Slow Down & Pay Attention to the Deep Six
Many people try yoga because of hip pain or tightness, looking to gain more flexibility in the tissue and increased range of motion. Often, the goal becomes how deep a student can get into an asana. For example deep pigeon pose, with less concern on creating balance in the joint. When it comes to external rotation of the hip, there can be an overemphasis on stretching the muscles and little awareness on strengthening them.
The gluteus maximus is the most superficial muscle (closest to the skin) responsible for external rotation of the hip. Six deeper muscles work together to bring the femur bone into external rotation in the hip socket: the piriformis, gemellus superior, obturator externus, gemellus inferior, obturator internus, and the quadratus femoris. Conversationally, they are referred to as the deep 6 lateral rotators or the piriformis and the GOGOQ’s. These muscles lie below the surface of the gluteus maximus and are essential in supporting the weight of the body while standing.
Causes of Weakness & Tightness
For those of us who sit a lot, the external rotators are prone to be both weak and tight. Sitting creates a constant amount of pressure on the muscles, which reduces blood flow and nervous system activity. Over time, tightness can lead to discomfort, inflammation, and compression of the sciatic nerve. Furthermore, weakness in these muscles is associated with knee osteoarthritis and knee pain due to the significant role these muscles play in aligning the femur, which then impacts alignment at the knee (Prins and van der Wurff, 2009).
The piriformis is typically the most familiar of the deep 6 rotators. Many students are referred to yoga because of sciatica (a condition where the sciatic nerve root is compressed due to lower back disc issues like herniation or degeneration) or piriformis syndrome (where the piriformis muscle is so tight that is compresses the sciatic nerve). Both conditions create pain and/or nerve symptoms in the posterior hip, with sensation running down the back of the leg. Both conditions are also typically treated with yoga postures that stretch the piriformis muscles in external rotation of the hip, like pigeon pose and figure four.
How To Stabilize these Muscles
Stretching the deep 6 rotators addresses tightness in the muscles but doesn’t address weakness. These muscles are key stabilizers in the alignment of the pelvis, as well as controlling the movement of the thigh bone in the hip socket. Strengthening the external rotators brings alignment to both the pelvis and knees. As a group, these muscles stabilize the hip in weight-bearing yoga poses like warrior 2 and side angle pose.
From anatomical position, the piriformis is superior and superficial to the other five muscles in the group. Given its position, it is more easily identifiable (both through palpation and sensation) and more likely to fire in weight-bearing poses where the thigh bone is in external rotation (warrior 2 and side angle pose). Without much thought or even body awareness, the piriformis does its job and engages as we move through standing poses that require external rotation at the hip. But if we don’t slow down and work with controlled movement, we lose the ability to connect to what is happening in the deeper, lower five stabilizing muscles, and this can develop into a muscular pattern where the lower five muscles become dormant leading to less stability in the joint.
Building Awareness by Isolating the Deep 6 Muscle Group
Start with an isolated movement that focuses solely on the engagement of the deep six: external rotation. Isolated strength training targets the deep muscles and also can reveal muscular imbalances (such as when one side fatigues more easily) as well as build strength and endurance over time.
Lie on your right side with your head, back ribs, back pelvis, and sole of feet all on one plane (you can lean against a wall to find this). Lift the left side of your waist away from the floor and draw the low belly into the body. Keeping the feet touching, inhale and lift your top knee, exhale and lower the knee, without moving the pelvis. Repeat until fatigue and then switch sides. If you find that one side fatigues with less repetition, repeat the weak side a second time.
Butterfly Hip Lifts
Lie on your back and draw the soles of the feet together, knees wide. Walk the heels away from your pelvis, so that the legs create a diamond shape. Bring your hands to your belly. On your inhale, lift your hips a few inches off of the floor (keeping your feet together and your belly drawing into the body). Exhale slowly lower the hips to the floor. Repeat until fatigue and then rest.
Creating Awareness of the Lateral Rotators
An effective way to assess whether or not you are engaging the deeper muscles of the lateral rotators is through palpation. First, locate the piriformis muscle so you can feel its engagement. Start with your stance as if you were setting up for triangle pose – right leg forward. Bring your right fingers to the middle of your gluteus maximus muscle and notice if there is any muscular engagement (there should be minimal). The piriformis is positioned right below the center of the gluteus maximus. Keeping your fingers on your piriformis muscle, bend your right knee, coming into warrior 2. As you externally rotate the right thigh bone, you will feel the engagement of the piriformis under your fingers. Come in and out of warrior 2 a few times to create an internal awareness of when the piriformis muscle is firing. Then switch to the left side.
Finding the Quadratus Femoris
Next, locate the quadratus femoris muscle. Again, starting with the stance for triangle pose (right leg forward), bring your right fingers to your right sit bone, then move the fingers just lateral to the sit bone (to the right when working on the right side). Relax your lower gluteus maximus muscle. Keep your fingers adjacent to the sit bone and slowly bend your knee coming into warrior 2. As you externally rotate the thigh bone away from the midline, you will feel the quadratus femoris muscle turn on. Slowly come back to stand with the legs straight. Repeat several times. Move slowly so that you can feel the muscle engage and you can create internal awareness on how to turn the quadratus femoris on.
After locating both the piriformis and quadratus femoris muscles, you can bring this awareness into your standing poses and create stability with mindful movement on the breath.
Once again, set up for triangle pose, right leg forward. Bring your right hand to your inner right knee. On your exhale slowly bend your right knee as you lower your right hand toward the floor, coming into side angle pose. The left hand can extend over your head. Inhale, slowly return to stand. Adding the breath, exhale to a count of eight as you slowly bend the knee and lower the hand into side angle pose and inhale back up to stand. Repeat until fatigue then switch sides. If one side fatigues with less repetition, repeat on the weak side a second time.
Increasing the Challenge: Half Moon Pose at the Wall
Come to a wall and stand the distance of the length of your leg away from the wall. Using a block under your left hand for stability, lift your right leg to the wall and turn the toes out to the side. Once you feel balanced, start to rotate the torso open to the side, drawing the belly in, and extending from the crown of the head to the foot on the wall. You can rest your top hand on your hip or reach it up. The work is happening in the standing leg: rotate the thigh bone away from midline while simultaneously hugging the hip in toward midline – this will activate the deep six. Hold for several breaths and switch sides.
The key to alleviating hip pain is through a combination of poses that both stretch and stabilize the muscle tissue. This often starts with body awareness and approaches that isolate the muscle groups to gain an innate understanding of the location and engagement of the muscle groups. Slowing down the practice can activate the deeper muscles responsible for external rotation at the hip and can lead to pain reduction and overall joint stability.
Prins, M.R. and van der Wurff, P. (2009). Females with patellofemoral pain syndrome have weak hip muscles: A systematic review. Australian Journal of Physiotherapy, 55(1). 9 – 15.