Trendelenburg Gait, otherwise referred to as a hip drop or trunk lean are all compensatory movement patterns that may lead to back pain over time. This article will demonstrate exercises to fix your Trendelenburg gait initiating with Activation -> Strengthening -> Movement Re-Training.
What is a Trendelenburg Gait?
Quick History Lesson: In 1895 Freidrich Trendelenburg described the Trendelenburg sign as weakness of hip abductor muscles in reference to congenital dislocations of the hip and progressive muscular atrophy. Fast forward to today: most orthopedic and physiotherapy textbooks describe this sign as a test of hip function.
Apley’s system of orthopaedics wrote: “Normally each leg bears half the body weight. When one leg is lifted the other takes the entire weight. As a result the trunk has to incline towards the weight-bearing leg. This is achieved by the hip abductors; their insertion is fixed and the pull is exerted on their origin. Consequently the pelvis tilts, rising on the side not taking weight. When this mechanism fails, Trendelenburg’s sign is positive. The pelvis drops instead of rising on the unsupported side.”
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Shown here are 2 movement strategies, both of which are most commonly caused by weakness and/or poor motor control of the hip abductors (particularly the gluteal muscles):
1. The first strategy (Trendelenburg) shown here is manifests as a pelvic drop, in which the pelvis of the limb that is in swing phase will DROP. This is because the recruitment of the hip abductors of the stance limb is less than optimal to maintain the pelvis level.
2. The second strategy (Compensated Trendelenburg) shown manifests as a trunk lean towards the stance limb. This movement strategy brings my center of mass over my base of support (the stance foot). This is a compensatory strategy to decrease the external moment that gravity will put on my hip abductors!
In a normal gait pattern, the trunk and pelvis are stable meaning there will be less than 5 degrees of movement in the frontal plane (from side to side).
Hip Dip & Raise
Why is recruitment of the Gluteal Muscles so difficult?
One reason is poor representational area in the primary motor cortex for these muscles! (Dr. Powers)
Here is a great way to improve muscle recruitment of the hip abductors, particularly the gluteus medius!
Evidence suggests that static isometric glute med toque is a poor predictor of frontal plane pelvic drop. You only need a 3/5 MMT of the Gluteus Medius to prevent a Trendelenburg gait pattern yet so many people present with this movement pattern. Hence, it is not so much strengthening, but motor control training that is important to prevent this compensatory movement pattern. This dynamic exercise helps with not only strength but MOTOR CONTROL of the hip abductors.
To perform this exercise:
✅Elevate the leg opposite to the one you want to work on. Allow a majority of your weight to be accepted through the leg that is in contact with the floor
✅Allow your pelvis to drop towards the leg on the elevated surface.
✅Focus on using your hip abductors to bring the pelvis back to a neutral alignment. Use a mirror to allow yourself to perform this with optimal form and progress to the point where you no longer require visual cues.
✅If strength and endurance are the goal then repeat until fatigue!
✅If Motor Control is the goal: REPEAT REPEAT REPEAT for numerous repetitions to make those neuroplastic changes in the brain! This is the only way to increase representation in your primary motor cortex!
Teaching a movement is divided into 3 parts: Activation, Strengthening, & Movement Training
This exercise would be categorized as an activation drill.
Note: Bolga et al did a study on Pelvic Drop determining a 57%-59& MVIC- That’s Great activation folks!
Strengthen the Hips!
Gluteus Medius Strength is important in applied sports setting, evidence suggests that unilateral Hip Abduction weakness has been associated with increase risk of injuries in sports such as soccer, ice hockey, and running. Weakness here has also been associated as the cause of knee, hip, and low back pathologies.
In support of this, it has been shown that athletes with STRONGER hip abduction strength are less likely to be injured compared with athletes with weaker hip abduction strength.
Here are 3 great exercises to improve strength here:
✅Supine to Side Plank (AKA Side Plank w/ Hip Abduction): 89–103 % MVIC (Maximal Voluntary Isometric Contraction) -NR Boren et al.
✅Side Lying Hip Abduction: 56% MVIC – NR Boren et al.
✅Clams: 62–77% MVIC -NR Boren et al.
-With hip in 45 degrees flexion, and knee in at least 45 degrees of flexion (To avoid Hamstring Compensation)
There is Evidence to suggest that Strengthening on it’s own will NOT help with poor movement pattern such as Trendelenburg or Dynamic Knee Valgus- You need to also train the muscle’s to activate at the right time which we call “Motor Control.”
Strengthening + Movement Re-Training
It is recommended to first Activate the weakened area (to increase corticomotor excitability) -> strengthen -> you can movement train. Because all the Glute Med strength in the world doesn’t matter if doesn’t activate at the appropriate time (AKA Motor Control).
Here are 2 Great exercises to challenge the muscle function of the hip abductors- primarily the Gluteus Medius. Remember- Keep your pelvis LEVEL, after all this is the Trendelenburg article!
Note: Feel free to hold these positions statically- this will facilitatie “encoding” for cognitive processes which are thought to play an important role in helping the learner create a motor memory. Static holds require prolonged focus and concentration, thus strengthening the corticomotor pathway to create motor learning.
Note 2: research has shown the importance of strengthening not only the Gluteus Medius, but also the Quadriceps and the Hamstrings. Increases in strength of the muscles, results in a reduction of the degree of Trendelenburg gait.
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While weakness of the hip abductors is a potential cause for medial knee collapse, a lack of motor control can also be the culprit of this poor movement pattern. This is especially prevalent among higher end athletes who demonstrate medial knee collapse with functional activities. In this case, the athlete more times than not has more than adequate strength, yet they fail to utilize and demonstrate the neuromuscular control necessary to engage the hip abductors during tasks. Too see if this is the case, give the athlete visual, verbal, or manual cues to facilitate hip abductor activation.
Single leg squat has shown to fire 52-82% MVIC of the Gluteus Medius‼️
-82, BW Boren et al.
-64% +/-24, BW Distefano et al.
-52 +/- 22, BW Ayotte et al.
Here, we demonstrate a resistance cue with a theraband. The theraband provides tension to drive the knee inward, into hip adduction. This slight resistance is enough to facilitate the hip abductors to fire during the single leg squat.
Note: This can also be used as a strengthening exercise once the athlete demonstrates good neuromuscular control…
Gluteus Medius Strength may be even more important in sports when the center of mass changes direction unexpectedly, requiring strength and stabilization during unilateral stance. Because of the nature of contact sports and the role of pelvic stability to maintain the summation of forces of movements that begin in the lower extremity, Gmed strengthening should be included in sports that require unilateral support, especially during body-to-body contact.
In these sports, unilateral Gmed strengthening while standing can be considered as sport specific. For example, single leg squats with external resistance can be included during the preseason or in-season for ice-hockey players but should not be a staple of an ice-hockey player’s general strength development. Some may take this idea further and prescribe such exercises on an unstable surface in an attempt to mimic the instability experienced during competition.
The cause of both Trendelenburg and Compensated Trendelenburg is often times due to inadequate gluteal function.This article demonstrated exercises to fix your Trendelenburg gait initiating with activation -> Strengthening -> Movement Re-Training. For additional gluteal exercises check out Here and Here.
1.Cichanowski et al. Hip Strength in Collegiate female athelte’s with patellofemoral pain. 2007.
2.Fredericson et al. Hip Abductor Weakness in distance runners with iliotibial band syndrome. 2000.
3.Thorborg et al. Eccentric Hip Adduction and Abduction strength in elite soccer players and matched control. 2011.
4.Tyler et al. The association of hip strength and flexibility with the incidence of adductor muscle strains in professional ice hockey players. 2001.
5.Leetun et al. Core Stability measures as risk factors for lower extremity injury in athletes. 2004.
6. Burnet et al. Isometric Gluteus Medius Muscle Torque and Frontal Plane Pelvic Motion During Running
7. Macadam et al. An Examination of the Gluteal Muscle Activity Associated with Dynamic Hip Abduction and Hip External Rotation Exercise: A Systematic Review. 2015.