Action Reaction Physical Therapy

A study by McCabe et al (NAJSPT 2007) demonstrated that the shoulder W exercise exhibited a moderate amount of posterior rotator cuff and lower trapezius EMG activity.  But more notable for me was the finding that this exercise produced minimal upper trapezius activity and the highest ratio of lower trapezius to upper trapezius activity.  It has been found that upper trapezius often overworks more than the lower trapezius and may cause a muscle imbalance. This imbalance often leads to impingement of the shoulder (supraspinatus and biceps tendon to be more specific), so that explains why I like an exercise that really emphasizes the lower trap and posterior rotator cuff, especially since a lot of us (but not all of us) are people weighed down by gravity, which pulls us forward so we develop a nice hunched over “cooked shrimp” posture.

How to do a good shoulder “W” exercise

I grasp a good piece of Theraband about shoulder width apart and hold with my thumbs up.  I’ve seen many people recommend that you point your thumbs back, I don’t really think that supinating your forearm changes the exercise so I’d rather keep the forearm in neutral and really just focus on the shoulder and scapula (don’t cock the wrist forward or back)

The other tidbit I would recommend, and the origin of the name “W” exercise, is that I like to keep a 90 degree angle at the elbow, which ends up form a “W” when you reach end range of external rotation.  This happens because the lat muscle mass causes your arms to abduct a little bit of your body.  I wouldn’t recommend trying to keep your forearms parallel to the ground.

If you perform the shoulder W exercise with thumbs back and keep your forearms parallel to the ground (and thus don’t form a “W”) I feel that you are really missing out on the scapula retraction and more importantly, the scapular posterior tilt that you achieve when forming a “W.”  Give it a whirl, and you’ll see what I mean.

The Role of the Gluteus Medius

When you really break down the function of the gluteus medius, you see that it is far more valuable as a pelvis and lower extremity dynamic stabilizer than it is a pure hip abductor.  This is apparent when looking at the mechanism of a Trendelenburg Gait.  The role of the gluteus medius during activities such as walking and running is to dynamically stabilize the pelvis in a neutral position during single leg stance.  As you can see in the photo below, weakness of the right gluteus medius will cause the left hip to drop when standing on the right limb.  Conversely, athletic patients are often masters of compensation and may be able to keep the pelvis in neutral while the lower leg will adduct and internally rotate.

In addition, the role of the gluteus medius as an external rotator of the hip when the hip is in a position of flexion is also important to consider.  These factors together are likely why dysfunction of this muscle is commonly found in several pathologies, such as iliotibial band, patellofemoral injuries, ACL, and ankle injuries.

Assessment of the Gluteus Medius

The authors describe several methods of evaluating the gluteus medius.  These include:

• Standard manual muscle testing of hip abduction in sidelying.  Because the gluteus medius also has an effect on other hip motions, I often recommend a full testing of hip flexion, abduction, ER, IR, and extension as well.
• Double- to single-leg stance test.  Simply a test such as the photo above.  The patient is instructed to stand on one limb and pelvis orientation is documented.
• I also recommend adding an upper body movement to the single-leg stance test. This will further challenge the patient, specifically the athletic patient.  During this, the patient is instructed to balance on one limb while reaching the arms overhead and leaning away from the stance leg.  This will move the patient’s center of gravity further away from the stance limb and require a greater amount of gluteus medius stabilization to avoid the dropped pelvis position.
• In addition to the above described, I would also recommend that patients should be observed during several functional activities, especially if a specific activity tends to exacerbate symptoms.  This could include eccentric step-downs, front lunges, or even running and jumping activities for athletes.  Watching the kinematics of the pelvis and lower body closely can be very beneficial, especially since I like to see functionally what my patients come in for in my clinic.

Treating the Gluteus Medius

Here are 3 phases of exercises I use to gradually get the patient back to the where they need to be with their gluteus medius strength.

The progression is designed to gradually enhance motor control, endurance, and strength.  Here are the three phases:

• Phase I: Nonweightbearing and basic weightbearing exercises such as clam shell exercises, sidelying hip abduction, standing hip abduction, and basic single leg balance exercises. Criteria to progress to stage II is that the patient can hold their pelvis level during single leg stance for 30 seconds.
• Phase II: The second stage progresses the weight-bearing exercises and gradually progresses stability exercises by (a) translating the center of gravity horizontally via stepping and/or hopping exercises; (b) reducing the width of the base of support, (c) increasing the height of the center of gravity by elevating the arms and/or hand-held weights, or (d) performing the exercises on unstable surfaces.
• Phase III: The third stage is used for athletes and designed to prepare them for function, sport-specific movement patterns.

Because it is such a valuable component of dynamic pelvis and lower extremity stability.  I also would encourage promoting hip stability during normal sagittal plane movements such as squatting.  To do this, I often just simply incorporate a piece of exercise tubing around the distal thigh (just higher than the knee) of the patient during exercises such as mini-squats, wall squats, and leg press.  The patient is instructed to isometrically set the hips in a neutral position while performing the exercise.  Cueing is often needed at first to be sure that the patient does not let their hips drip into adduction and internal rotation.  I have found great success in this type of exercise as it required the hips to dynamically stabilize against a hip adduction/internal rotation moment during common functional activities.

Overall, a great review of some of the basics regarding the gluteus medius and definitely a great starting point to develop a comprehensive rehabilitation or injury prevention program.