Day 7: The 7th of 12 Hip Tips today. Moving on to exercise interventions now, starting with one of my least favourite ones. In fact, I would go so far to say this exercise should be banned! At a minimum, for people with hip pain. We'll talk 2 top reasons why in this tip. If you've missed any of the previous hip tips, you can visit the blog listing page here.
Tip #7 Ban the Clam! At least for those with Hip Pain
The ‘clam’ or ‘clamshell’ exercise has become an iconic exercise for gluteal and specifically for gluteus medius conditioning. This exercise involves lying on your side with varying degrees of hip and knee flexion and raising the top knee while keeping the ankles together – bringing the top hip into abduction and external rotation. Many health and exercise professionals are very attached to this particular exercise and it is often the go-to for many clinicians when treating anyone with hip pain or gluteal weakness. No-one who visits my clinic walks away with this exercise in their program. In this mini-blog, I will focus on a couple of good clinical reasons why you shouldn't prescribe the clam.
1. Why you should NOT prescribe clams for gluteal tendinopathy/GTPS
When I see patients who come to me having failed previous exercise based interventions for lateral hip pain, there are often a couple of prominent features of their exercise program that have higher risk of provocative. The most common, is the clam! This means that despite the inclusion of some other useful exercises, they have often failed to progress because they have been persistently irritating their condition with 1-2 unhelpful exercises. Remove these from the program and more often than not, things start to turn around.
So why are they provocative? The primary reason is most likely to be the combination of repetitive compression and friction as the ITB moves anteriorly and posteriorly over the greater trochanter during the clam action. As the knees come together the ITB is wrapped firmly around the greater trochanter, compressing the gluteal tendons and bursae against the underlying bony trochanter. This exercise also does not provide an adequate or balanced stimulus for the abductor synergists, but that's a conversation for another day. I would recommend you remove clams from your protocols for people with gluteal tendinopathy/GTPS/trochanteric bursitis.
2. Why you should NOT prescribe clams for hip joint-related pain or after hip arthroscopy
Most often, joint change begins in the anterior aspect of the joint and chondrolabral rim pathologies are common. Sometimes there may be associated paralabral cysts which sit adjacent to the labrum, usually in the anterior – anterolateral rim region. The psoas tendon sits deep to the iliacus muscle belly, a little anteromedially in a neutral hip position, but during the clam action, the psoas tendon translates laterally across the anterior rim towards the anterior inferior iliac spine. Irritability in this anterior rim region is likely to be increased by the repetitive movement of the psoas tendon across the anterior joint, particularly if the muscle is active in this motion, increasing tension in the tendon and compression imposed against underlying structures.
Philippon and colleagues suspected possible links between iliopsoas related pain and exercise selection following hip arthroscopy1. They assessed recruitment of iliopsoas and gluteus medius with fine wire electromyography (EMG) during various exercises including clam exercises. They found a moderate level of iliopsoas activity during clam exercises and advised these exercises should not be used in early stages and with caution in intermediate phases of post-operative rehabilitation. There were lower levels of activation in a clam performed from 0 degrees hip flexion than with hips and knees flexed 45degrees, but remember the more hip extension, the more passive tension there will be in the psoas tendon and therefore compression of the tendon itself and the underlying bursa and rim structures of the joint. Clams will also place load on the anterior capsule due to the external rotation action. Remember that a considerable proportion of surgeons do not close the capsule after hip arthroscopy and there is a risk of iatrogenic anterior instability, so you need to closely consider your exercise selection and application post scope.
The other consideration with respect to effects of clams on the anterior joint structures is the degree of femoral version with which your patient presents. In those with excessive femoral anteversion, prescribing repetitive forced external rotation may well provoke associated anterior joint pain and add to the anterior stability challenge imposed on their joint. It is important to be aware of the implications for femoral malversion for load management strategies, exercise therapy and manual therapy. (Not sure how to assess femoral version? The clinical assessment technique is available in my video library)
I would recommend you remove clams from your protocols for people with anterior joint pain or after hip arthroscopy. There are many other great options with less risk of provocation.
There are so many other reasons to 'ban the clam' around optimisation of muscle function and balance within the abductor synergy, but that topic is just too long for this blog. If you would like to learn more about muscle function around the hip and pelvis, you might like my online course Dynamic Stabilisation of the Hip & Pelvis and if you would like further information about other exercise options for gluteal tendinopathy, try this course, or hip joint related anterior hip pain, try this one.
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