{"id":1469,"date":"2012-07-14T12:04:13","date_gmt":"2012-07-14T19:04:13","guid":{"rendered":"https:\/\/blog.brianschiff.com\/?p=1469"},"modified":"2012-07-14T12:14:28","modified_gmt":"2012-07-14T19:14:28","slug":"the-role-of-piriformis-pectineus-in-hip-rehab","status":"publish","type":"post","link":"https:\/\/blog.brianschiff.com\/?p=1469","title":{"rendered":"The Role of the Piriformis &#038; Pectineus in Hip Rehab"},"content":{"rendered":"<p>I have been a bit behind on blogging as of late. \u00a0I try to aim for one per week, but I also strive to deliver sound and relevant content. \u00a0Additionally, I do not seek outside contributors so finding time to write can be tricky with work and family life too. \u00a0So, forgive me for any apparent inconsistency in posting. \u00a0Just know that I will always try to provide valuable content. \u00a0Today&#8217;s post centers around an article in the July 2012 edition of AJSM.<\/p>\n<p style=\"text-align: center;\"><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter size-medium wp-image-1470\" title=\"sample_cover\" src=\"https:\/\/blog.brianschiff.com\/wp-content\/uploads\/2012\/07\/sample_cover-231x300.gif\" alt=\"sample_cover\" width=\"162\" height=\"210\" srcset=\"https:\/\/blog.brianschiff.com\/wp-content\/uploads\/2012\/07\/sample_cover-231x300.gif 231w, https:\/\/blog.brianschiff.com\/wp-content\/uploads\/2012\/07\/sample_cover.gif 262w\" sizes=\"auto, (max-width: 162px) 100vw, 162px\" \/><\/p>\n<p>My work at the Athletic Performance Center has provided me an increased opportunity to work with FAI and athletic hip injuries. \u00a0This is an area of evolution and growth in our field, so I find it particularly interesting to see rationale and thought processes centering around the timing, contribution and selection of hip exercises for active patients\/athletes.<\/p>\n<p>This article comes from the Steadman Philippon Research Institute in Vail, CO. \u00a0The purpose of the study was to measure the highest activation of the piriformis and pectineus muscle during various exercises. \u00a0The hypothesis was that highest pectineus activation would occur with hip flexion and moderate activity with internal rotation, whereas the highest activation with the piriformis would be with external rotation and\/or abduction.<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter size-medium wp-image-1471\" title=\"anterior_hip_muscles\" src=\"https:\/\/blog.brianschiff.com\/wp-content\/uploads\/2012\/07\/anterior_hip_muscles-247x300.jpg\" alt=\"anterior_hip_muscles\" width=\"247\" height=\"300\" srcset=\"https:\/\/blog.brianschiff.com\/wp-content\/uploads\/2012\/07\/anterior_hip_muscles-247x300.jpg 247w, https:\/\/blog.brianschiff.com\/wp-content\/uploads\/2012\/07\/anterior_hip_muscles.jpg 330w\" sizes=\"auto, (max-width: 247px) 100vw, 247px\" \/><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter size-medium wp-image-1472\" title=\"250px-posterior_hip_muscles_1\" src=\"https:\/\/blog.brianschiff.com\/wp-content\/uploads\/2012\/07\/250px-posterior_hip_muscles_1-247x300.png\" alt=\"250px-posterior_hip_muscles_1\" width=\"247\" height=\"300\" srcset=\"https:\/\/blog.brianschiff.com\/wp-content\/uploads\/2012\/07\/250px-posterior_hip_muscles_1-247x300.png 247w, https:\/\/blog.brianschiff.com\/wp-content\/uploads\/2012\/07\/250px-posterior_hip_muscles_1.png 250w\" sizes=\"auto, (max-width: 247px) 100vw, 247px\" \/><\/p>\n<p>Methods: 10 healthy volunteers completed the following 13 exercises:<\/p>\n<ol>\n<li>Standing stool hip rotation<\/li>\n<li>Supine double leg bridge<\/li>\n<li>Supine single leg bridge<\/li>\n<li>Supine hip flexion<\/li>\n<li>Side-lying hip ABD with external rotation<\/li>\n<li>Side-lying hip ABD with internal rotation<\/li>\n<li>Side-lying hip ABD against a wall<\/li>\n<li>Hip clam exercise with hips in 45 degrees of flexion<\/li>\n<li>Hip clam exercise with hips in neutral<\/li>\n<li>Prone heel squeeze<\/li>\n<li>Prone resisted terminal knee extension<\/li>\n<li>Prone resisted knee flexion<\/li>\n<li>Prone resisted hip extension<\/li>\n<\/ol>\n<p>All of these exercises have been reported to be used in hip rehab following arthroscopy or recovery from injury. \u00a0The exercises were executed slowly and methodically with a metronome to reduce EMG amplitude variations.<\/p>\n<p><!--more-->RESULTS<\/p>\n<p><strong>Pectineus<\/strong><\/p>\n<ul>\n<li>Highest activation with supine hip flexion in concentric phase<\/li>\n<li>Exercise with hip ABD and\/or hip extension were found to have low (&lt; 20%) activation except for single leg bridge (peak amplitudes at 26.5%)<\/li>\n<li>Single leg bridge was much higher than any of the prone or side-lying exercises<\/li>\n<\/ul>\n<p><em>Top (3) Pectineus Exercises<\/em><\/p>\n<ol>\n<li>Supine hip flexion<\/li>\n<li>Single leg bridge<\/li>\n<li>Double leg bridge<\/li>\n<\/ol>\n<p>Hip flexion sequence (top to bottom pictured below with image from AJSM):<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter size-medium wp-image-1473\" title=\"hip-flexion-sequence\" src=\"https:\/\/blog.brianschiff.com\/wp-content\/uploads\/2012\/07\/hip-flexion-sequence-156x300.png\" alt=\"hip-flexion-sequence\" width=\"156\" height=\"300\" srcset=\"https:\/\/blog.brianschiff.com\/wp-content\/uploads\/2012\/07\/hip-flexion-sequence-156x300.png 156w, https:\/\/blog.brianschiff.com\/wp-content\/uploads\/2012\/07\/hip-flexion-sequence.png 364w\" sizes=\"auto, (max-width: 156px) 100vw, 156px\" \/><\/p>\n<p><strong>Piriformis<\/strong><\/p>\n<ul>\n<li>4 of the 10 participants were removed due to inactive EMG signal or demonstrated significant spikes and other artifacts during motion<\/li>\n<li>Highest activation occurred during resisted hip extension in concentric phase<\/li>\n<li>Highest activation with eccentric phase of exercise occurred with single leg bridge<\/li>\n<li>Side-lying hip ABD in external rotation and prone heel squeeze were found to have similar levels of peak EMG as the resisted hip extension and single leg bridge<\/li>\n<\/ul>\n<p><em>Top (3) Piriformis Exercises<\/em><\/p>\n<ol>\n<li>Prone heel squeeze<\/li>\n<li>Single leg bridge<\/li>\n<li>Single leg hip ABD with external rotation<\/li>\n<\/ol>\n<p>Prone heel squeeze finish position (in slight hip extension) pictured below with image from AJSM:<\/p>\n<p style=\"text-align: center;\"><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter size-medium wp-image-1474\" title=\"prone-heel-squeeze\" src=\"https:\/\/blog.brianschiff.com\/wp-content\/uploads\/2012\/07\/prone-heel-squeeze-300x193.png\" alt=\"prone-heel-squeeze\" width=\"243\" height=\"157\" srcset=\"https:\/\/blog.brianschiff.com\/wp-content\/uploads\/2012\/07\/prone-heel-squeeze-300x193.png 300w, https:\/\/blog.brianschiff.com\/wp-content\/uploads\/2012\/07\/prone-heel-squeeze.png 378w\" sizes=\"auto, (max-width: 243px) 100vw, 243px\" \/><\/p>\n<p>** Note: The top three final rankings for each muscle group were based on peak and mean EMG amplitudes in concentric and eccentric phases of the exercises.<\/p>\n<p><strong>Article Takeaways<\/strong><\/p>\n<p>The pectineus was not very active in rotation (internal or external). \u00a0Its increased activity in the bridges indicate it is an important hip stabilizer and involved in preventing external rotation. \u00a0It is also likely pivotal in closed chain sports activity like acceleration and pivoting movements. \u00a0The authors specifically feel it is key to sports such as dance, soccer, basketball, hockey and ice skating.<\/p>\n<p>The piriformis was most active when stabilizing\/maintaining external rotation as evidenced by the prone heel squeeze and single leg bridge. \u00a0The highest levels surprisingly occurred in activities that required hip extension and\/or were performed in hip extension. \u00a0Therefore, the muscle would seem to function most as a an external rotation stabilizer maintaining \u00a0hip position as the thigh extends. \u00a0The authors note that this would mean it is vital in controlling\/guarding against internal rotation with toeing off in running, jumping, or the skating stride as well as limiting internal rotation coming out of such athletic positions.<\/p>\n<p>The authors feel their findings indicate limiting external rotation after hip surgery may also cause deconditioning of the piriformis. \u00a0While necessary to protect healing tissues, they speculate this functional weakness may lead to knee valgus and increased hip internal rotation. \u00a0More research needed on this one.<\/p>\n<p>Limitations in this study include: small population of subjects, no ADD (adduction) exercises to measure pectineus activity, only one exercise with combined ER\/IR and trouble with electrodes for EMG on the piriformis.<\/p>\n<p><a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed?term=pectineus%20and%20piriformis\" target=\"_blank\"><strong>Click here for the article abstract<\/strong><\/a><\/p>\n<p><strong>My personal thoughts<\/strong><\/p>\n<p>I think we always need to consider how we function in weight bearing as we look at these studies and activation patterns. \u00a0There is of course a time for isolation strengthening in early rehab aimed at turning the muscles on if you will, but the body is sophisticated and all these muscles do work together either in synergy or antagonistic ways. \u00a0Dynamic stability is often lost due to poor neuromuscular patterning or weakness. \u00a0The body gives way to gravity and poor motor memory in the absence of adequate stabilization.<\/p>\n<p>I was telling the ATC that works with me at the clinic just the other day that <strong>resisting forces is just as important if not more so for our athletes when the aim is injury prevention and fine motor control. <\/strong>We often get caught up in strengthening to produce performance and movement but we must not lose sight of the importance of restraining unwanted movement through proper muscle activation. I think this little study reminds us of that very important message.<\/p>\n<p><strong><\/strong><\/p>\n","protected":false},"excerpt":{"rendered":"<p>I have been a bit behind on blogging as of late. \u00a0I try to aim for one per week, but I also strive to deliver sound and relevant content. \u00a0Additionally, I do not seek outside contributors so finding time to write can be tricky with work and family life too. \u00a0So, forgive me for any [&hellip;]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[43,7,31,28,8,12,5],"tags":[193,435,177,120,215,150,148,121,426],"class_list":["post-1469","post","type-post","status-publish","format-standard","hentry","category-hip","category-injury-prevention","category-knee","category-medicine","category-rehab","category-running","category-sports-performance","tag-femoroacetabular-impingement","tag-hip","tag-hip-exercise","tag-hip-pain","tag-hip-rehab","tag-hip-stability","tag-hip-strengthening","tag-hip-weakness","tag-running"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v20.10 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>The Role of the Piriformis &amp; 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