Hip Arthrosis

Definition

What is hip osteoarthritis?

The hip joint is the articulating connection between the pelvis and the femur. The femoral head is embedded in the acetabulum. The cartilage layer between these two structures provides a low-friction gliding surface. Hip osteoarthritis (coxarthrosis) is a degenerative disease of the hip joint. It is, after knee osteoarthritis, the most common form of osteoarthritis in humans. It arises from wear of the cartilage surface in the acetabulum and on the femoral head. The disease often develops over years and remains unnoticed for a long time. It usually occurs in older adults, typically after the age of 50 to 60. Cartilage damage is classified into four stages:

• Stage/Grade I: Soft cartilage
• Stage/Grade II: Rough surface with fissures
• Stage/Grade III: Deep fissures in the cartilage reaching down to the bone
• Stage/Grade IV: Complete wear of the cartilage with exposed bone. This is also referred to as a bone slick.

Where do the pains come from in hip osteoarthritis

The intensity and frequency of pain in hip osteoarthritis (coxarthrosis) can vary greatly from person to person. Even in the same person, hip joint pain can occur with different intensity and frequency. Many people mistakenly believe that only the worn cartilage causes the pain. However, the variability of hip joint pain shows that cartilage loss alone is not responsible for the pain. If that were the case, the pain would be constant and felt with every movement of the hip joint. Affected individuals often report phases of complete pain freedom as well as severe pain around the hip joint. This proves that not only cartilage health and thickness should be the basis for further measures. X-rays and other imaging procedures should therefore not be the sole basis for assessing severity of osteoarthritis and treatment. As with all tissues in the body, cartilage is continuously being built up and broken down. The goal in everyday life must be that breakdown processes do not outweigh building processes.

The variability of pain intensity and frequency is also related to various internal processes that occur in hip osteoarthritis. Here are the most common causes that lead to pain in the hip:

• Cartilage degeneration

  The joint cartilage acts as a shock absorber between the femoral head and the acetabulum. When the cartilage is lost, additional pressure can be placed on the periosteum, which is highly sensitive to pain due to the blood vessels and nerves it contains.

• Joint inflammation (synovitis)

  Cartilage wear can trigger inflammatory processes in the joint lining. The resulting increase in joint fluid production leads to swelling, warmth and pain.

• Joint effusions

  The increased production of joint fluid in response to cartilage breakdown exerts additional pressure on the joint, which can cause pain and a feeling of tension.

• Irritation of surrounding tissue

  Changes in the joint can also irritate surrounding structures such as ligaments, tendons, muscles and fascia, leading to pain and increased joint stiffness.

• Bone changes (osteophytes)

  With progressing hip osteoarthritis, bony growths form that can press on nerves or soft tissues, causing additional pain and limitations in movement.

• Microfractures in the bone (subchondral changes)

  The increasing loss of cartilage places more load on the underlying bone, which can lead to small fractures and bone densification that also cause hip pain.

• Myofascial tension

  The musculoskeletal system senses the mis- and overloading of the hip joint and attempts to protect the joint and cartilage by tensing muscles and fascia, limiting hip movement. This tension of myofascial structures can cause pain during movement because movement is performed against this increased tension.

Causes of hip osteoarthritis

The causes of cartilage loss and associated pain in hip osteoarthritis (coxarthrosis) are closely related to our modern lifestyle and changed environmental conditions. In the past, our ancestors had to move more and more holistically to obtain food, whether by hunting, gathering berries or farming. These activities were often performed barefoot and on natural ground, which led to well-developed foot and leg muscles.

Over the millennia our lifestyle has changed dramatically. Today modern civilization is often characterized by lack of movement and a sedentary lifestyle. When we move, it usually happens on hard, flat surfaces like concrete or asphalt and in supportive, inflexible shoes. These changed movement habits and conditions lead to physical adaptations that can contribute to the development of hip osteoarthritis. The following describes the impacts of these factors on the development of hip joint osteoarthritis (coxarthrosis).

Lack of movement and sedentary lifestyle

Due to the modern lifestyle characterized by lack of movement and prolonged sitting, the musculoskeletal system is misloaded. Lack of movement and a sedentary lifestyle lead to physical adaptations that can cause the breakdown of hip joint cartilage. The following changes play a significant role in the development of hip joint osteoarthritis:

• Weakened muscles

  Lack of movement and a sedentary lifestyle cause essential muscles to atrophy. Foot, leg and hip muscles play a crucial role in the cartilage health of the hip joint. A functional foot musculature supports the foot’s longitudinal arch, which acts as the first instance to reduce force impact on the hip joint and thus on its cartilage during standing and walking. Furthermore, the foot and leg muscles ensure a natural roll-off of the foot and protect against uncontrolled collapse of the foot after heel strike. Uncontrolled foot collapse transmits a jolt to the hip on each step instead of guiding it physiologically. This mis- and overloading leads to overuse and can contribute to hip joint osteoarthritis. The leg and hip muscles stabilize the hip joint and keep it in the correct position. An active and tensed musculature around the hip joint further protects the cartilage from force impacts during every movement. The importance of functioning muscles is therefore essential for joint cartilage health.
  

• Foot misalignments

  Weakened muscles can additionally lead to foot deformities. The responsible musculature can no longer support the longitudinal arch, resulting in a fallen or flat foot. When the longitudinal arch collapses, the foot’s shock-absorbing function during walking and standing is lost. The acting force is transferred via the feet and knees to the hips and their cartilage with each step. The increased load can damage the cartilage over time and thus lead to hip osteoarthritis and hip pain. Foot misalignments can also cause an uneven distribution of body weight, leading to excessive load on the hip joints, which can accelerate cartilage loss. In addition, conditions such as a valgus foot, pronation or supination can shift the leg axis, altering the position of the femoral head in the acetabulum. This increases load on a specific area of the hip cartilage and promotes osteoarthritis of the hip joint.
  

• Restricted cartilage nutrition

  Cartilage in the hip is not supplied directly by blood vessels. Instead, it receives nutrients from the synovial fluid, which is pumped into the joint through movement. Lack of movement and a sedentary lifestyle disturb this process. As a result, the cartilage is not sufficiently supplied with nutrients and oxygen. The cartilage loses elasticity and resilience, increasing friction and wear. Over time, this can lead to the development of hip osteoarthritis.
  

• Fascial dysfunction

  Fascia can change their original structure and become brittle when loaded irregularly and unphysiologically. As a result, the fascial network loses its elastic effect and leads to increased tension around the hip joint. The increased tension presses the femoral head and the acetabulum closer together. This additional pressure from the closer bones excessively wears the cartilage layer. Thus, osteoarthritis in the hip joint can develop. Furthermore, changes in the fascial structure can impair joint mobility and lead to stiffening. More on this in the following section.
  

• Joint stiffness

  Due to lack of movement and prolonged sitting, joints are not moved through their maximal possible range of motion. Especially during daily sitting, the hip joint is barely moved. Excessive sitting also shortens, among others, the hip flexors, changing pelvic position and thus altering load on the hip joint cartilage. The shortened muscles also reduce the range of motion of the hip joint. Lack of movement and a sedentary lifestyle result in a natural stiffening of the joints, which leads to increased wear in the still possible range of motion. When ankle joints stiffen, hip joints also suffer. Lack of foot mobility prevents a natural roll-off and thus increases force impact on the hip joint.

Hard, flat floors and inflexible, supportive shoes

Hard, flat floors and inflexible, supportive shoes have significant impacts on the hip joints and can cause or exacerbate hip osteoarthritis. The following factors play a major role in the development of hip joint osteoarthritis.

• Reduced shock absorption and increased force impact

  When walking on hard, flat floors and in inflexible, supportive shoes, higher forces act on the musculoskeletal system, particularly during heel strike. The stiffness of industrial floors and the rigidity of conventional shoe soles prevent absorption of these forces, leading to increased load on the body. This increased force initially affects the feet and is then transferred via the knees to the hips. The worse the feet can absorb forces, the more the hips are stressed. The cartilage in the hip joint is thus subjected to greater strain with every step.
  
  Due to the increased and early force impact at heel strike, the possible reaction time of the responsible muscles is shortened. If the muscles cannot contract in time, the corresponding joint is insufficiently stabilized, leading to mis- and overloading. Insufficient muscular tension of the feet results in an uncontrolled collapse of the midfoot after heel strike. The so-called collapsing foot (floppy foot) arises and causes an additional jolt to the hip joint, further damaging the cartilage. The hip-stabilizing leg and pelvic muscles may also be unable to react quickly enough due to the early and increased force impact. Reduced muscle tension leads to an unstable hip joint, increasing cartilage load and potentially leading to hip osteoarthritis over time.

• Restricted foot function and muscle weakening

  Hard, flat floors and inflexible, supportive shoes reduce foot movement with every single step. The restricted foot function thus limits movement of the structures above. The less movement generated in the lower extremities, the more inactive the responsible musculature becomes, leading to muscle weakening. Studies show that inflexible, supportive shoes are often associated with reduced muscle activity in the calf and thigh muscles. Reduced muscle function especially in the foot, leg and pelvic muscles results in insufficient stabilization of the hip joint, which promotes increased cartilage breakdown.

• Unnatural movement sequence

  Natural movement patterns are designed to react dynamically to changing ground. Hard, flat floors and inflexible, supportive shoes significantly impair a physiological movement sequence. On the one hand, lack of muscle activation at heel strike causes the foot to collapse uncontrolled downward. The collapsing foot and its consequences on the hip joint were described in the previous section. On the other hand, the hardness and inflexibility of industrial floors as well as the rigidity of conventional shoe soles prevent a natural roll-off of the foot. This restricted foot movement limits the travel distance of each step. To still move forward, the required movement must now come from the hip, resulting in a hip-oriented gait. As a result, the hip joint is subjected to much greater load with each step, accelerating cartilage degeneration. Moreover, inflexible, supportive shoes reduce sensory feedback from the foot, decreasing information exchange and thus adaptability. This results in monotonous loading, which is particularly harmful to the hip joint. The lack of variation and constant pressure on certain parts of the hip can cause microtraumas in the joint that develop into hip osteoarthritis over time.

Symptoms of hip osteoarthritis

It is important to mention that the following lists are the most common symptoms of hip osteoarthritis. The list of hip osteoarthritis (coxarthrosis) symptoms is not exhaustive. Atypical hip joint osteoarthritis symptoms are also possible and are not listed here. Symptoms of hip joint osteoarthritis often depend on factors such as pain sensitivity, cause of injury, degree of injury, physical constitution, etc. To obtain a definitive diagnosis, a physician should be consulted.

• Hip pain: Pain in the hip region commonly occurs and can radiate to different areas. In hip osteoarthritis, groin pain or radiations into the legs are not unusual. Hip joint pain is often activity-related and can worsen during the day. At a later stage, hip osteoarthritis pain may occur at night or at rest.
• Stiffness: Especially after rest periods, such as on getting up in the morning or after prolonged sitting, the hip can feel stiff and immobile. This can be both an early symptom and a long-term symptom of hip osteoarthritis.
• Reduced mobility: The range of motion of the hip can be limited, making walking, bending or climbing stairs difficult.
• Muscle weakness: The muscles surrounding the hip joint may weaken, leading to noticeable instability of the hip joint.
• Swelling and inflammation: In some cases swelling and inflammation in the hip area can occur, causing additional pain.
• Altered gait: Affected individuals may develop a limp to compensate for hip pain and reduce load on the affected hip.
• Weather-dependent hip complaints with osteoarthritis: Increased pain and stiffness in damp or cold weather are typical hip joint osteoarthritis symptoms.
• Crunching or rubbing noises: In severe osteoarthritis, crunching or rubbing noises may occur when moving the hip, indicating cartilage wear.
• Variable pain perception: From no hip joint pain to extreme pain, the pain in the same person can vary during the day. This is a strong indication that not the degenerated cartilage but the myofascial structures are the source of pain. Reason: Cartilage damage is constant, but tensions and blockages are not.

Conventional therapy - What helps with hip osteoarthritis

To treat hip joint osteoarthritis pain, there are several approaches. Some hip osteoarthritis therapies are presented below. The list of these therapies is not exhaustive. Various measures can also be combined to treat hip osteoarthritis. A medical consultation is recommended to determine the appropriate therapy for hip joint osteoarthritis.

• Physiotherapy: Special hip osteoarthritis exercises and therapy methods aim to improve mobility, strengthen muscles and relieve the joint. Symptoms of hip joint osteoarthritis can be reduced after a short time.
• Exercise therapy: Gentle training (e.g., swimming, cycling or yoga) promotes mobility and muscle strength without overloading. It also improves circulation, which is beneficial in hip osteoarthritis treatment.
• Weight reduction: Overweight places additional load on the joints. Weight loss can therefore significantly improve symptoms of hip joint osteoarthritis. Reducing body weight decreases pressure on the hip joint, thereby relieving the cartilage.
• Orthopedic aids: Braces or orthoses to support and stabilize the hip joint. Insoles to correct deformities and relieve certain joint areas.
• Dietary changes: A balanced diet rich in omega-3 fatty acids and antioxidants can have anti-inflammatory effects and positively influence disease progression.
• Acupuncture: Pain relief by stimulating specific points.
• Heat or cold therapy: Heat to relax tense structures, cold to relieve inflammation. The appropriate temperature needs to be tested in hip osteoarthritis treatment.
• Magnetic or electrotherapy: Promotes blood circulation and relieves pain.
• Pharmacotherapy: Painkillers and anti-inflammatory medications. This approach addresses only the symptoms of hip osteoarthritis without eliminating the causes of its development. Cartilage-building medications can help promote healing of cartilage tissue.
• Joint injections: In hip joint osteoarthritis, hyaluronic acid can contribute to improving joint lubrication and relieving hip osteoarthritis pain. Cortisone can reduce inflammation in acute flare-ups and relieve pain in hip joint osteoarthritis.
• Autologous blood therapy: This method uses the healing properties of the patient’s own blood to regenerate joint cartilage and relieve hip osteoarthritis pain.
• Surgical interventions: If conservative measures are no longer sufficient, surgical procedures such as hip arthroscopy or hip replacement may be necessary. Such measures should always be considered after various conservative coxarthrosis therapies have failed to produce the desired result.

kybun mode of action - What helps with hip osteoarthritis

kybun products aim to eliminate the health-damaging effects of hard, flat floors and inflexible, supportive shoes and to actively address lack of movement and a sedentary lifestyle. Due to the elastic-springy properties of kybun products, the musculoskeletal system is both relieved and activated. The relief ensures that, as a first step, load on the hip joint cartilage is reduced. Through activation, the causes of hip osteoarthritis are addressed so that hip complaints due to osteoarthritis become a thing of the past in the long term. Thus kybun shoes are very suitable for hip osteoarthritis because they help in treatment through the following mechanisms:

• Natural foot roll and increased range of motion thanks to elastic-springy material

  Thanks to the compressive capability of the kybun sole, the heels can slowly sink into the elastic-springy material during heel strike. This slow sinking allows the foot muscles to prepare for the upcoming load. The tensed muscles prevent uncontrolled, cartilage-damaging foot collapse and enable a natural foot roll off through the toes. Utilizing the full range of motion of the feet already covers a considerable distance without requiring this movement to be compensated for by the hip joint. Instead of a hip-oriented gait, a foot-oriented gait is initiated, relieving the hip joint cartilage and thus reducing the risk of hip osteoarthritis. Furthermore, the jolts to the hip joint are reduced by the natural foot roll because the acting force is converted into forward motion. Additionally, active roll-off on the elastic-springy kybun material uses the entire range of motion of the foot. This automatically generates more movement in the knee and hip joints. As a result, the hip joint is not always moved within the same limited range that promotes cartilage loss, but across the entire possible range of motion. The result is a reduction of point-load intensity. Several studies have also shown that natural and physiological loading can promote cartilage rebuild.

• Muscle activation and stabilization of the hip joint

  When walking in kybun shoes, the heels sink deep into the compressible elastic-springy sole. This allows the full load to be built up slowly and in a controlled manner, giving the body more time to tense the relevant muscles. The tensed leg muscles stabilize the hip joint and load the cartilage in a natural way. In contrast, loads during walking on hard, flat floors and in inflexible, supportive shoes hit the body undamped. The increased force and reduced reaction time prevent the responsible muscles from tensing in time. This leads to insufficient stabilization of the hip joint and thus to mis- and overloading of the cartilage.

• Reduction of force impact from hard, flat floors through damping effect

  When the heel strikes in kybun shoes, the elastic-springy material is compressed. Thanks to the compressive capability of the kybun sole, the rearfoot can sink deep into the material. This slow and controlled sinking reduces the force and thus the load on the hip joint and cartilage. Similar to an airbag in a car, the kybun sole minimizes the force impact by its damping effect.

• Activation and strengthening of muscles through elastic-springy property

  When walking and standing on the elastic-springy kybun surface, the body must constantly make small compensatory movements to maintain balance. The intentional slight instability of kybun products challenges the balance system and specifically activates the stabilizing deep muscles responsible for stability and posture. As a result, the hip joint is better stabilized and protected by the surrounding musculature. At the same time, coordination skills are improved because the interaction between the nervous system and muscles is enhanced. This leads to better body awareness and more precise movements, which ultimately protects the hip joint from osteoarthritis.

Balance and EMG

Balance ability was measured with a force plate by movement of the center of mass from front to back (ant-post) and sideways (med-lat) while standing. In parallel, electromyography (EMG) recorded muscle activity.

• Promotion of circulation through increased activity

  The knee joint also needs numerous nutrients for the nourishment, maintenance and regeneration of cartilage. These nutrients are transported to the relevant tissue via the blood and synovial fluid. In addition, anti-inflammatory substances are transported to the knee joint via the blood while harmful and inflammation-promoting signaling molecules are removed. This constant fluid exchange thus supplies the cartilage and keeps it elastic and resilient. The elastic-springy kybun materials promote movement and thereby activate the muscles around the knee joint. In this way circulation is increased, which in turn supports the benefits mentioned above.
  

• Promotion of movement and reduction of sedentary behavior

  The elastic-springy kybun products promote joy in movement because walking and standing on the unique material relieves the knee joints. Movement activates and strengthens muscles and promotes circulation. The advantages of these two processes were described in previous sections. Because kybun products can also reduce the duration of sitting, harmful shortenings and blockages of myofascial structures can be avoided. Increased walking and standing stretch and lengthen commonly shortened hip flexors as well as the posterior chain of calf and thigh muscles, which positively affects knee joint alignment and pressure on knee joint cartilage.
  

• Care and protection of the fascia

  Fascia stabilize the knee joint and distribute load evenly with each step, which protects against cartilage wear. Healthy and functional fascia are elastic and free from adhesions and tension. Elastic fascia promote knee mobility and support good circulation, which is important for nutrient supply and cartilage regeneration. Thanks to kybun shoes, a natural movement sequence is possible, keeping the fascia elastic.
  

• Optimized pressure distribution

  When walking and standing in kybun shoes, the entire sole of the foot is surrounded by the elastic-springy material. This leads to optimized pressure distribution in the feet. As a result, point pressure on the knee joints and their cartilage can be reduced. In addition, the constant slight movement on kybun products increases the contact area, which can also reduce focal pressure points. This can help protect cartilage from injury and wear.

Application tips for hip osteoarthritis

Before you wear kybun shoes for the first time, you should consider some application tips. Correct use can help relieve hip osteoarthritis pain. In addition, treat hip osteoarthritis through a targeted hip osteoarthritis therapy, which is explained in the next section.

• Wear kybun shoes initially only as long as your body tolerates. Introduce wearing breaks if hip complaints increase or if the musculoskeletal system becomes fatigued. Hip osteoarthritis treatment takes time. Due to the activating property of kybun products, muscles are trained, which can cause so-called initial reactions, especially at the beginning.
  
• With hip joint pain you should walk more often than stand. While standing, constant pressure can place higher load on the joint cartilage and lead to further tensions and blockages. Movement promotes circulation, releases tense muscles and fascia, and distributes load across the entire hip joint.
  
• Press your heel into the elastic-springy material. Try to find a loading point where hip joint pain is reduced or does not occur.
  
• Try to actively roll off over the forefoot and toes as much as possible. By increasing range of motion in the feet, a greater travel distance via foot roll-off is generated, relieving the hips. The goal is a foot-oriented gait instead of a hip-oriented gait.
  
• Try alternating walking speeds after some time. Switch from walking to trotting and back. Stay at each speed for about 15 seconds. By changing speeds, tensions in and around the hip joint can be better released. Test which speed causes the least or no pain.
• Try the following exercises to enhance the effectiveness of kybun shoes and to increase the probability of recovery.

What to do for hip osteoarthritis? Helpful exercises

To enhance the effectiveness of kybun shoes and increase the likelihood of relieving hip osteoarthritis pain, we recommend performing the following exercises for hip joint osteoarthritis. The selection of exercises is not exhaustive and can be supplemented by additional exercises. In principle, during all exercises pain in the hip joint must not increase. If any exercise increases hip osteoarthritis pain, it must be stopped. Pleasant and releasing “pain” outside the pain point in the hip joint (e.g., in the thigh) and a reduction of hip joint osteoarthritis symptoms are desirable.

The exercises are divided into the following areas: “Correct walking in kybun shoes”, “Muscle length training”, “Fascia rolling” and “Strengthening”. Ideally, the different areas are used complementarily as therapy for hip osteoarthritis.

Correct walking in kybun shoes

The quality of each individual step is crucial in treating coxarthrosis to reduce hip complaints and eliminate mis- and overloading. kybun shoes therefore offer an ideal therapy for hip joint osteoarthritis and can be worn both for early symptoms and for advanced hip osteoarthritis.

Controlled foot movement

• Gently press the heel into the elastic-springy material to find the loading pressure and point at which a step is possible without pain.
• Place midfoot and forefoot slowly and controlled.
• Controlled foot posture so that the foot does not tilt inwards or outwards.
• Roll off slowly and controlled via the forefoot.
• Slow exercises help to rebuild the stabilizing muscles.
• Perform consciously every day while using kybun products.

Quick step frequency

• Movement sequence identical to Exercise 1.
• Now incorporate short steps with a high step frequency that cause movement in the hip joint, always using the full range of motion of the feet.
• If you have hip joint pain, increase step length and reduce frequency.
• Important! Maintain an upright posture while standing and walking. Perform consciously every day while using kybun products.

Muscle length training

Muscle length training is crucial in coxarthrosis treatment because hip complaints often arise from shortening, tension and blockages of myofascial structures. Targeted stretching exercises can actively address these shortenings, tensions and blockages and therefore represent an ideal therapy for hip osteoarthritis.

Hip opener

• Start position in quadruped (all-fours).
• Place the left foot forward next to the hands.
• Stretch the right leg back and place the foot flat. Ensure that the hip and spine are aligned.
• To intensify the stretch, push the hip forward and down depending on individual mobility.
• Perform 1–2 times daily.
• Hold the exercise 3 x 30 seconds.

Glutes

• Start position lying on your back.
• Stretch both arms out at a 90-degree angle to the sides and place the left leg bent over the right side.
• With the right hand press the bent knee downwards.
• Ensure both shoulder blades remain on the floor.
• Perform 1–2 times daily.
• Hold the exercise 3 x 30 seconds.

Fascia roller

Fascia training with a foam roller is important in coxarthrosis treatment because the condition often results from shortenings, tensions and blockages of myofascial structures. Regular rolling out of shortened and tense myofascial chains makes the foam roller an active therapy for hip joint osteoarthritis.

Gluteal muscles

• Start position seated with both legs bent.
• Roll out the corresponding gluteal half with the fascia ball. Increase pressure by resting one leg on top. If wrist pain occurs, the exercise can also be performed on the forearms.
• Perform the exercise slowly and controlled.
• Adjust pressure to personal tolerance, but work up to a tolerable pain threshold.
• Roll out focal adhesions more intensively or hold position at these points.
• 3 minutes per side.
• Perform 1–2 times daily.

Lateral thigh muscles

• Start position lying on your side.
• Place a large roller between the outer thigh area and the floor.
• Use the top leg to stabilize and guide the movement at a right angle.
• Roll the lateral thigh actively from the hip to above the knee joint.
• Perform exercises slowly and controlled.
• Adjust pressure to personal tolerance, but work up to a tolerable pain threshold.
• Roll out focal adhesions more intensively or hold position at these points.
• Straightening the top leg can intensify the exercise.
• 3 minutes per side.
• Perform 1–2 times daily.

Strengthening

Targeted strength training helps strengthen the muscles around the hip and thereby relieve the hip joints and their cartilage and eliminate typical hip joint osteoarthritis symptoms. Strengthened muscles can better absorb the forces acting on the hip joints with each movement. In addition, muscles stabilize the hip joints and protect them from mis- and overloading. Strengthening exercises are an effective therapy for hip joint osteoarthritis and help to relieve hip osteoarthritis pain in the long term.

Hip thrust

• Start position: lying on your back with knees bent (hip-width). Arms are stretched shoulder-width towards the feet.
• Actively lift the hips off the floor and move towards the ceiling (hips should be fully extended at the top of the exercise).
• Hold the top position for 4 seconds.
• Ensure the force comes from the glutes (not the heels or the back of the thighs).
• Lower the hips slowly again without the glutes touching the floor.
• 3 sets of 8–12 repetitions.
• Perform 2–3 times per week.

Squats

• Start position: standing, feet slightly wider than hip-width and slightly externally rotated.
• Slowly and controlled go into a deep squat. Push the hips back and shift weight onto the heels.
• Ensure force comes from the glutes. Stabilize the knees so they do not collapse inward or outward.
• Slowly and controlled stand up again. If balance is an issue, hold onto a stable object with your hands.
• 3 sets of 8–12 repetitions.
• Perform 2–3 times per week.