Hip Muscles Dr. Tamer Emam Testing Muscles of the Lower Extremity 1.Hip Flexion. 2.Hip flexion, abduction and external (lateral) rotation with knee flexion

Hip Muscles

Dr. Tamer Emam

Testing Muscles of the Lower Extremity

1. Hip Flexion. 2. Hip flexion, abduction and external (lateral) rotation

with knee flexion.3. Hip Extension.4. Hip abduction. 5. Hip Abduction from flexed position6. Hip Adduction7. Hip External Rotation8. Hip Internal rotation

Hip Flexion1- ANATOMY:Agonist / Prim mover : Psoas major and iliacusOrigin:

Psoas major: transverse processes of L1-L5 and the vertebral bodies of T12-L5

Iliacus: anterior 2/3 of iliac fossa

Insertion:

Psoas major: lesser trochanter of the femur

Iliacus: lesser trochanter of the femur

Nerve Supply:

Psoas major: lumbar plexus , nerve root from L1-to-L4

Iliacus: lumbar plexus, Femoral nerve L2-L4

Action: powerful hip flexion Synergist / Accessory Muscles: Rectus Femoris (RF), Sartorius, Tensor fasciae latae (TFL) and

Pectineus.

2- Range of motion: 0 to 115-1250

3- Stabilization: 1. contraction of anterior abdominal muscles to fix lumbar spine

and pelvis. 2. weight of trunk.

4- Effect of weakness and contracture: 1- Difficulty in: climbing stair, walking up or down the incline, getting up

from a reclined position. 2- In marked weakness: walking is difficult because the leg must

brought forward by pelvic motion. 3- Effect of contracture: Bilateral– Increased lumbar lordosis. Unilateral–hip abduction combined with external

rotation.

5- Factor Limiting of motion: - With knee flexed, contact of thigh on abdomen. - With knee extended, tension of Hamstring Muscles.6- Substitution: *Sartorius: external rotation and abduction of the hip *Tensor fasciae latae: internal rotation and abduction of the hip.

7-Procedures: a- Position of Patient: b- Position of Therapist : inner hand, Outer hand, Direction of Resistance c- Test d- Instruction to patient

The patient is short sitting with thighs fully supported and legs hanging over the edge. The therapist stands next to the test leg. The therapist places one hand on the distal thigh and proximal knee, and applies resistance in a downward direction as the patient actively flexes at the hip

TEST PROCEDURESGRADES “3” FAIR

Patient position: sitting with legs over the edge of table. Patient grasp the edge of table to stabilize pelvis or arms may be crossed on the chest if patient is stable enough.Therapist position and grasp: therapist stand beside the tested leg, proximal hand is pressing the iliac crest down to stabilize pelvis..Command:Raise up your leg vertically toward your chest (in mid line)……relax

Patient position: the same as grade 3.

Therapist and Patient Instructions: same as for grade 3 plus Resistance is applied proximal to the knee joint..

Resistance:Grade 4: a moderate leading resistance is given directly opposite to the line of motion.Grade 5: a maximum resistance is given in the same manner as grade 4 plus hold at the end of ROM.

Command:The same as grade 3 plus…. Hold when test grade 5…. Relax

GRADES “4” AND “5”GRADES “4” AND “5”

Grades 4 and 5 “good and normal”

Patient position: side lying with affected leg down, trunk, pelvis and legs are straight. Upper leg is supported.Therapist and Patient Instructions: therapist stand behind the patient, the proximal hand stabilize the pelvis, and distal hand support the upper leg.

Command:With flexed knee move your leg toward your chest…..relax

MMT FOR GRADES 2 “POOR”

Patient position: supine lying, both legs are extended and affected leg nears the edge of the table.

Therapist and Patient Instructions: therapist stand beside the table, distal hand supporting the affected leg, the proximal hand palpate contraction in psoas major just distal to inguinal ligament.

.Command:Try to pull your leg toward your chest….relax

MMT FOR GRADES 1 AND 0 “TRACE AND ZERO”

Hip flexion, abduction, and external rotation with knee flexion

1- ANATOMY: -

Agonist / Prim mover : Sartorius

Origin: anterior superior iliac spine (ASIS)

Insertion: upper medial surface of body of tibia

Action: - flexes hip and knee

- With flexed hip, laterally rotates the thigh

Nerve supply: branches of femoral nerve, L2-L3-L4

Synergist / Accessory Muscles: hip and knee flexors. hip external rotators,

and hip abductor.

2- Range of motion: NO specific ROM because of two-joint muscle.

3- Fixation: a. Contraction of abdominal muscles to fix pelvis. b. Weight of trunk.4-Effect of weakness and contracture: effect of weakness: loss of antro- medial instability of

the knee joint. effect of contracture: flexion, abduction and lat. Rot.

Deformity of the hip with knee flexion. 5- Factor Limiting of motion: Non, because incomplete range of motion.

6- Substitution: Iliopsoas or the Rectus Femoris results in pure hip flexion

without abduction and external rotation.

7- Procedures: a- Position of Patient: b- Position of Therapist : inner hand, Outer hand, Direction of

Resistance c- Test d- Instruction to patient.

The patient is short sitting with thighs supported on table and legs hanging over side. The therapist stands lateral to the test leg while placing one hand on the lateral side of the knee and using the other hand to grasp the medial anterior surface of the distal leg. Hand at knee gives downward and inward resistance. Hand at ankle gives downward and outward resistance. Patient flexes, abducts, and externally rotates the hip and flexes the knee.

TEST PROCEDURESGrades “3” fair

Patient position: sitting with legs over the edge of the table. Heel of limb to be tested in front of opposite ankle.

Therapist position and grasp: therapist stand beside the patient. The proximal hand stabilizes the pelvis.

Command:Raise your heel up to knee with flexion, abduction and lateral rotation of hip and flexion of knee ……relax.

Patient position: the same as grade 3. Therapist and Patient Instructions: same as for grade 3 plus proximal hand is placed the knee to resist hip flexion and abduction. Distal hand above ankle to resist hip lateral rotation.Resistance:Grade 4: a moderate leading resistance is given directly opposite to the line of motion.Grade 5: a maximum resistance is given in the same manner as grade 4 plus hold at the end of ROM.


GRADES “4” AND “5”


Patient position: supine lying, with heal of limb to be tested on opposite ankle.

Therapist position and instruction: therapist stand beside the patient, the proximal stabilize the pelvis.

Command:Slide your heel along leg to knee with flexion, abduction and external rotation of hip and knee flexion ……relax

MMT for Grades 2 “poor”

Patient position: same as grade 2 with hip flexed and lateral rotated.

Therapist and Patient Instructions: same as grade 2 but therapist one hand supporting leg under knee and proximal hand palpate near the origin of sartorius muscle just below ASIS.

Command:Try to pull your thigh towards you, flexing hip joint … relax

MMT for Grades 1 and 0 “trace and zero”

Hip Extension 1. ANATOMY:

Prim mover / agonist: Gluteus maximus and Hamstring

Origin of Gluteus maximus – outer rim of ilium (medial aspect) – dorsal surface of sacrum and coccyx – sacrotuberous ligament

Insertion of Gluteus maximus : – Illiotibial tract of fascia lata(primary insertion) – gluteal tuberosity of femur

Action of Gluteus maximus : – powerful extensor of hip – laterally rotates thigh – upper fibers aid in abduction of thigh – fibers of IT band stabilize a fully extended knee

Nerve supply of Gluteus maximus : inferior gluteal nerve,

L5,S1,S2 Synergist / Accessory Muscles: Adductor magnus (inferior part), Gluteus medius (post part), 2- Range of motion: 0 to 10- 150 degrees (hyper)

3- Fixation a. Contraction of ilio costalis lumborum and quadratus lumborum muscle. b. Weight of trunk.4- Effect of weakness and contracture: 1- Effect of weak. Bilaterally makes walking difficult., difficult in raising the

trunk from foreword-bent position. 2- Patient must push themselves to an upright position by using their arms

during walk. 3- Effect of contracture: walking with Hyper extension deformity. 5-Factor Limiting of motion: a. Tension of iliofemoral ligament. b. Tension of hip flexor muscles. 6-Substitution: by extending lumbar spine. Therapist must support the pelvis.

7- Procedures: a- Position of Patient: b- Position of Therapist : inner hand, Outer hand, Direction of Resistance c- Test d- Instruction to patient

The patient lies prone on the table. The therapist stands on the side of the test leg, at pelvis level. One hand stabilizes the pelvis, and the other hand is placed on the distal calf. The hand on the distal calf applies resistance in a downward direction ad the patient actively extends at the hip.

TEST PROCEDURES

Grades “3” fairPatient position: half prone lying with flexed knee, affected leg away from the therapist, and sound leg supported on a stool.

Therapist position and grasp: therapist stand beside the table at level of hip joint, proximal hand support the pelvis.

.Command:Raise up your leg ……relax

Patient position: the same as grade 3.Therapist and Patient Instructions: same as for grade 3 plus Resistance is applied proximal to the knee joint..Resistance:Grade 4: a moderate leading resistance is given directly opposite to the line of motion.Grade 5: a maximum resistance is given in the same manner as grade 4 plus hold at the end of ROM.




Patient position: side lying with affected leg down, hip flexion and knee extension. Upper leg supported.

Therapist and Patient Instructions: therapist stand behind the patient, the proximal hand stabilize the pelvis, and distal hand support the upper leg

Command:Move your leg backward……relax


Patient position: same as grade 3.

Therapist and Patient Instructions: same as grade 3 but therapist palpates with two hands the upper and lower portion of the muscle.

Command:Squeeze your buttocks… relax


Alternate position of hip extension but isolate gluteus maximus

To isolate gluteus maximus, all positions must be associated with knee flexion

Hip abduction

1- ANATOMY: Prim mover/ agonist: ( Gluteus medius and Gluteus minimus)

Gluteus medius: Origin: from the outer surface of the ilium, posterior gluteal line(behind) and anterior gluteal line(below).

– upper fascia (AKA gluteal aponeurosis)

Insertion: lateral aspect of greater trochanter of femur

Action: - anterior and lateral fibers abduct and medially rotate the thigh

- the posterior fibers laterally rotate and may assist in extension.

- stabilizes the pelvis and prevents free limb from sagging during gait

Nerve: superior gluteal nerve, L4,5,S1

Gluteus minimus Origin: outer aspect of ilium (between anterior and inferior gluteal lines)

Insertion: – greater trochanter (anterior to medius) – articular capsule of hip joint

Action: - abduct and medially rotate the thigh – stabilizes the pelvis and prevents free limb from sagging

during gait

Nerve: superior gluteal nerve, L4,5,S1

Hip abduction Synergist / Accessory Muscles: Upper fiber of Gluteus maximus, Sartorius, TFL.

2- Range of motion: 0 to 45 degrees

3- Fixation: a. Contraction of lateral abdominal muscles and latissimus dorsi. b. Weight of trunk.

4- Effect of weakness and contracture: Effect of weakness: unilateral: positive (trendlingburgh test) Bilateral: waddling gate Effect of contracture: positive Ober’s test5- Factor Limiting of motion:

– Tension of distal band of iliofemoral ligament and pubocapsular ligament.

– Tension of hip adductor muscle.6- Substitution: - Patient may “hike hip” by approximating pelvis to thorax using lateral trunk

muscles. - hip external rotation with flexion. - TFL substitution

7- Procedures: a- Position of Patient: b- Position of Therapist : inner hand, Outer hand,

Direction of Resistance c- Test d- Instruction to patient.

The patient is side lying with test leg uppermost. The therapist stands behind the patient and stabilizes with one hand at the hip. This hand is proximal to the greater trochanter. The other hand applies resistance across the lateral surface of the knee. Patient abducts hip against downward resistance.

TEST PROCEDURES

Grades “3” fairPatient position: side lying and affected leg is upper and slightly extended while lower leg is flexed for balance.

Therapist position and grasp: therapist stand behind the patient, proximal hand support the pelvis.

.Command:Raise up your leg without lateral rotation of hip ……relax


Therapist and Patient Instructions: same as for grade 3 plus Resistance is applied proximal to the knee joint..Resistance:Grade 4: a moderate leading resistance is given directly opposite to the line of motion.

Grade 5: a maximum resistance is given in the same manner as grade 4 plus hold at the end of ROM.




Patient position: supine lying with legs extended, the affected leg is away from the therapist.

Therapist position and instruction: therapist stand beside the table, the proximal hand stabilize the pelvis, and distal hand grasp around the ankle to fix leg on the table.

Command:Move your leg outward without lateral rotation……relax



Therapist and Patient Instructions: same as grade 2 but therapist one hand grasp the ankle of affected leg and other hand is placed on lateral aspect of the ilium above greater trochanter to palpate contraction.Command:Try to move your leg outward without lateral rotation… relax


Hip Abduction from flexed position1- ANATOMY: Prim mover /agonist ( Tensor Fascia Latae):

Origin: - anterior aspect of iliac crest - anterior superior iliac spine (ASIS)

Insertion: anterior aspect of IT band, below greater trochanter

Action:– medially rotate & abduct a flexed thigh – tenses IT tract to support femur on the tibia during standing

Nerve: superior gluteal nerve, L4,L5,S1 Synergist / Accessory

Gluteus medius, and Gluteus minimus

2- Range of motion:No specific Rom, because of two-joint muscle.

3-Fixation: 1. Contraction of lateral abdominal muscles and latissimus dorsi 2. weight of trunk.

4- Effect of weakness and contracture: Effect of weakness : pt walks with Leg with tendency to rotate hip

laterally Effect of shortness: Bilaterally– results in anterior pelvic tilt and

sometimes bilateral knock-knees, Unilateral– results in lateral pelvic tilt. Effect of contracture: hip flexion, and knock knees.

5-Factor Limiting of motion: - Non, ROM incomplete 6-Substitution: by Hip lateral rotator muscles.

7- Procedures: a- Position of Patient: b- Position of Therapist : inner hand, Outer hand, Direction of


The patient is side lying with test leg uppermost, and hip flexed to 45 degrees. The therapist stands behind the patient and stabilizes with one hand at the hip. This hand is proximal to the greater trochanter. The other hand applies resistance across the lateral surface of the knee. Patient abducts hip against downward resistance.

Hip Adduction1- ANATOMY: Prim mover /agonist (Adductors magnus,

Adductors Brevis, Adductors Longus, Pectineus and Gracilis)

Origin Insertion Adductors magnus Ischial tuberosity (inf-lat) Femur (linea aspera) Adductors Brevis Pubis Femur (linea aspera) Adductors Longus Pubis Femur (linea aspera) Pectineus Pubis Femur (linea aspera) Gracilis Pubis Femur (linea aspera)Action: Hip AdductionNerve supply: All Adductors are supply by Obturator nerve (L2,3,4) Pectineus is supplied by Femoral n.(L2-L3)

Synergist / Accessory Muscles: Obturator externus, Gluteus maximus.

2- Range of motion: 0 to 15- 203- Fixation: by Weight of trunk 4- Effect of weakness and contracture: - Effect of weakness : patient unable to adduct the leg during walking. - Effect of shortness: patient walks with adducted legs. - Effect of contracture: unable to abduct leg during gate cycle. 5- Factor Limiting of motion: 1. Contact with opposite limb. 2. When hip is flexed, tension of ischiofemoral ligament6- Substitution: by 1. hip flexor muscles. 2. Hamstring muscle.

7- Procedures:a- Position of Patient: b- Position of Therapist : inner hand, Outer hand, Direction of


The patient is side lying with the test leg lowermost and resting on the table. The uppermost leg is abducted to 25 degrees and supported by the examiner. The therapist stands behind the patient at the knee level. The resistance hand is placed on the distal medial femur of the test leg. Resistance is applied in a downward motion while the patient actively adducts.

TEST PROCEDURES

Grades “3” fair:

Patient position: side lying and affected leg is down and upper leg is abducted 25 degrees and supported.

Therapist position and grasp: therapist stand behind the patient, both hands support the upper leg.

Command:Raise up your leg until contact the other leg ……relax


Therapist and Patient Instructions: same as for grade 3 plus distal hand support the upper leg and proximal hand is placed proximal to the knee joint to give resistance.

Resistance:

Grade 4: a moderate leading resistance is given directly opposite to the line of motion.


Command:

The same as grade 3 plus…. Hold when test grade 5…. Relax



Patient position: supine lying, the affected leg is away from the therapist and abducted 45 degrees.

Therapist position and instruction: therapist stand beside the table, the proximal hand stabilize the pelvis, and distal hand grasp around the ankle to fix leg on the table.

Command:Move your leg toward the other leg without rotation……relax

Grade 2 “poor”:


Therapist and Patient Instructions: same as grade 2 but therapist one hand grasp the ankle of affected leg and other hand is placed on medial aspect of the thigh to palpate contraction.

Command:Try to move your leg outward without lateral rotation… relax

Grades 1 and 0 “trace and zero”

Hip External Rotation 1- ANATOMY: Prim mover /agonist (Obturators internus and externus, Gemellae

superior and inferior, Piriformis, Quadratus Femoris, Gluteus maximus “posterior”

Origin Insertion Obturators internus Ischium and Pubis Femur (trochanteric fossa ) Obturators externus Ischium and Pubis Femur (greater trochanter) Gemellae Superior Ischium Femur (greater trochanter) Gemellae Inferior Ischial tuberosity Femur (greater trochanter) Piriformis Sacrum Femur (greater trochanter) Quadratus Femoris Ischial tuberosity Femur Gluteus Maximus Ilium , sacrum Femur (gluteal tuberosity)

Nerve supply: Obturators internus: Nerve to Obturators internus (L5-S1) Obturators externus: Nerve to Obturators externus (L3-L4) Gemellae Superior: Nerve to Gemellae Superior (L5-S1) Gemellae Inferior: Nerve to Gemellae Inferior (L5-S1) Piriformis: Nerve to Piriformis (S1-S2) Quadratus Femoris: Nerve to Quadratus Femoris (L5-S1) Gluteus Maximus: Inferior gluteal n.(L5-S2)Action: Hip lateral rotationSynergist / Accessory Muscles:Sartorius, Biceps femoris, Adductors magnus and longus

2- Range of motion: 0 to 45

3- Fixation: by Weight of trunk

4- Effect of weakness and contracture: - Effect of weak : result in medial rot. accompaied by foot pronation with knock-

knees. - Effect of contracture: result in abduction position with limited medial rot. Of the hip

accompained by outward position of the toes in standing position

5- Factor Limiting of motion: 1. Tension of lateral band of iliofemoral ligament.

2. Tension of hip medial rotator muscles.

6- Substitution: - Sartorius ( Hip flex,abd, and ext rot.)



The patient is short sitting. The therapist sits on a stool or kneels beside patient. The therapist places one hand at the lateral aspect of the distal thigh and applies resistance in a medial direction. The other hand grasps the medial ankle just above the malleolus, and applies resistance in a lateral direction. The patient is actively externally rotating at the hip.

TEST PROCEDURES


Patient position: sitting with legs over the edge of the table. Patient grasps edge of the examining table to stabilize the pelvis.

Therapist position and grasp: therapist stand in front of the patient, on side of affected leg. The proximal hand applies pressure above the knee to prevent abduction and flexion of the hip.

Command:Bring your foot over the other leg keeping your thigh in contact with table ……relax


Therapist and Patient Instructions: same as for grade 3 plus distal hand is placed on medial surface of the leg just above the ankle to give resistance.

Resistance:



Command:




Patient position: supine lying, the affected leg is in medial rotation and away from the therapist.

Therapist position and instruction: therapist stand beside the table, the proximal hand is placed on the anterosuperior iliac spine to stabilize the pelvis.

Command:Turn your leg outward ……relax

Grade 2 “poor”:


Therapist and Patient Instructions: same as grade 2 but therapist one hand is palpating deeply for muscle contraction behind the greater trochanter.

Command:Try to turn your leg outward … relax


Hip Internal Rotation 1- ANATOMY: Prim mover /agonist ( Gluteus minimus and medius, Tensor fascia

latae):

Origin Insertion

Gluteus Minimus Ilium (outer surface) Femur (greater trochanter)Action: Hip medial rotation

Nerve supply: Gluteus Minimus: Superior gluteal n.(L4-S1)Action : Hip medial rotation

Synergist / Accessory Muscles: Tensor fascia latae, Gluteus minimus and medius.

2- Range of motion: 0 to 45

3- Fixation:

- Weight of trunk

4- Effect of weakness and contracture:

- walking with lat. Rot.

5- Factor Limiting of motion:

1. when hip is extended, tension of iliofemoral Ligament.

2. when hip is flexed, tension of ischiocapsular ligament.

3. tension of hip lateral rotator muscles.

6- Substitution:

by lifting the pelvis on the tested side.



The patient is short sitting. The therapist sits on a stool or kneels beside patient. The therapist places one hand at the medial aspect of the distal thigh and applies resistance in a lateral direction. The other hand grasps the lateral ankle just above the malleolus, and applies resistance in a medial direction. The patient is actively internally rotating at the hip.

TEST PROCEDURES


Patient position: sitting with legs over the edge of the table. Patient grasps edge of the examining table to stabilize the pelvis.

Therapist position and grasp: therapist stand in front of the patient, on side of affected leg. The proximal hand applies pressure above the knee to prevent adduction and flexion of the hip.

Command:Bring your leg outward keeping your thigh in contact with table ……relax


Therapist and Patient Instructions: same as for grade 3 plus distal hand is placed on lateral surface of the leg just above the ankle to give resistance.

Resistance:



Command:




Patient position: supine lying, the affected leg is in lateral rotation and away from the therapist.

Therapist position and instruction: therapist stand beside the table, the proximal hand is placed on the anterosuperior iliac spine to stabilize the pelvis.

Command:Turn your leg inward ……relax

Grades “poor”:


Therapist and Patient Instructions: same as grade 2 but therapist one hand is palpating deeply for muscle contraction near its origin posterior and distal to anterior superior iliac spine, distal hand grasps around the ankle.

Command:Try to turn your leg inward … relax


FLEXIBILITY TESTS

TRENDELENBURG SIGN

• Procedure: subject assumes unilateral stance without upper extremity assistance. Examiner observes patient from behind.

• Interpretation:– Normal: Hip on opposite side should rise slightly– Abnormal

• Dropping of pelvis on the opposite side• Shifting center of gravity over stance leg*These findings indicate abductor weakness of stance

leg

FLEXIBILITY• Thomas Test:

– Procedure: Patient in supine, both knees brought to chest. Patient holds unaffected leg, keeping their back flat against the table. The tests leg is allowed to drop into extension. Next the knee is allowed to drop into flexion

– Interpretation:• Hip should extend to 0 degrees; if this is not achieved,

tightness of one-joint hip flexors is indicated• If able to achieve full hip extension, but note 80

degrees of knee flexion, then tightness of the two joint hip flexors (rectus femoris) is indicated

• Abduction of the hip and/or external rotation of the tibia indicate ITB tightness

THOMAS TEST: NORMAL ILIOPSOAS AND RECTUS FEMORIS

THOMAS TEST: TIGHT ILIOPSOAS AND RECTUS FEMORIS

FLEXIBILITY

• Ober’s Test:– Procedure: Patient in side-lying with test side

up. The knee may extended or flexed to 90 or 30 degrees. The hip is maintained in slight extension. The test leg is abducted, then allowed to lower toward the table with the pelvis stabilized

– Interpretation:• Normal: able to abduct parallel to the examining

surface• Inability to adduct to parallel indicates tightness of

the ITB

OBER’S TEST: NORMAL ITB/TFL

OBER’S TEST: TIGHT ITB/TFL

FLEXIBILITY

• Hamstring Flexibility1. Passive Straight Leg Raise

– Normal: should achieve at least 80 degrees of hip flexion– Reproduction at 45 degrees or less may indicate lumbar

radiculopathy

2. Popliteal Angle• Patient is supine with test leg’s hip flexed to 90

degrees• The knee is passively extended• Interpretation

– Normal: Angle of flexion should be 15 to 20 degrees or less

– Abnormal: If angle of flexion is greater than 15 to 20 degrees, this is indicative of hamstring tightness

ELY’S TEST

• Procedure: Patient in prone. The knee of tested leg is flexed by the examiner

• Interpretation:– Normal: Able to fully flex the knee without

creating hip flexion– Abnormal: Flexion of the hip prior to full knee

flexion indicates Rectus Femoris tightness

Documents

Hip Muscles Dr. Tamer Emam Testing Muscles of the Lower Extremity 1.Hip Flexion. 2.Hip flexion, abduction and external (lateral) rotation with knee flexion