One of the most common denominators in my clients with chronic back pain is a lack of gluteal activation and strength. This pattern is sometimes referred to as gluteal amnesia, a term coined by Dr. Stuart McGill. Usually due to a life of prolonged sitting, people forget how to use their glutes and their back suffers.
There are several different muscles in the buttocks, with the gluteus maximus and gluteus medius being two of the most important ones. The gluteus maximus is the biggest muscle in the human body. It has the job of keeping the trunk straight in a standing posture and for propelling us upward and forward (extending the hip). The gluteus medius functions to abduct the hip (pull away from midline) and stabilize the hip and spine, especially when on one leg. When these muscles are not used properly, the spine can suffer significantly. I am often asked “How could I have been doing these movements all my life without using these huge important muscles? Wouldn’t I know it?” One of my favorite analogies goes as follows, from Bill Fabrocini: If you have a car with one flat tire and you push the gas, the car is still going to go. You can probably drive a long way with that flat tire. Though at some point the axle, or another important part of the car, is going to give out from the stress and you are going to have a much bigger problem than just a flat tire. So, it goes with the human body. You can still move without using your glutes, but at some point, the spine, or another joint is going to break down.
Probably the most common movement pattern where gluteal amnesia is apparent is the squat pattern. When the glutes don’t fire properly during activities like squatting, the lumbar erectors and hamstrings take over and exert enormous forces through the lumbar spine (low back). This one is easy to check. Stand in front of a mirror and squat down. If your knees drop inward towards each other as you squat down, you probably suffer from gluteal amnesia.
Thankfully, gluteal amnesia can be fixed. Once identified by a trained specialist, an exercise protocol can be undertaken to reverse this pattern. The following are some simple exercises to do this. But remember, the goal is to incorporate gluteal activation into your daily activities and sports. A skilled therapist can help you with this.
Bridge: Lie on your back with knees bent. Tighten your abdominals and squeeze your glutes. Lift the hips off the ground without rolling up through the spine. Hold for five seconds. You should feel the muscles in your butt contracting on both sides. The hamstrings should be relaxed. If you feel that the hamstrings are doing most of the work, push your feet away from yourself into the floor. This will activate the quads and relax the hamstrings. After holding for five seconds, repeat 10 or 12 times.
Clam Shell: This is a very basic exercise to activate gluteus medius (along with some other muscles). Lie on your side with knees and hips bent. Place your thumb on the bone in the front of your hip. This is called your ASIS. Lay the fingers across your hip as shown and they will be on the gluteus medius. Open the knee up like a clam shell. Repeat several times, thinking about the muscle under your fingers.
Modified Clam Shell: To start the strengthen the glutes, move to this exercise once you have done clam shell. The key to this exercise is to open the hip up and slightly outward, making sure not to pull the knee towards the chest. You also want the knee slightly above the foot in the opening phase of the exercise. Lay on your side with knees and hips at 90 degrees. Brace your core and start the movement by contracting the gluteus medius (follow directions in clam shell). Open the hip up and out (with foot) to about 45 or 50 degrees. Lower slowly with control.
Squats: After you have mastered some of the above exercises, you are ready to try squats. In the beginning, use a chair or bench to get the feel of the movement. Place the chair or bench behind you. Stand with legs shoulder width apart and feet forward or slightly out turned. Squat back at a 45-degree angle so that your butt slightly touches the bench. Then drive upward using the glutes to extend the hip. If you are doing this right, you should feel the muscles in your butt working more than the muscles in your thighs. A trick that can help activate the glutes is to push outward with the heels (“spreading the floor with the feet”) as you rise. This should make you feel the glutes working. Again, if your knees are dropping in, you are probably not using the glutes.
Reactivating your glutes after years of inactivity in those muscles can be very challenging. Often, it takes the help of a skilled therapist to accomplish this goal. If you suffer from chronic back pain and have not been evaluated for gluteal amnesia, you need to be.