Case Report

Physical Therapy Management of Patients With

Chronic Low Back Pain and Hip Abductor
Weakness
Seth Peterson, PT, DPT, OCS1,2; Thomas Denninger, PT, DPT, OCS3

ABSTRACT abductor weakness. The results indicated that this approach

Background and Purpose: Hip abductor dysfunction is com- may be effective in reducing pain and improving function,
mon in individuals with chronic low back pain (CLBP). Pre- particularly for older patients.
vious research investigating abductor strengthening in the Key Words: older adult, muscle strength, back pain
heterogeneous CLBP population is sparse and has failed to
target those patients most likely to benefit. The aim of the (J Geriatr Phys Ther 2017;00:1-11.)
current case series was to describe the physical therapy man-
agement and outcomes of 3 patients with CLBP matching a
previously identified subgroup characterized by substantial BACKGROUND
hip abductor weakness.
The relationship between impaired gluteal function and
Case Description: Three nonconsecutive patients with CLBP—
a 77-year-old man, a 78-year-old woman, and an 85-year-old low back pain (LBP) is well established. Weakness and
woman—were treated in an outpatient physical therapy clinic. tenderness of the gluteus medius muscle, responsible for
All 3 patients matched a previously identified CLBP subgroup abduction of the hip, is a common finding in individuals
characterized by substantial hip abductor weakness. with LBP.1-3 Nadler et al4 showed an increased likeli-
Intervention: Patients were treated using a targeted exercise hood of future LBP in female athletes with hip abductor
approach consisting mostly of hip abductor strengthening for weakness. Studies have also associated impaired gluteus
11 to 17 visits over 8 to 10 weeks. Patients received additional
treatments including heel lift and pain neuroscience educa- medius muscle endurance5 and firing patterns6 with the
tion when indicated. development of LBP. In cases of LBP and coexisting glu-
Outcomes: By discharge, all patients had made clinically teal tendinopathy, which is present in about 35% of those
important improvements in pain (3- to 7-point reduction on with LBP, treatment of the gluteal tendon pain has led to
the Numeric Pain Rating Scale), function (10- to 16-point improved functional outcomes.3,7 This evidence points to
change on the Modified Oswestry Disability Index), and per- a relationship between LBP and hip abductor weakness,
ceived improvement (6-7 on Global Rating of Change Scale).
although the precise nature of this relationship has not yet
Lumbar range of motion was painless, and hip abductor
strength was improved from 2+/5 to 3+/5 in all 3 patients. been determined.
These gains were maintained at 3-month follow-up. Theories relating LBP and hip abductor weakness
Discussion: The current case series describes the use of a often focus on an inability of the gluteus medius muscle
targeted exercise approach consisting mostly of hip abduc- to laterally stabilize the pelvis during unipedal activities
tor strengthening in a group of patients with CLBP and hip such as gait, and expert opinion commonly highlights
the importance of this muscle in LBP rehabilitation.8,9
1ProActive Physical Therapy, Tucson, Arizona. Despite the established relationship between LBP and hip
2Department of Physical Therapy, Arizona School of Health abductor weakness, little has been published describing
Sciences, A.T. Still University, Mesa, Arizona. physical therapy management of these patients. Current
3ATI Physical Therapy, Greenville, South Carolina. physical therapy guidelines for LBP recommend several
Each subject was informed that data concerning the case treatment strategies depending on the patient’s presenta-
would be submitted for publication and were actively tion,10 but they primarily focus on trunk muscle strength-
engaged throughout the process. Patient confidentiality was ening and specific exercise. Few studies have investigated
protected. the effect of hip abductor strengthening in patients with
The authors declare no conflicts of interest. LBP. In a small study Kendall et al11 found a 48% reduc-
Address correspondence to: Seth Peterson, PT, DPT, OCS, tion in nonspecific LBP when 10 participants performed
10550 North La Canada Dr, Suite 160, Oro Valley, AZ, a single standing hip abductor strengthening exercise
85737 ([email protected]). for 3 weeks, but this difference did not reach statistical
Kevin Chui was the decision Editor. significance or affect the magnitude of pelvic drop. In a
Copyright © 2017 Academy of Geriatric Physical Therapy, subsequent randomized controlled trial, Kendall et al12
APTA. found no benefit of adding hip muscle strengthening to a
DOI: 10.1519/JPT.0000000000000148 lumbopelvic motor control exercise program (described

Journal of GERIATRIC Physical Therapy 1

Copyright © 2017 The Academy of Geriatric Physical Therapy, APTA. Unauthorized reproduction of this article is prohibited.
 Case Report

as cocontracting the transversus abdominus, multifidus, CLBP intensity were quantified with the 11-point Numeric
and pelvic floor muscles during various tasks) in patients Pain Rating Scale (NPRS), where 0 represents no pain and
with nonspecific LBP. However, the hip muscle strength- 10 represents the worst pain imaginable. He reported no
ening program was only described as “open and closed pain as he sat in the examination room but rated his worst
chain,” and hip abductor strength measurements were leg pain as a 7 and his worst LBP as a 9. His CLBP was
not reported. Neither of these studies11,12 made an effort aggravated by standing longer than 7 minutes and walking
to identify participants with impaired hip abductor longer than 10 minutes. The patient reported having leg
strength before study inclusion. Therefore, lack of inter- pain during these activities only when his LBP had been
ventional success may be a result of failure to account aggravated to 7 or greater. Sitting immediately relieved his
for the existence of a potential subgroup within the LBP pain. The patient reported having 4 episodes of LBP over
population, thereby diluting the treatment effect. the previous 50 years. Seventeen months before his initial
Currently, various LBP classification systems exist to physical therapy evaluation, he tripped while stepping off
identify subgroups of patients in a way that is descriptive, a curb, tearing his right gluteus medius muscle. The patient
prognostic, or attempts to direct treatment.13 Subgroup- underwent gluteus medius repair surgery immediately
matched treatment approaches have been shown to improve after the fall. Three weeks after surgery, postoperative
clinical outcomes when compared with nonmatched alter- rehabilitation was initiated and continued for 8 weeks.
natives.14-16 However, the benefit of using this approach in The patient did not believe his gait pattern was fully
the chronic low back pain (CLBP) population is currently normalized and began noticing LBP and leg pain about 5
unclear.17-19 Barriers frequently cited to using this approach months after surgery. During the subsequent 12 months,
in the CLBP population are higher frequency of psychoso- he worked as a grocery store salesman and noticed the
cial factors (eg, depression and fear-avoidance behavior) or CLBP gradually worsened until he had difficulty perform-
the coexistence of contributing pathology.20 ing his job duties. His goal for physical therapy was to
Recently, Cooper et al1 were able to identify the exis- improve his pain-free standing and walking duration to 30
tence of a descriptive subgroup of patients within the CLBP minutes to allow for less interference with his job duties.
population presenting with significant gluteus medius mus- The patient’s medical history included hypertension, ath-
cle weakness (≤3/5 strength during manual muscle test), erosclerosis, and depression. He denied any recent changes
gluteal tenderness, and a Trendelenburg sign. However, in gait, bowel and bladder habits, strength, weight, or
no study has investigated or described treatment protocols sleep patterns.
in this subgroup, making evidence-based clinical manage- Patient 2 was a 78-year-old woman referred to physical
ment challenging. The aim of the current case series was to therapy with sharp right-sided CLBP ranging from 0 to 9
describe the physical therapy management and outcomes of on the NPRS. She also experienced tightness and numbness
3 patients with CLBP matching a previously identified sub- in her right buttock and lateral hip that was less frequent
group characterized by substantial hip abductor weakness. than her CLBP but could increase to a 6. Her CLBP was
aggravated when standing from a seated position, whereas
CASE DESCRIPTION her CLBP and hip pain were both aggravated by walking
Three nonconsecutive patients with a chief symptom of or ascending stairs. Walking for 10 minutes increased both
CLBP were evaluated at an outpatient physical therapy symptoms to their worst pain level, at which time 1 minute
clinic over 12 months. For the current case series, CLBP of sitting relieved the symptoms completely. As a result, the
was defined as pain persisting for at least 3 months and patient could not resume shopping, which was her main
on at least half the days in the previous 6 months.20 In source of social engagement. The symptoms for which the
the current case series, CLBP will be used specifically to patient was seeking treatment began 7 months prior after
refer to LBP that has persisted for this length of time. To a chiropractic lumbar manipulation. The patient reported
establish minimum homogeneity in clinical presentation, being the recipient of a lumbar manipulation to address
all 3 patients had met the criteria described by Cooper gradual-onset LBP of about 3 weeks’ duration, but the
et al1 (≤3/5 hip abductor strength, gluteal tenderness, and manipulation worsened her symptoms. Six months after
a positive Trendelenburg sign). None of the 3 patients had the manipulation, she was still having LBP and lifted sev-
a history of lumbar surgery, lumbar fracture, hip surgery eral large boxes from the floor of a grocery store. Her pain
within the previous year, or signs or symptoms of upper increased over the following 2 days, prompting her to visit
motor neuron involvement. None of the patients were a physical therapist. The patient had a history of hyperten-
smokers, using pain medication, or long-term users of sion and osteopenia. No radiographs had been taken. Her
corticosteroids. goals for physical therapy were to return to her functional
status of 8 months prior, which included being able to
Patient Characteristics stand from a chair without pain, navigate the 17 stairs in
Patient 1 was a 77-year-old man with right-sided LBP of her home without pain, and shop for at least 30 minutes
12 months’ duration. The patient also noticed occasional before having to sit. She denied any clumsiness of gait,
(3 times a week) “burning” pain that would travel down unexpected weight loss, night pain, or bowel and bladder
the lateral aspect of his right leg into his foot. Leg pain and changes, and had no history of cancer.

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 Case Report

Patient 3 was an 85-year-old retired woman with left-

sided CLBP extending caudally to the gluteal fold and
laterally to the flank and greater trochanter. She described
the pain as varying from a 2 at best to a 5 at worst. Her
pain was increased to a 5 within the first few steps after
standing but settled to a 3 after about 10 steps. Her
CLBP would increase after 10 minutes of walking, forcing
her to sit and interfering with trips to the grocery store.
Approximately once daily, standing caused pain rated 2 of
10 down the lateral aspect of her leg and into the anterior
ankle. The patient’s symptoms had developed gradually
over 2 years. Her goals for physical therapy were to walk
through the grocery store without being limited by her
CLBP and to stand and walk without pain after sitting in a
chair. Hip radiographs were negative for arthritic changes.
Flexion-extension radiographs of the lumbar spine showed Figure 1. Assessing the impact of hip abductor weakness
a stable 5-mm anterolisthesis of L4 on L5. Her medical his- on gait. (A) The impact of hip abductor weakness on gait
tory included hypertension, hypothyroidism, and osteopo- was assessed by asking the patient to place either arm
rosis. She denied any clumsiness of gait, unexpected weight overhead during gait. Reduction in pain with only the con-
loss, night pain, or bowel and bladder changes, and did not tralateral arm overhead was thought to result from reduced
have a history of cancer. hip abductor requirements from translating the center of
mass over the ipsilateral hip. (B) If no change was seen,
testing was progressed by preventing frontal plane move-
Examination ment of the pelvis during a stepping task and assessing
Outcome measures were administered at baseline, 4 weeks, the response on the patient’s low back pain.
discharge, and 3-month follow-up. The NPRS was used to
track changes in pain within and between sessions. It has a immediately eliminated his CLBP. This response was
minimal clinically important difference (MCID) of 2 points thought to be a result of reduced load on the hip abduc-
in the LBP population.6 The Global Rating of Change tors from weight transfer over the right hip. However,
(GROC), a 15-point scale scored from −7 (a very great reliability and validity of this test have not been examined,
deal worse) to +7 (a very great deal better), was admin- and reduced symptom secondary to trunk muscle activa-
istered to quantify perceived level of improvement over tion was also considered. Lumbar active range of motion
time.21 In existing research, GROC scores of +5 or greater (AROM) reproduced his CLBP during extension and with
have been used to indicate a meaningful change,21 and right lateral flexion, both of which were visually estimated
an MCID of 3 has been reported.22 Limitations in activi- to be 50% limited. Straight leg raise testing (SLR) elicited
ties and participation were measured with the Oswestry symptoms in the posterior thigh at approximately 75° bilat-
Disability Index (ODI). The ODI consists of 10 items erally, which was interpreted as normal. Active straight leg
scored from 0 to 5 points for a total possible score of 50 raise (ASLR) testing reproduced CLBP during elevation of
points, with a higher score indicating greater disability. the left leg and was relieved with abdominal bracing. Hip
The ODI has been validated in individuals with CLBP and abduction manual muscle testing was performed using
has an MCID of 10 points.23 Finally, the Fear Avoidance break tests as described by Kendall.26 The patient was
Beliefs Questionnaire was administered at baseline to deter- positioned in side-lying with the tested leg on top and the
mine whether maladaptive beliefs were likely to influence bottom knee slightly flexed for stability. The tested hip was
prognosis. This questionnaire consists of physical activity tested in neutral rotation, slight extension and the pelvis
and work subscales, where scores greater than 15 of 24 rolled slightly forward. Downward pressure was applied
on the physical activity subscale are associated with worse in the typical fashion for a strength assessment greater
outcomes.24,25 All patients underwent a lower quarter neu- than 3/5.26 When a patient was unable to perform the test
rological examination with unremarkable findings. against gravity, a gravity-minimized supine testing position
Patient 1 had a Trendelenburg sign during stance on the was used.26 For patient 1, hip abductor strength was 2+
right leg, and walking 50 ft in the clinic produced CLBP of 5 on the right and 4 of 5 on the left. Gluteal tenderness
rated 5 of 10 on the NPRS. The Trendelenburg sign was was noted during palpation. Passive accessory mobility
considered positive when the patient did not maintain a testing at L4 and L5 produced sharp CLBP at the onset
level pelvis or had to lean their trunk over the stance limb of resistance but was judged to have more excursion than
to pelvic drop during gait. The relative influence of hip adjacent, nonpainful segments.
abductor weakness on CLBP with gait was tested by having Patient 2 had CLBP rated a 7 of 10 on the NPRS during
the patient place either arm overhead during gait (Figure 1). a sit-to-stand transition, but the pain settled immediately
Placement of the ipsilateral arm overhead increased his to her resting pain level of 4. Static postural examination
CLBP, whereas placing the contralateral arm overhead revealed a kypholordotic posture and a pes planus foot

Journal of GERIATRIC Physical Therapy 3

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 Case Report

posture. During gait examination, a Trendelenburg sign manually resisted hip abduction and extension in supine,
was evident during stance on the right leg. While walking, eliciting a gluteus medius muscle contraction with the elimi-
the patient reported CLBP rated a 7 of 10 and right but- nation of gravity (Figure 2). Once the quality of this contrac-
tock symptoms rated a 5. Placement of the contralateral tion was judged to be improved, gait was reassessed. The
arm overhead during gait reduced these symptoms to 5 CLBP with gait improved from a 5 to a 1 in patient 1, from
and 3, respectively. She was able to navigate an 8-inch a 7 to a 4 in patient 2, and from a 4 to a 1 in patient 3. These
step with her right lower limb, but vaulting from the left rapid improvements were thought to confirm the hypothesis
lower limb was observed. This task also produced LBP of CLBP related to hip abductor weakness. Given the sub-
and buttock pain rated a 9 and 6, respectively. Lumbar stantial hip abductor weakness present in these patients, ini-
flexion AROM was full with LBP reproduced at end range. tial management consisted of gravity-assisted, non–weight-
During lumbar extension AROM, hinging at L4 to L5 was bearing exercises with the goals of improving motor control
observed. The SLR testing elicited symptoms in the pos- and dissociation of hip and lumbar extension. Exercises
terior knee and was approximately 80° bilaterally. ASLR were progressed once the patient was able to perform the
testing reproduced right-sided LBP with elevation of the new exercise through a full range of motion with proper hip
right leg, which improved with manual compression of the abductor recruitment. A detailed description of the exercise
pelvis. Hip abduction strength was a 2+ of 5 on the right progression is provided in Appendix 2. A resisted posterior
and 3+ of 5 on the left. Gluteal tenderness was present. pelvic tilt (Figure 3) and other motor control exercises were
Hip mobility testing was deemed full and was pain-free used with all patients to address impaired trunk control
bilaterally. Passive accessory mobility testing produced and elicit an abdominal contraction in a pain-free direction
LBP during central and right unilateral pressure at L4, L5, (Appendix 1). Finally, weight-bearing exercises were added
and S1. Excursion of L4 and L5 was deemed hypermobile to improve gluteus medius muscle activity in standing once
compared with adjacent segments. The upper lumbar spine the Trendelenburg sign had improved and patient symptoms
and thoracic spine were hypomobile in the presence of a with prolonged standing had diminished. Weight-bearing
pronounced kyphosis but produced no pain. exercises were progressed from bipedal to unipedal when
Patient 3 had a pronounced kypholordotic posture. patients could control frontal plane excursion of the pelvis
Standing from a chair revealed a weight shift away from without discomfort. Home exercises were updated routinely
the left lower limb and caused CLBP rated a 4 of 10. to reflect the most challenging exercises that could be suc-
Stepping with her right lower limb was more painful than cessfully completed by the patient. Home exercises never
stepping with her left leg when first walking. Gait examina- exceeded 4 in number, which was thought to improve the
tion revealed a Trendelenburg sign during stance on the left chance of adherence.
lower limb that caused pain rated a 4 of 10. When placing Placement of an adjustable heel lift in the shoe of the
the contralateral arm overhead, her pain with gait was not contralateral foot was attempted during the second visit in
altered. Differentiation testing was progressed by manually all patients as a means of reducing the load on the gluteus
stabilizing the patient’s pelvis as she took a forward step, medius muscle via weight transference over the symptomatic
which reduced her pain from a 4 to a 2 (Figure 1). Lumbar hip joint.28 The heel lift reduced CLBP with gait by 50%
AROM was limited in flexion but caused no pain. All other in patients 1 and 3. Patient 2 noticed no change. Patients
directions were full and painless except for left lateral flex- 1 and 3 were instructed to wear the heel lift and begin to
ion, which generated mild pain at end range. The SLR test- decrease its size over time, as hip strength improved and
ing produced posterior thigh symptoms bilaterally but was CLBP resolved. Pain neuroscience education consisting of
approximately 50° on the left and 65° on the right. ASLR neurophysiology of pain processing, peripheral sensitization,
testing was painful when lifting the right lower limb and and hurt not equaling harm29 was administered to patient 2
improved with abdominal bracing. Hip range of motion to address her apparent high levels of fear-avoidance beliefs.
was full and painless in all directions. Gluteal tenderness
was present in the left hip. Hip abduction strength was 2+
of 5 on the left and 3+ of 5 on the right. Passive accessory
mobility testing produced pain only during left unilateral
pressure at L4 and L5, which appeared to be hypermobile
compared with adjacent segments.

INTERVENTION
On the basis of the clinical examination of the patients
alongside current evidence, interventions were administered
using an impairment-based model of clinical reasoning Figure 2. Manually resisted hip abduction exercise.
Manually resisted hip abduction and extension were per-
(Appendix 1). Test-retest assessment was used frequently
formed in supine to elicit a contraction of the gluteus
because it was believed that within-session changes would medius muscle in a gravity-minimized position. The
influence prognosis.27 Given the substantial hip abductor patient’s contralateral hip was positioned in flexion to
weakness in these 3 patients, trial treatment consisted of minimize stress on the lumbar spine.

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 Case Report

These concepts were reiterated during the course of her (Table 2). Only patient 2 reported having a recurrence
care. Once patients had met their goals for physical therapy of LBP during the 3-month follow-up period, which had
and were independent with a home exercise program that mostly resolved with adherence to her home program.
included weight-bearing exercises, they were discharged.
DISCUSSION
OUTCOMES The aim of the current case series was to describe the physi-
All 3 patients demonstrated significant improvements in cal therapy management and outcomes of 3 patients with
pain, disability, and perceived level of improvement over CLBP and substantial hip abductor weakness. Utilizing
8 to 10 weeks of physical therapy. Discharge occurred a primary hip abductor exercise approach, all patients
after 11 visits for patient 1, 17 visits for patient 2, and 12 demonstrated clinically meaningful improvements on the
visits for patient 3. The magnitude of change surpassed the GROC and ODI by discharge and had maintained these
MCID for all subjective outcome measures at discharge improvements after 3 months. Improvements in gluteus
(Table 1). Occasional mild LBP was still present in all medius muscle strength, the Trendelenburg sign, and lum-
patients at discharge, but the worst pain level had improved bar AROM were also seen at discharge. These results
quickly, surpassing the MCID of 2 points in all 3 patients conflict with a randomized controlled trial by Kendall
by week 4. The GROC and ODI met clinical significance et al,12 which found participants with CLBP did not ben-
by week 4 in all patients except for patient 3, where the efit from the addition of undefined hip muscle strengthen-
ODI did not meet the MCID until discharge. All patients ing to a lumbopelvic motor control program. However,
met the subjective goals agreed upon at the initial physical Kendall et al12 did not identify hip abductor weakness
therapy evaluation: Patient 1 could stand all day at work in their inclusion criteria, and the exercise program was
without pain, patient 2 could navigate steps painlessly, and neither described nor referenced in the study and was not
patient 3 could walk through a grocery store without pain. supervised by a physical therapist. Kendall et al12 also
At discharge, all 3 patients had 3+ of 5 hip abduction excluded patients older than 65 years, a population that
strength, no gluteal tenderness, and a Trendelenburg sign has been regularly excluded from studies investigating the
that was improved but not resolved (Figure 4). Provocative subgrouping of LBP.14,32 Exclusion of these patients may
lumbar movements had improved in all patients by week be important because prevalence of gluteus medius tendon
4 and were painless by discharge. Three months later, pathology and muscle atrophy increases with advancing
all patients maintained significant improvements in pain, age,33 suggesting individuals with hip abductor dysfunc-
disability, and perceived level of improvement over time tion tend to be older. A retrospective study of 185 magnetic

Table 1. Subjective Outcome Measures of Patients in the Current Case Series

Subjective Outcome Measure Baseline Week 4 Discharge 3-mo Follow-up
Worst pain reporteda
Patient 1 9 5 2 3
Patient 2 9 6 2 2
Patient 3 5 4 2 2
Oswestry Disability Indexb
Patient 1 20 10 3 4
Patient 2 22 18 9 7
Patient 3 18 16 10 8
Global Rating of Changec
Patient 1 NA 6 7 6
Patient 2 NA 6 7 6
Patient 3 NA 4 6 7
FABQ-PAd
Patient 1 9 NA NA NA
Patient 2 24 NA NA NA
Patient 3 6 NA NA NA
Abbreviations: FABQ-PA, Fear Avoidance Beliefs Questionnaire Physical Activity; NA, not applicable.
aThe patient’s worst pain level in the last 24 hours was recorded using the 11-point Numeric Pain Rating Scale, where 0 equals no pain and 10 equals the worst pain imaginable.30
bThe raw scores from the Oswestry Disability Index are reported. Scores can range from 0 to 50 points, and higher scores indicate greater disability.23
cThe raw Global Rating of Change scores are reported. Scores can range from −7 (a very great deal worse) to +7 (a very great deal better).31
dThe FABQ-PA is scored from 0 to 24 points, and higher scores indicate greater fear avoidance beliefs.19

Journal of GERIATRIC Physical Therapy 5

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 Case Report

coexisting hip abductor weakness. Cooper et al1 identified

a descriptive CLBP subgroup characterized by a hip abduc-
tor manual muscle test grade of less than or equal to 3 of
5, gluteal tenderness, and a positive Trendelenburg sign.
According to Cooper et al,1 the interrater reliability of the
Trendelenburg sign and gluteal tenderness was perfect and
reliability of the hip abductor manual muscle test grade was
Figure 3. Manually resisted posterior pelvic tilt. A strap- good (intraclass correlation coefficient = 0.597). The stron-
resisted posterior pelvic tilt was performed to elicit an gest single predictor of LBP in the study’s population was
abdominal contraction in a painless direction (arrow).
the gluteus medius manual muscle test grade of less than or
equal to 3 of 5 (ΔR2= 0.461, P = .001),1 which is consis-
resonance images by Chi et al33 found tendinopathy to be tent with other studies.6 Although the Trendelenburg sign
present in 54% of those in their 60s and 81% of those appears clinically useful in cases of severe hip abduction
in their 70s. Furthermore, low-grade partial tears were weakness, such as those in the current case series, its ability
common, but high-grade tears were uncommon and full- to predict more modest gluteus medius muscle weakness
thickness tears were nonexistent.33 These findings suggest is questionable.35 In a 2013 study,35 an ultrasound-guided
that gluteal tendon pathology is common in older adults, block of the superior gluteal nerve in healthy participants
but the majority of such pathology should be amenable to resulted in a 52% decrease in hip abductor strength but
treatment. The 3 patients in the current case series were all still did not alter frontal plane motion of the pelvis. This
older than 65 years and responded well to high-intensity evidence further supports a large variation in strength
strengthening of the hip abductors. This outcome supports between the subgroup identified by Cooper et al1 and the
a previous study that found improved muscle strength, size, healthy population.
and functional mobility in older adults after 8 weeks of The current case series has several limitations that war-
high-intensity strength training.34 However, the older age rant consideration. Because it is a case series, broad con-
and tendon quality of patients in the current case series may clusions cannot be made regarding a cause-and-effect rela-
have limited their strength improvements, considering they tionship or efficacy of this approach. Exercises addressing
were all discharged at lower than normal levels. impairments of motor control and endurance of the trunk
To our knowledge, the current case series is the first to muscles were cointerventions administered to all patients
describe in detail the physical therapy management, partic- during their episode of care, making it difficult to determine
ularly the exercise prescription, of patients with CLBP and any influences these exercises may have had on their LBP

Table 2. Objective Outcome Measures of Patients in the Current Case Series

Objective Outcome Measure Baseline Week 4 Discharge
Provocative lumbar movements
Patient 1 Extension (50% limited), right lateral End-range right lateral flexion None
flexion (50% limited)
Patient 2 End-range flexion None None
Patient 3 End-range left lateral flexion None None
Gluteus medius strength, involveda
Patient 1 2+ 3 3+
Patient 2 2+ 3 3+
Patient 3 2+ 3− 3+
Gluteal tenderness
Patient 1 Present Present Absent
Patient 2 Present Present Absent
Patient 3 Present Present Absent
Trendelenburg sign
Patient 1 Present Present, improved Present, improved
Patient 2 Present Present, improved Present, improved
Patient 3 Present Present, improved Present, improved
aHip abduction strength was tested manually and graded using a scale ranging from 0 to 5, where 0 represents no palpable muscle contraction and 5 represents the ability to hold the test position
with maximal resistance from the therapist.26

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 Case Report

Future investigations should also consider including indi-

viduals older than 65 years.

CONCLUSION
The current case series described the physical therapy
management and outcomes of patients with CLBP and
substantial hip abductor weakness treated primarily with
hip abductor strength training. All 3 patients had decreased
CLBP, increased gluteus medius muscle strength, and
increased functional ability over 8 weeks. These gains
were maintained at 3-month follow-up. In the future, well-
designed clinical trials should seek to validate this subgroup
within the CLBP population and determine whether those
individuals would benefit from hip abductor strengthen-
ing in addition to evidence-informed physical therapy
management.

ACKNOWLEDGMENTS
The authors would like to acknowledge Tim Fearon, PT,
DPT, FAAOMPT, as integral to developing several of the
concepts described herein and for having reviewed an ear-
lier copy of this article.

Figure 4. Improvement in the Trendelenburg sign for REFERENCES

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 Case Report

APPENDIX 1 Exercise 4. Supine Hip Abduction and Extension

Description of Common Exercises Used in the

Current Case Series

Exercise 1. Abdominal Brace with March

Purpose: To use the assistance of gravity to strengthen the

hip abductors and improve dissociation of the hip and lum-
bar spine in a well-tolerated position for the lumbar spine.
Performance: The patient was positioned in supine
Purpose: To train and challenge the ability of the abdomi-
with the hips flexed and legs supported on a chair.
nals to stabilize the trunk during leg movement.
Using an exercise band for resistance, the patient
Performance: Positioned in hook lying, the patient first
extended and abducted the hip as far as possible with-
engaged the transversus abdominus and then performed a
out lumbar extension.
posterior pelvic tilt into the table. The patient lifted 1 lower
limb from the table until the hip reached 90° of flexion. The
Exercise 5. Clamshell
limb was then lowered back to the starting position, avoid-
ing any movement in the trunk.

Exercise 2. Bridge With Gluteal Emphasis

Purpose: To improve motor control and strengthening of

the hip abductors while moving against gravity with a
shortened lever arm.
Performance: The patient was positioned in side-lying with
Purpose: To strengthen the gluteal muscles while improv- the knees flexed to 90° and the hips flexed to 30°. Keeping
ing the patient’s ability to dissociate lumbar extension both feet together, the patient lifted the top knee as far
and hip extension. as possible without moving from the lumbar spine. Hip
Performance: Positioned in hook lying with the feet flexion was progressed to 60° when possible. Resistance
elevated, the patient performed a posterior pelvic tilt and was applied only after appropriate motor control had been
lifted the pelvis from the table as far as possible without established.
lumbar extension. A strap was usually placed around the
knees to elicit a simultaneous isometric contraction into Exercise 6. Tandem Balance
hip abduction.

Exercise 3. Bridge With Segmental Lowering

Purpose: To improve motor control of the trunk muscles

and the patient’s ability to dissociate lumbar extension and
hip extension.
Performance: Positioned in hook lying, the patient main-
tained a posterior pelvic tilt while lifting the pelvis from the
table. The patient then lowered the pelvis by bringing each
spinal segment back to the table in a craniocaudal direction
(arrow).
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 Case Report

Purpose: To address balance deficits while introducing a Purpose: To increase the demand on the gluteus medius
stabilizing task on the trunk and hip abductors in a weight- muscle while performing a squat.
bearing position. Performance: The patient was standing with an exercise
Performance: The patient stood with 1 foot positioned ball positioned at her opposite hip. The patient pressed lat-
directly in front of the other as if standing on a balance erally into the exercise ball while simultaneously perform-
beam. This position was held for 30 seconds before being ing a squat (arrow).
progressed to an unstable surface.
Exercise 9. Hip Hike
Exercise 7. Lateral Ball Press

Purpose: To improve the ability of the hip abductors to

laterally stabilize the pelvis in a weight-bearing unipedal
position similar to gait.
Performance: The patient stood facing a wall. With a slight
forward lean, the patient flexed the contralateral hip and
elevated the contralateral ilium. Dorsiflexion of the con-
tralateral ankle and plantar flexion of the ipsilateral ankle
Purpose: To perform an isometric contraction of the gluteus were also encouraged.
medius muscle while in a weight-bearing position.
Performance: In a stable standing position, the patient
Exercise 10. Hip Hike With Exercise Ball
pressed laterally (arrow) into an exercise ball positioned
at her opposite hip until a good isometric contraction
of the gluteus medius muscle was perceived. This posi-
tion was held for varying lengths depending on patient
response.

Exercise 8. Squat With Lateral Ball Press

Purpose: To further strengthen the hip abductors in a posi-

tion that challenges the muscles to control and reverse a
contralateral pelvic drop.
Performance: The patient was standing with an exercise
ball positioned at her opposite hip. The patient stood on
the involved limb. While pressing laterally into the ball, the
patient flexed the contralateral hip and elevated the contra-
lateral ilium, rolling the ball upward (arrow).

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 Case Report

APPENDIX 2

Exercise Progression by Patient

Exercises Added for Each Patient by Visit
Exercisea 1 2 3
Non–weight-bearing
Abdominal brace with march 2 2 4
Bridge with gluteal emphasis 2 1 2
Bridge with segmental lowering 1 3 2
Supine hip abduction and extension 3 2 3
Clamshell 4 3 3
Weight-bearing (bipedal)
Tandem balance 3 3 3
Lateral ball press 4 3 4
Squat with lateral ball press 5 6 6
Weight-bearing (unipedal)
Hip hike 9 10 8
Hip hike with exercise ball 11 Not applicableb 10
aExercises were added once the patient was able to perform the exercise through a complete range of motion with good muscle activation. Exercises were modified for each patient, including
repetitions and hold times.
bThe patient was unable to perform this exercise with good control and muscle activation before discharge.

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