If you have ever been to a physio, more than likely you’ve been told you have “weak glutes” and its part of the reason for your (insert body part) injury. For the physios reading this, think about how you treat and question whether what you are saying is really what is happening. The common justification for the emphasis on glute strengthening is that having reduced hip strength will lead to excessive femoral adduction and internal rotation (thigh turning inward & knees turning inward) which further causes pronation (flat feet). The thought is that since this is happening, load to the (knee, shin, foot) will increase therefore contributing to your injury.

Don’t get me wrong, sometimes this really is the case but often times I believe it is over diagnosed and a risk factor that may not even have evidence to support it. I’m not here to say glute exercises aren’t important and that we shouldn’t strengthen it, but we should look into the evidence to dissect what we actually know.

Since this topic is very broad, there is no way to discuss all the different types of injuries. I will focus my discussion on tendons (specifically Achilles and patellar).
 

Achilles Tendinopathy

I’m going to introduce 2 papers that suggest limited evidence for the support of weak glutes being a factor for Achilles tendinopathy. Azevedo and colleagues compared runners with Achilles tendinopathy with non-injured controls and found that there was less muscle activation in the glute med muscle in those with Achilles tendinopathy. Habets, et al. (2017) also found a weakness in the hip muscles in those with Achilles tendinopathy compared to non-injured controls.

Patellar Tendinopathy

Zhang et al. (2018) also found that those with patellar tendinopathy have decreased isometric strength in their hip abductors and external rotators compared to controls.
 

The Flip Side

However, despite these limited studies, I am still not convinced that the glutes play that large of a factor leading up to these injuries. We must understand that these studies DO NOT establish any causal relationships.

A counter argument with these studies is that these people may have developed these changes AFTER the onset of the injury and it was not the fact that they had weak glutes that lead them to the injury. Another explanation may be that since they have developed this painful condition, they would most likely want to “unload” the area, which leads to atrophy, or a decrease in activation (i.e. If it hurts, they don’t want to load it. If they don’t load it, it becomes weak. If it becomes weak, it may also explain a decrease in muscle activation.)
 

Conclusion

So where does this lead us? The point of the blog is to stimulate clinical reasoning and reflect on how we treat. Do we put too much emphasis on “external factors”? (I.e. mal-alignments, postures, imbalances) Is there a real basis for looking at these factors in something like tendons?

My views on tendons are pretty simple. If the Achilles tendon is what you are treating, you should focus most of your intervention on that. If you are treating the patellar tendon, primarily focus on that. Once you have established that, you can then look for other factors but a priority has to be the tendon you are treating. The reason for this is that, at the end of the day even though all strengthening is important, you have no idea whether strengthening the glutes is really doing anything to what you are treating. On the contrary, if you monitor the load going through the specific tendon and directly strengthen the affected tendon, you are surely on the right path to recovery.

References

Azevedo et al. (2009). Biomechanical variables associated with Achilles tendinopathy in runners. BJSM 43(4):288-92

Habets et al. (2017). Hip muscle strength is decreased in middle-aged recreational male athletes with midportion Achilles tendinopathy: A cross-sectional study. Phys Ther Sport. 25:55-61.

Zhang et al. (2018). Isometric strength of the hip abductors and external rotators in athletes with and without patellar tendinopathy. European Journal of Applied Physiology, 118(8), 1635–1640.