If you have read any of my previous articles about hip pain, back pain, or knee pain you will know how important hip mobility and gluteal strength is to maintaining optimal joint stability and efficient movement. Anyone with pain in these areas will know how difficult it can be to either restore mobility to the hip, or strengthen the glutes without inflaming other areas of the body. The knee can be particularly vulnerable to instability caused by the hip and finding the right exercises to correct this dysfunction can be very frustrating and take considerable time. You will also know how critical it is to have optimal foot stability for achieving hip control. Training these weak areas separate to each other is a good start, but you will never make lasting changes until you link them together in an integrated movement. Two of the best exercises that I have used successfully in recent times to do this are the hip airplane and leg extension with rubber tubing pulling laterally on the tibia. In this article, I will explain how to do these exercises, why they work so well, and the various progressions you can use to enhance joint stability and strength of the body. This is one of those occasions.

Tight Hips Sacrifice Stability of the Lumbar Spine and Knee

The most interesting thing with both of these exercises are that they are not new in any way. In fact, I actually thought very little of them for a long time and avoided using them thinking that they had little to offer. Like many things to do with health and fitness if you stay working in this field long enough, and if you are open to new ideas and better ways of doing things you will find you see things differently. I wrote about this in great detail in the article last year (why I prefer reading books) and gave insights into many things I changed my mind about. I have been wrong on many occasions and most of the mistakes I have made eventually led me to some of my best ideas and programs. These two exercises are one of those occasions!

The quote below brings up a very important point that relates to both of the exercises featured in this article and is something I have discussed multiple times when it comes to strengthening the VMO and the knee. 

Before we get straight into the two exercises it is important to understand how stiff hips wreak havoc on joints like the knee and lower back.

When the hips become stiff and tight the end result is more motion created at the lumbar spine when you bend or flex the trunk, or more motion at the knee when you plant your foot in a single leg stance as used in walking or running. In both cases this additional motion at the lumbar spine or the knee exposes these joints to instability and damage.

The hips are designed to be very mobile, having to withstand both direct loading stresses and large rotational forces with weight-bearing activities. It is especially vulnerable to injury in sports that involve pivoting or twisting movements, such as soccer, football, tennis and golf. Because the muscles around the hip joint attach directly on to the joint capsule, they have a large influence on the range of movement. Rotational forces place tremendous strain on your ligaments, tendons and muscular structures designed to protect the joint.

Below you can see a classic example of tight hips corrupting the way you bend over to pick up something off the ground. Without adequate hip mobility your lumbar spine has no choice but to bend and flex during movements that it should remain stable and in neutral. Most people would blame this on a weak core, but the abdominal muscles will have no choice but to sacrifice any strength or function to bend over to the ground for the hips are too tight.

The guy on the left demonstrates good bending form by using his hips to save his lumbar spine. The guy in the middle is unable to use his hips correctly and has no choice but to flex his lumbar spine to reach that low to the ground. The skeleton on the far right shows how exposed the spine is if the hips do not move backwards during the bending action. 

With regards to knee pain, the tight hips creates huge problems when the knees are forced into a twisting or bending sideways movement, (eg ACL tear) known as valgus or Varus, and lastly if they hyper-extend. The knee joint is more or less a hinge, it cannot twist and rotate itself, and it cannot bend the other way either. The rotation of the leg must come from the two joints above and below the knee, being the HIPS and the ANKLES. Both of these joints have the ability to move in almost every direction but if either of these two joints lose their mobility the knee has no choice but to sacrifice stability to make up for the lost range of movement.

Often it is the hips that are responsible for the instability of the knee but we cannot ignore the role of the feet here too. More on that shortly.

For more detail on this I highly suggest to read the article – Are tight hips the cause of your back or knee pain?

Tight Hips Often Creates Weak Glutes

Stiffness at the hip will inhibit your attempts to strengthen the glutes. This is known as muscle inhibition and is something I have covered several times in previous articles relating to hip pain and knee pain. Check out the index page to see the various articles on these topics.

The body is very smart and can anticipate pain before you even move. It can instantly rearrange and change motor programs and movements to protect itself from harm and is another factor to consider when observing what appears to be a tight muscle or a weak muscle. Using a thorough assessment process is essential to ensure you do not miss the protective mechanism at work in a movement. It can be difficult to spot the real problem as you will see many other things happening that are a compensation to protect the real underlying problem.

In Vladimir Janda’s book “Assessment & Treatment of Muscle Imbalance” who first coined the terms tonic and phasic muscles he explains in great detail how muscle inhibition works.

• In simple terms tonic system muscles are prone to tightness or shortness and are more concerned with stability, posture, and working for long periods. They are made up mostly of slow twitch fibres and are easily facilitated with constant repetitive movements. Hip flexor muscles like ITB, TFL, and even rectus femoris are part of the tonic muscle system.
• On the other side is the phasic system muscles who are prone to weakness or inhibition and more concerned with fast and powerful movements. They are predominately fast twitch muscle fibres and require specific movement to keep them functional. The glutes are part of the phasic muscle system.

The tonic muscles by way of their design begin to develop a method of overworking and dominating all movements and in essence “shut down” or "steal" the phasic muscles workload completely. This creates an imbalance within the body as muscles which are not capable of performing various movements continue to work excessively, eventually developing trigger points and tightness. Meanwhile at the same time other muscles like the gluteus maximus are becoming weaker due to a lack of work.

Optimal Foot Stability Is Critical To Knee Alignment

The feet are a part of the body that is often missed during treatment for knee injuries. The feet themselves may have no pain at all but they could be the underlying cause of all the problems.

It makes sense to start at the feet as they are the first part of the body to touch the ground when we move. Our feet and ankles are meant to withstand incredibly high forces and should provide more in terms of shock absorption than perhaps any other body part. Unfortunately, we begin to gradually lose this ability once we start wearing shoes. Over time, the feet, ankles, and toes become inhibited. And as we expose our feet to some trendy shoes with all types of padding and support, this only make matters worse and exacerbates the lazy and weak feet muscles.

Besides minimizing the ability to withstand intense ground reactive forces, the body gradually begins sending fewer and fewer signals to the feet, leading to distortions in proprioception and loss of innervation all the way up the kinetic chain. This is where poor stability evolves and injuries are born! I have seen countless ACL injuries that began with poor foot stability.

You will find tons of additional information about foot stability and many of the isolated exercises to improve this in the article - Exercise solutions for weak feet

Recent research has found by actively attempting to internally rotate the tibia inwards, the VMO will increase its activation potential. This may be due to the fibres of the VMO also act to internally rotate the tibia through the patella. The two following exercises pay close attention to this fact and are one of the main reasons I like them so much.

Okay, so now that you have a better understanding of how the hips and the feet contribute to knee instability it is time to look at the two exercises I am using at the moment. The first one I will look at is the “hip airplane” exercise.

How to Do the Hip Airplane

Make sure you watch the video below that features all the progressions and regressions you can use with this exercise.

This first exercise is a variation of the single leg Romanian deadlift. The major differences with this exercise versus the standard single leg RDL is the added rotational movement of the hip in the air and the proprioception demands needed to maintain balance. The RDL and especially the single leg RDL are known as great exercises for lower back pain and hip pain as it works perfectly to realign the femoral head back deep into the hip socket glutes by releasing the hip and strengthening the glutes.

This is not a new exercise and has been around for a very long time. It is sometimes used in Yoga classes and is a favourite of Dr Stuart McGill for treating back pain as shown in his book “Back Pain Mechanic” on page 120.

I must admit I never used to think all that highly of this particular exercise and for years ago I avoided it. I now know that I was missing out on some important skills due to my ignorance and stubbornness of spending the time to really learn what it does and how it works.

Now that my eyes have been opened I realise that the beauty of this exercise is how well it combines proprioception, foot stability, and gluteal strength of the stance leg with lateral mobility of the hip in the air.

With so many moving parts it can take some time to truly master this movement but the pay-off is fantastic, especially for someone with patella tracking problems. Why?

Due to the rotation of the hip in the air the body would normally begin to rotate inwards at the foot and the hip to follow. Unfortunately, the single leg stance prevents this from happening as you will fall over instantly. Instead, the body senses the loss of stability and begins to counter the rotation with an opposing rotational force to maintain the single leg stance. This torsion effect is what engages the glutes, the muscles of the foot and ankle, and most importantly the VMO muscle of the knee. The VMO plays a pivotal role in providing knee stability and is often very weak with those suffering with knee pain.

The proprioception part comes into it when you take your eyes off the horizon. With the traditional single leg exercises you can keep your eyes fixed on a point ahead which enables you to maintain good balance and control. This version takes that ability away from you and forces your ankle and feet to work twice as hard which is fantastic for improving knee stability.

Once you have mastered the body-weight version and can complete 3 sets of 8-12 reps it is time to use a progression to further enhance single leg stability and overall knee strength. Below is two screenshots of the progressions I feature in the video that you can use to further challenge the muscles of the feet and hips to maintain knee alignment and stability.

By using rubber tubing to pull the tibia into external rotation forces the body to react and pull the tibia inwards, which as I explained earlier will increase the VMO activation level. This is known as reactive neuromuscular training and is something I have used a lot over the years but usually with the femur. This time I focused on more on the tibia and muscles of the feet and found it to be more useful than some of my more traditional exercises as seen in the article – How to strengthen the VMO in an integrated movement

While this is an excellent exercise and my preferred version it can be too difficult to do in the early stages of rehabilitation or strengthening. Finding a way to regress the movement is important and the following exercise is one way you can do this.

Knee Extension with Rubber Tubing

I have never liked the traditional leg extension machine and countless research has shown this to be a terrible way to improve quadriceps strength. The shearing forces placed upon the knee joint is counter-productive to what it is meant to achieve.

However, this version is much different. Instead of trying to annihilate the quadriceps with load it is more concerned with targeting the glutes by applying a lateral resistance with rubber tubing. There is still some quadriceps strength involved but it is minimal in comparison to the demands on the hip.

Once again you can see how the rubber tubing attempts to pull the tibia into external rotation forcing the glutes to pull against it to correct the alignment problem. This is known as “feeding the mistake” to make the body use the weakened muscles of the VMO and especially the glutes.

This is one of those exercises that looks really easy when you watch someone else do it, only to find out that it is pretty tough when you do it yourself. I have found this is a great way to learn how to control lower limb alignment and get used to using the glutes to control the hip without serious amounts of strength being required. A great stepping stone exercise to the much harder standing exercises like the hip airplane and single leg deadlift.

The main drawbacks of this exercise is the obvious lack of integration by not standing up and also the lack of foot stability required, so you will need to add some exercises for the feet separately to continue working on that part of the equation. 

Apart from that it can be a great exercise to complement the various other exercises in your knee strengthening program.

You will find great information about the VMO and knee pain exercises in the articles in the links below.

• Weak VMO – How to strengthen in 5 steps
• Knee pain has nothing to do with the knee itself
• How to complete a knee pain assessment

Do You Need More Help?

I suggest if you are someone with a chronic knee problem right now your best bet is to get my full KNEE PAIN program shown below. I created this program a few years ago to provide a program in a simple step by step process to effectively change all of the things we have just spoken about in this article. We have been able to successfully help hundreds of all types of knee injuries, (if not thousands over the internet) using this exact program. Click here to see a preview trailer of what is in the video.

Click here to get a copy of this program.

Summary

While these two exercises appear to be quite simple, they are much harder than they look. Using rubber bands to assist the body in providing a stability correction can be a real game changer for activating muscles that are often weakened or inhibited in normal movement patterns. By combining these exercise with “big” movements like squats, lunges, step-ups, and various other knee loaded movements you give your body every chance of learning to move more efficiently and without limitation or pain.

For more ideas and information on specific topics I may not have covered in detail be sure to check out our INDEX PAGE on the website that has over 300 of our best articles. These are all sorted into categories for quick reference so you can find what you are after more easily. You can also subscribe to our FREE fortnightly newsletter by clicking here.

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