Treating Runner's Knee: Don't Forget the Gluteus Muscles

NHL Bruins hockey is back!  It is always a great week when hockey is back in action and the fall season is in full force.  Autumn is my favorite season and it is a great time to be out running and training.  The cool weather is more kind to the body and the colors and smells remind us of home.  What a great time of year.

I wanted to follow up on my last post about running injuries and in particular patellofemoral pain syndrome.  As you may recall from the last post, PFPS or runner's knee, is the most common injury at the knee in runners.  The pain results from changing contact forces at the patellofemoral joint due in part to increased rotation at the femur and poor dynamic pelvic control.  That leaves us with the question of why this all occurs.  This post will be a discussion about lower extremity control and the role of the gluteus muscles. 

Anatomy of the Gluteus Maximus and Medius

The gluteus muscles reside on the posterior or back part of our hips just below our back.  They extend to the proximal part of the hamstring and outward to the greater trochanter (the hip bone on the outside of your hip that sticks out).  The gluteus maximus covers a large area allowing for high power production and large force generation.  The gluteus medius runs from the top inside of your hip bone down to your greater trochanter.

Gluteus Maximus

The gluteus maximus has three sections upper, middle, and lower.  Each section performs a slightly different function.  The upper fibers abduct the hip (move away from the center of the body), the middle fibers externally rotation the hip (thigh bone rotates outward), and the lower fibers extend the hip (move the leg behind the body).  These three actions work to stabilize the pelvis and leg, provide shock absorption, and provide power.

 

Gluteus Medius

The action of the gluteus medius is to abduct the hip and stabilize the pelvis.  This muscle primarily works by keeping the opposite hip from dropping when standing on one leg (or running).  It is essential for these two gluteal muscles to work together to stabilize and control all the force that comes through the legs during walking, running, and sports.

Nerve Innervation

I wanted to briefly touch on some nerve anatomy without getting into too much detail.  The gluteus maximus is controlled by the inferior gluteal nerve.  The inferior gluteal nerve originates from the rami of L5, S1, and S2.  What you need to know about these letters and numbers is that the inferior gluteal nerve starts at the nerves the come out from the lower back.  This is an important distinction since it tells us we need to pay attention to what the lower back and trunk are doing when training the gluteal muscles and lower extremities.  If a runner is trying to strengthen the gluteal muscles but has poor core control, then the nerves which supply the gluteal tissues may be compressed and therefore the strengthening is in vain

The gluteus medius muscle is supplied by the superior gluteal nerve.  It is comprised from the divisions of L4, L5, and S1.  So again we see how the strength, control, and stabilization of the lumbar spine will affect the control, strength, and function of the buttocks muscles.  Any runner who is looking to improve the control and alignment of their running form needs to work the buttocks muscles while keeping proper strength and control of the trunk. 

"Gray828" by Henry Vandyke Carter - Henry Gray (1918) Anatomy of the Human Body (See "Book" section below)Bartleby.com: Gray's Anatomy, Plate 828. Licensed under Public Domain via Commons -
https://commons.wikimedia.org/wiki/File:Gray828.png#/media/File:Gray828.png

Lower Extremity Alignment: The Gluteus Muscles in Action

Now that hip anatomy 101 is completed we can discuss how the gluteal muscles work to control the lower extremity.  As discussed previously, patellofemoral pain syndrome is partially caused by genu valgus, femoral adduction, femoral internal rotation, and a “knee strategy”.  The term “knee strategy”, coined by Dr. Chris Powers at USC, refers to squatting with a body position consisting of an upright trunk with knees forward of the toes.  This posture is heavily dependent on the usage of the quadriceps.  To review, all these actions noted above increase pressure and forces at the knee cap causing tissue overload, stress, and pain.  

The role of the gluteal muscles is to properly align the lower extremity and therefore a “hip strategy” is needed.  A “hip strategy” is characterized by knees behind toes, forward trunk lean, and hip hinge.  This posture places more emphasis and load on the gluteal muscles thus taking pressure off the quadriceps and therefore the patellofemoral joint

Here is a great example of the difference between a knee and hip strategy. 

"Knee Strategy": Upright trunk and knees forward of toes

Hip strategy for runner's knee

"Hip Strategy": Forward trunk lean, hip hinge, and knees behind toes

Hip Strategy: Needing Gluteal Activation and Strength

In order to relieve pressure and pain from the knee we now know controlling the alignment of the lower extremity is crucial.  Controlling the lower extremity means using a hip strategy, keeping the knees out, and keeping your trunk stable.  Sounds easy right.  In reality, to be able to consistently control lower extremity alignment during a highly skilled action such as running is quite difficult.  It is difficult due to the complex motor patterns needed and the high forces experienced.  If it was as easy as telling all runners to “keep their knees out” then we wouldn’t see such a high percentage of injuries in running occurring at the knee.

Proper lower extremity control with knees pointing forward, hips and pelvis stable

Proper lower extremity control

So how do we go about strengthening the gluteus maximus and medius?  It is important first to re-learn how to tighten the gluteal muscles.  The human body is exceptional at compensating in the presence of weakness.  When the gluteal muscles are weak the body will transfer some of the work to the hamstrings, TFL, quadriceps, and lumbar spine.  It is not uncommon for runners to have a hamstring strain, followed by patellar tendonitis, followed by patellofemoral pain syndrome.  It is likely the body is just shifting forces to other structures when it should be using the gluteal tissues.  As this process continues the body learns to use every other muscle besides the buttocks. In my experience treating runners, this is often a difficult first stage in the rehabilitation process since it demands a great deal of energy and mental focus to use the hips versus other structures. 

Hip Activation

Although there are countless exercises to engage the gluteus muscles I will here discuss one in particular, the “fire hydrant”.  This is one of the best buttocks exercises out there.  It is designed to activate all three regions of the gluteus maximus (remember from above: upper, middle, and lower fibers).   The fire hydrant works by using the gluteus maximus at a point where it is fully engaged at the end of the available motion.  This allows increased neural activation from the brain to stimulate as many nerve fibers as possible.  Take a look at the exercise and you will understand how the name “fire hydrant” came about.

Activation--Strengthening--Dynamic Control 

Activating the hip is just step one in getting back to running without knee pain.  After you have learned to tighten the gluteal muscles you need to get them strong enough to withstand high loads with high volume (running).  Muscle fiber adaptations with strengthening takes approximately 6 weeks so do not get discouraged if the process to run pain free takes longer than you might think.  After getting your hips strong enough to tolerate running you need to gain “dynamic control” of your lower extremity.  This involves plyometrics, jumping, and exercises performed at running speed.  This is often the most difficulty stage to master due to the complexity of movement and higher muscular demands. 

Runner’s knee can keep you from doing what you love.  If you want to run pain free you need your gluteus maximus and medius muscles to help you.

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