Learning About the Trendelenburg Sign- Frontal Plane
If you have any pain, please consult with your physician or physical therapist prior to attempting any of the movements suggested. This content is intended for clients who have been screened in the Foundations/ Practical Strength curriculum.
As we noted last week, there is this strong connection between the gluteals and the knee joints. It is a fact that many people experiencing knee pain have a quadricep dominant pattern, overusing their quads and underusing their posterior muscles.
We explored this further during the dynamic squat test (if you missed last week’s post you can catch up here).
During this week’s writing, we will explore how some of the glutes (the glute medius/ glute minimus) are used when we bear weight. We will look at what the absence of this strength means for both the hip and knee joints.
First a little clinical anecdote (names have been changed, of course).
A couple of years back, Sophia came to see me after being referred by another patient of mine. She had been having hip pain for years. And though she regularly did cardio, she had never been to physical therapy or engaged in any form of strength training.
She was due to have total hip surgery in a couple of weeks, and was looking to get a “pre-hab” (pre surgical) exercise routine.
(As an aside, recall that strength building takes at best 6 weeks. The only thing we can do with so little time is familiarize a client with post-surgical exercises and expectations, and take measurements of pre-surgical range of motion and strength).
As I watched her move, I noticed a severe Trendelenburg sign. A Trendelemburg sign denotes glute medius weakness. You look for it like this:
When a mover attempts to bear weight on one leg the pelvis of the leg she is weight bearing on elevates (up toward her ribs), while the opposite pelvis drops.
As you can imagine, this creates a bending in the spine. This also creates huge compressive forces across the hip joint- a perfect recipe for osteoarthritis.
As I went on to measure her hip, her joints moved passively beautifully (very uncommon with end stage osteoarthritis, which is usually marked by bony end feels to movement and limited movement with cracking- crepitus). And when I went to test the strength of her gluteals, she tested at a 2/5. Very, very weak. It should be noted that weakness and strength loss occurs with pain.
This client did not have the strength needed at her glutes to support herself when she bore weight- even just in simple standing- and yet here she was playing tennis, hiking etc.
Our bodies are quite miraculous in what they let us get away with!
I knew straight away, that without this basic strength, her surgery would be really challenging. I attempted to discuss the findings with the patient, but she was not open to discussion. I performed my one session and sent an evaluation with my findings to her MD. She was seen for her surgery as planned, and had a very difficult and long recovery – fraught with major setbacks and unnecessary, outrageous pain.
In order to weight bear healthfully through our legs, the gluteals on the side of our pelvis (our glute medius and glute minimus) must be able to support our pelvis in a stable way during a single leg stance. Because walking is a movement that requires single leg, then double leg support, you must train to the highest demand to perform well.
Self-Assessing Your Glute Medius/ Glute Minimus- Trendelenburg Sign: DO try this at home:
If you have a full length mirror, stand so that you can view yourself straight on. If you are not too shy, you could have a loved one film you facing front.
Locate your pelvic. Feel for the place where your pelvis protrudes forward. This area is known as the ASIS. Place both hands there for reference.
Start by standing on one leg. Notice if you are able to do this and maintain an even position at your pelvis. Notice if one pelvis drops or lifts.
Perform on each side, and make a note of any findings.
If you have any deviations from pelvic alignment above, stop there.
If not, let’s progress to a two legged squat.
Bend at your hips and knees as you would to sit in a chair and return to standing. Notice if your knees fall in toward one another, or bow out. If you do not notice any challenges to this alignment, increase the challenge by doing 12 – 15 repetitions. Watch for any changes.
Increasing the challenge- single leg:
If you have performed the above assessment and your knee is lined up perfectly, try the same series of techniques while standing on one leg.
Be honest with yourself in assessing your ankle/ knee/ hip and pelvis alignment.
Don’t be afraid to use something like a stable dresser to hold onto while you are performing the movement. You’re not testing your balance- you are looking for any movement anomalies. Jot down any findings.
In our practical strength training we focus on performance of muscles so support good mechanics in all planes of motion. To build awareness of your glute medius and minimus, check out your non- weight bearing side leg lifts. You can find them in our lower body warm up video.
Happy Moving (and stabilizing)!
For more info on gluteals , join us for our Fire Up Your Glutes Workshop this month, as we will explore more about gluteal anatomy, how to best mobilize as well as strengthen the gluteals and how to use your gluteals in everyday life.