Guest