HIP JOINT HIP FLEXION Muscles tested: 1. Psoas Major Muscle

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HIP JOINT
HIP FLEXION
 Muscles tested:
1. Psoas Major Muscle:
- Origins:
a) Ventral surfaces of transverse processes of all lumbar vertebrae.
b) Sides of bodies and corresponding intervertebral discs of the last thoracic and all lumbar
vertebrae and membranous arches, which extend over the sides of the bodies of the lumbar
vertebrae.
- Insertion: Lesser trochanter of femur.
- Nerve Supply: (Lumbar plexus) L1, L2, L3, L4.
- Action: Flexion of the hip joint.
2. Iliacus Muscle:
- Origins:
a) Superior 2/3 of iliac fossa.
b) Internal lip of iliac crest.
c) Ilio-lumbar and ventral sacroiliac ligaments.
- Insertion: Lateral side of the tendon of Psoas major, just distal to the lesser trochanter.
- Nerve Supply: (Femoral Nerve) L2, L3, L4.
- Action: Flexion of the hip joint.
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 Accessory Muscles:
1. Rectus femoris.
2. Sartorius.
3. Tensor of fascia latae.
4. Pectineus.
Range of Motion:
The hip with the knee flexed will permit a range of motion of approximately 115˚ to
125˚. The range of motion of the hip flexion can be limited by:
a) Contact of the thigh on the abdomen when movement is performed with the knee in flexion.
b) Tension of the hamstring muscles when movement is performed with the knee in extension.
Test Procedures:
* Grade 3 “Fair Strength”:
- Patient Starting Position: Sitting with legs over edge of table. The patient grasps the edge of
the table to stabilize pelvis or arms may be folded on the chest if patient is stable enough.
- Therapist Position and Grasps: Therapist stands at the foot of the table. The proximal hand is
pressing on the iliac crest down to stabilize pelvis.
- Command: “Raise your leg up vertically in the midline towards your chest through full ROM,
RELAX”.
* Grade 4 ”Good Strength”:
- Patient Starting Position: Same as for grade 3.
- Therapist Position and Grasps: Same as for grade 3, plus the distal hand is applied proximal to
the knee joint to give resistance.
- Resistance: Moderate resistance is given in the form of pressing down directly, opposing the
line of pull.
- Command: Same as for grade 3.
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* Grade 5 “Normal Strength”:
- Patient Starting Position: Same as for grade 4.
- Therapist Position and Grasps: Same as for grade 4.
- Resistance: Maximum leading resistance is given in the form of pressing down directly
opposing the line of pull, plus hold position at the end of range of motion.
- Command: Same as for grade 4, plus “hold” at the end of range of motion.
* Grade 2 “Poor Strength”:
- Patient Starting Position: Side lying with the affected leg down, with the trunk, pelvis and legs
are straight. The upper leg is supported.
- Therapist Position and Grasps: The therapist stands behind the patient, with the proximal hand
stabilizes the pelvis at the side of the affected or tested leg, while the distal hand supports the
upper leg.
d) The patient is allowed to flex the knee to prevent tension brought by the hamstring muscles.
- Command: “With flexed knee move your leg toward your chest through full range of motion,
RELAX”.
* Grade 1 and 0 “Trace and Zero Strength”:
- Patient Starting Position: Back lying (supine); both legs are extended and the affected leg is
near the edge of the table.
- Therapist Position and Grasps:
a) Therapist stands beside the table, distal hand supporting the affected leg.
b) The proximal hand palpates the contraction in psoas major just distal to the inguinal ligament.
- Command: “Try to pull your leg towards your chest, RELAX”.
Substitutions:
a) Substitution by the Sartorius in hip flexion causes lateral rotation and abduction of the thigh.
b) Substitution by the Tensor fasciae latae in hip flexion causes medial rotation and abduction of
the thigh.
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Effect of weakness of the hip flexor muscles:
Weakness in the hip flexor muscles decreases the ability to flex the hip joint and results
in marked disability in:
a) Stair climbing.
b) Walking up or down the incline.
c) Getting up from reclined position.
d) Bringing the trunk forward in the sitting position preliminary to rising from a chair.
In marked weakness, walking is difficult because the leg must be brought forward by a
pelvic motion (produced by the lateral abdominal muscle action) rather than by hip flexion.
Main types of contractures and their effects on posture:
a) Bilateral hip flexion deformity will be combined with increased lumbar lordosis.
b) Unilateral hip flexion contracture is often combined with hip abduction and external rotation.
Hint:
When the trunk is weak, the test will be more accurate from a supine position.
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MANUAL MUSCLE TESTING FOR HIP FLEXION
Grade 3: Fair Strength
Grade 4-5: Good, Normal Strength
Grade 2: Poor Strength
Grade 1-0: Trace and Zero Strength
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HIP EXTENSION
 Muscles Tested:
1. Gluteus Maximus
- Origins:
a) Posterior gluteal line of ilium and portion of bone superior and posterior to it.
b) Posterior surface of lower part of sacrum.
c) Side of coccyx.
d) Aponeurosis of erector spinae.
e) Sacro-tuberous ligament and gluteal aponeurosis.
- Insertions:
a) Larger proximal portion and superficial fibers of distal portion of muscle into tract of fasciae
latae muscle.
b) Deeper fibers of distal portion into gluteal tuberosity of femur.
- Nerve Supply: Inferior gluteal nerve: L5, S1, S2.
- Actions:
a) Extends and laterally rotates the hip joint.
b) Assists in adduction of the hip joint with the lower fibers.
c) Through its insertion into the ilio-tibial tract, helps to stabilize the knee extension.
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2. Semitendinosus
3. Semimembranosus
- Origin: Tuberosity of ischium by tendon common with
- Origin: Tuberosity of ischium proximal and lateral to
long heads of Biceps femoris.
Biceps femoris and Semitendinosus.
- Insertions:
- Insertion: Postero-medial aspect of medial condyle of
a) Proximal part of medial surface of body of tibia.
tibia.
b) Deep fascia of the leg.
- Nerve Supply: Sciatic Nerve (L4, L5, S1, S2).
- Actions:
a) Extend the hip joint and assist in the hip medial rotation.
b) Flex and medially rotate the knee joint.
4. Biceps Femoris:
- Origins of Long Head:
a) Distal part of sacro-tuberous ligament.
b) Posterior part of tuberosity of ischium.
- Insertions:
a) Lateral side of head of fibula.
b) Lateral condyle of tibia.
c) Deep fascia on lateral side of leg.
- Nerve Supply:
a) Long Head: Tibial branch of sciatic nerve: L5, S1, S2, S3.
b) Short Head: Peroneal branch of sciatic nerve: L5, S1, S2.
- Action:
a) The long head extends the hip joint and assist in the hip lateral rotation.
b) The long and short heads of Biceps femoris flex and laterally rotate the knee joint.
Range of Motion:
Beyond the mid line the normal extension of the hip is of 10 o to 15o. The range of motion
of the hip extension can be limited by:
a) Tension in the ilio-femoral ligament.
b) Tension in the hip flexor muscles.
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Test Procedures:
* Grade 3 “Fair Strength”
- Patient Starting Position: Half prone lying with flexed knee, affected leg away from the
therapist, sound leg supported on a stool.
- Therapist Position and Grasps: The therapist stands beside the table, facing the patient at the
level of the hip joint, while the proximal hand stabilizes the pelvis.
- Command: “Rise up your leg through full range of motion, RELAX”.
* Grade 4 “Good Strength”:
- Patient Starting Position: Same as for “Grade 3”.
- Therapist Position and Grasp: Same as for “Grade 3” plus; the distal hand is placed proximal
to the knee joint to give resistance.
- Resistance: Moderate leading resistance is given in a form of pressing down directly opposing
the line of rising.
- Command: Same as for “Grade 3”.
* Grade 5 “Normal Strength”
- Patient Starting Position: Same as for “Grade 3 – 4”.
- Therapist Position and Grasps: Same as for “Grade 4”.
- Resistance: Maximal leading resistance is given in a form of pressing down directly opposing
the line of rising, plus hold position at end of the range of motion.
- Command: Same as for “Grade 4” plus “hold” at the end of the range of motion.
* Grade 2 “Poor Strength”:
- Patient Starting Position: Side lying, with affected leg on the table, hip flexed, knee extended
and the uppermost leg supported.
- Therapist Position and Grasps: The therapist stands behind the patient, with the proximal hand
stabilizes the pelvis and the distal hand supports the upper most leg.
- Command: “Move your leg backward through full range of motion, RELAX”.
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* Grade 1 and 0 “Trace Strength and 0”:
- Patient Starting Position: Same as for “Grades 3 - 4 - 5”.
- Therapist Position and Grasps: Same as for “grades 3 – 4 - 5” but the therapist palpate with his
two hands the upper and lower portion of the muscles. Contraction of the gluteus maximus
muscle will result in a narrowing of the gluteal crease.
- Command: “Squeeze or press your buttocks together, RELAX”.
Special procedure to isolate the Gluteus Maximus Muscle:
To isolate the Gluteus Maximus Muscle, all the test tasks must be performed with the
knee in flexion.
Effects of weakness of the hip extensor muscles:
a) Bilateral marked weakness of the Gluteus maximus muscle makes walking extremely
difficult, and necessitates the aid of crutches.
b) The individual bears weight on the extremity in a position of postero-lateral displacement of
the trunk over the femur (hyperextension of the hip joint).
c) Raising the trunk from a forward-bent position requires the action of the Gluteus Maximus. In
cases of weakness, the patients must push themselves to an upright position by using their arms.
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MANUAL MUSCLE TESTING FOR HIP EXTENSION
Grade 3: Fair Strength (No external resistance)
Grade 4, 5: Good and Normal Strength
Grade 4 - 5 – Alternate Positions
- For hip extension tightness
- In supine
Grade 2: Poor Strength
Grade 1–0: Trace and Zero Strength
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HIP ABDUCTION
 Muscles Tested:
1. Gluteus Minimus:
- Origins:
a) External surface of ilium between anterior and inferior gluteal lines.
b) Margin of greater sciatic notch.
- Insertions:
a) Anterior border of greater trochanter of femur.
b) Hip joint capsule.
- Nerve Supply: Superior gluteal nerve (L4, L5, S1).
- Actions:
a) Abducts and medially rotates the hip joint.
b) May assist in the flexion of the hip joint.
2. Gluteus Medius:
- Origins:
a) External surface of ilium between iliac crest and posterior gluteal line dorsally.
b) Anterior gluteal line ventrally.
c) Gluteal aponeurosis.
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- Insertion: Oblique ridge on lateral surface of greater trochanter of femur.
- Nerve Supply: Superior gluteal nerve (L4, L5, S1).
- Actions:
a) Abducts the hip joint.
b) The anterior fibers medially rotate and may assist in the flexion of the hip joint.
c) The posterior fibers laterally rotate and may assist in the extension of the hip joint.
 Accessory Muscles:
1. Tensor Fasciae Latae.
2. Gluteus Maximus (upper fibers).
Range of Motion:
From the midline to full range of motion, the hip joint can abduct for 45°. This range of
motion may be limited by:
a. Tension of the distal band of ilio-femoral ligament and the pubo-capsular ligament.
b. Tension of the hip adductor muscles.
Test Procedures:
* Grade 3 “Fair Strength”:
- Patient Starting Position: Side lying, the affected leg is uppermost and slightly extended
beyond mid-line, while the lower knee is flexed for balance.
- Therapist Position and Grasps: The therapist stands behind the patient, with the proximal hand
stabilizing the pelvis.
- Command: “Raise your leg up through full range of motion without lateral rotation of hip,
RELAX”.
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* Grade 4 “Good Strength”:
- Patient Starting Position: Same as for “Grade 3”.
- Therapist Position and Grasp: Same as for “Grade 3” plus, the distal hand is placed proximal
to the knee joint to give resistance.
- Resistance: Moderate leading resistance is given in a form of pressing down directly opposing
the line of rising.
- Command: Same as for “Grade 3”.
* Grade 5 “Normal Strength”:
- Patient Starting Position: Same as for “Grade 3 – 4”.
- Therapist Position and Grasps: Same as for “Grade 4”.
- Resistance: Maximal leading resistance is given in a form of pressing down directly opposing
the line of pull.
- Command: Same as for “Grade 4”, plus “hold” at the end of the range of motion.
* Grade 2 “Poor Strength”:
- Patient Starting Position: Back lying, with both legs extended and the affected leg away from
the therapist.
- Therapist Position and Grasps: The therapist stands beside the table, while the proximal hand
stabilizes the pelvis and the distal hand grasps around the ankle to fix the leg on the table.
- Command: “Move your leg backward through full ROM without lateral rotation, RELAX”.
* Grade 1 and 0 “Trace Strength and 0”:
- Patient Starting Position: Back lying with legs extended.
- Therapist Position and Grasps: The therapist stands beside the table. The distal hand grasps
the ankle of the affected leg, while the proximal hand is placed on the lateral aspect of the ilium
above the greater trochanter of the femur to palpate contraction.
- Command: “Try to move your leg outward through full range of motion without lateral
rotation, RELAX”.
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Stabilization:
When testing the Gluteus Medius and Minimus or the abductors as a group in the side
lying position, the stabilization is necessary but often difficult. It requires a strong fixation by the
therapist. The slight flexion of the hip and knee of the under or lower leg aids in stabilizing the
pelvis against anterior or posterior tilt.
Substitution and role of stabilization applied by the examiner:
a) The examiner’s proximal hand attempts to steady the pelvis to prevent, if possible, any
unnecessary movement or dropping of the pelvis laterally.
b) Any one of these six shifts in position of the pelvis may result primarily from trunk weakness
or indicates an attempt to substitute by the anterior or posterior hip muscles or lateral abdominals
in the movement of hip abduction.
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MANUAL MUSCLE TESTING FOR HIP ABDUCTION
Grade 3: Fair Strength
Grade 4, 5: Good & Normal Strength
Grade 2: Poor Strength
Grade 1, 0: Trace and Zero Strength
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HIP ADDUCTION
 Muscles Tested:
1. Pectineus:
- Origin: Surface of superior ramus of pubis between the ilio-pectineal eminence and pubic
tubercle.
- Insertion: Pectineal line of femur.
- Nerve Supply: Femoral and obturator nerves: L2, L3, L4.
2. Adductor Magnus:
- Origins:
a) Inferior pubic ramus.
b) Ramus of ischium, (anterior fibers) and ischial tuberosity (posterior fibers).
- Insertions:
a) Medial to gluteal tuberosity.
b) Middle of linea aspera.
c) Medial supracondylar line.
d) Adductor tubercle of medial condyle of femur.
- Nerve Supply: Obturator and Sciatic nerves (L2, L3, L4, L5, S1).
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3. Gracilis:
- Origins: Inferior half of symphysis pubis and medial margin of inferior ramus of the pubic
bone.
- Insertion: Proximal part of medial surface of body of tibia, distal to condyle.
- Nerve Supply: Obturator nerves (L2, L3, L4).
4. Adductor Brevis:
- Origin: Outer surface of inferior ramus of pubis.
- Insertion: Distal 2/3 of pectineal line, and proximal half of medial lip of linea aspera.
- Nerve Supply: Obturator nerves: L2, L3, L4.
5. Adductor Longus:
- Origin: Anterior pubis at junction of crest and symphysis.
- Insertion: Middle 1/3 of medial lip of linea aspera.
- Nerve Supply: Obturator nerves: L2, L3, L4.
Range of Motion:
From the hip abduction position to the midline the range of motion is 45°. This range of
motion of hip adduction may be limited by:
a. Contact with the other leg.
b. When the hip is flexed, tension of the ischio-femoral ligament.
Test Procedures:
* Grade 3 “Fair Strength”:
- Patient Starting Position: Side lying with both legs resting on the table; the affected leg is
down. The upper leg is supported in approximately 25° of abduction.
- Therapist Position and Grasps: The therapist stands behind the patient, with both hands
supporting the upper leg.
- Command: “Raise your leg up until it contacts the upper leg, RELAX”.
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* Grade 4 “Good Strength”:
- Patient Starting Position: Same as for “Grade 3”.
- Therapist Position and Grasp: Same as for “Grade 3” but supporting the upper leg is done only
by the distal hand. The proximal hand is placed proximal to the knee joint to give resistance.
- Resistance: Moderate leading resistance in a form of pressing down directly opposing the line
of rising.
- Command: Same as for “Grade 3”.
* Grade 5 “Normal Strength”:
- Patient Starting Position: Same as for “Grade 4”.
- Therapist Position and Grasps: Same as for “Grade 4”.
- Resistance: Maximum leading resistance is given in a form of pressing down on the lower leg,
directly opposing the line of rising, plus hold position at end of the range of motion.
- Command: Same as for “Grade 4” plus “hold” at the end of the range of motion.
* Grade 2 “Poor Strength”:
- Patient Starting Position: Back lying, with both legs extended and the affected leg away from
the therapist in 45° of abduction.
- Therapist Position and Grasps: Therapist stands beside the table, while the proximal hand
stabilizes the pelvis. At the side or affected leg, the distal hand fixes the sound leg on the table,
proximal to the ankle joint.
- Command: “Move your leg towards the other without rotation of the hip, RELAX”.
* Grade 1 and 0 “Trace Strength and 0”:
- Patient Starting Position: Supine, the affected leg is away from therapist in 45° of abduction.
- Therapist Position and Grasps: Same as for grade 2 but the distal hand grasps the ankle of the
affected leg. The proximal hand palpates contraction of the muscle fibers on the medial aspect of
the thigh.
- Command: “Try to move your leg toward the other leg without rotation of the hip, RELAX”.
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Substitutions:
a) Anterior tilting of the pelvis or flexion of the hip allows substitution of hip flexors.
b) Forward rotation of the pelvis with extension of the hip shows attempt to hold with lower
fibers of Gluteus Maximus.
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MANUAL MUSCLE TESTING FOR HIP ADDUCTORS
Grade 3: Fair Strength
Grade 4, 5 – Good &Normal Strength
Grade 2- Poor Strength
Grade 1- 0: Trace and Zero Strength
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HIP EXTERNAL ROTATION
 Muscle Tested:
1. Piriformis
- Origins:
a) Pelvic surface of sacrum, between and lateral to 1, 2, 3, 4 pelvic sacral.
b) Margin of greater sciatic foramen and pelvic surface of sacro-tuberous ligament.
- Insertion: Superior border of greater trochanter of femur.
- Nerve Supply: Sacral Plexus (L5, S1, S2).
2. Quadratus Femoris
- Origin: Proximal part of lateral border of tuberosity of ischium.
- Insertion: Proximal part of quadrate line extending distally from inter-trochanteric crest.
- Nerve Supply: Sacral Plexus (L4, L5, S1, S2).
3. Obturator Internus:
- Origins:
a) Internal or pelvic surface of obturator membrane and margin of obturator foramen.
b) Pelvic surface of ischium posterior and proximal to obturator foramen, and to a slight extent,
from the obturator fascia.
- Insertion: Medial surface of greater trochanter of femur, proximal to trochanteric fossa.
- Nerve Supply: Sacral Plexus (L5, S1, S2, S3).
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4. Obturator Externus:
- Origin: Rami of pubis and ischium, and external surface of obturator membrane.
- Insertion: Trochanteric fossa of femur.
- Nerve Supply: Obturator Nerve (L3, L4).
5. Gemellus Superior:
- Origin: External surface of spine of ischium.
- Insertion: With tendon of Obturator Internus into medial surface of greater trochanter of femur.
- Nerve Supply: Sacral Plexus (L5, S1, S2, S3).
Muscle Actions:
a) All the above muscles laterally rotate the hip joint.
b) The Quadratus femoris and Obturator Externus may assist in adduction of the hip joint.
c) The Piriformis, Obturator Internus and Gemelli may also assist in abduction with flexed hip.
Range of Motion:
With the knee in flexion the hip lateral rotation is of 45o of motion. With the knee in
extension, the range of motion may be limited by:
a) Tension of lateral band of ilio-femoral ligament.
b) Tension in the hip medial rotator muscles.
Test Procedures:
* Grade 3 “Fair Strength”:
- Patient Starting Position: Sitting with legs over the edge of the table. Patient grasps edge of the
examining table to stabilize the pelvis. Place a towel under the thigh and knee.
- Therapist Position and Grasps: Standing in front of the patient on the side of the affected leg.
The proximal hand applies a counter pressure above the knee joint to prevent abduction and
flexion of the hip.
- Command: “Bring your foot over other leg, keeping your thigh in contact with table, RELAX
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* Grade 4 “Good Strength”:
- Patient Starting Position: Same as for “Grade 3”.
- Therapist Position and Grasps: Same as for “Grade 3”, plus the distal hand is placed on the
medial surface of the leg just above the ankle joint to give resistance.
- Resistance: Moderate leading resistance is given in a form of pressing down and laterally,
directly opposing the line of motion through full range of motion.
- Command: Same as for “Grade 3”.
* Grade 5 “Normal Strength”
- Patient Starting Position: Same as for “Grade 4”.
- Therapist Position and Grasps: Same as for “Grade 4”.
- Resistance: Maximum leading resistance is given in a form of pressing down and laterally,
directly opposing the line of motion plus “hold position” at the end of the range of motion.
- Command: Same as for “Grade 4”, plus “hold” at the end of the range of motion.
* Grade 2 “Poor”:
- Patient Starting Position: Back lying, with the affected leg is in medial rotation, away from the
therapist.
- Therapist Position and Grasps: The therapist stands beside the table at the level of the patient
thigh. The proximal hand is placed on the antero-superior iliac spine to stabilize the pelvis.
- Command: “Turn your leg outward through full range of motion, RELAX”.
* Grade 1 and 0 “Trace and Zero Strength”:
- Patient Starting Position: Same as for “Grade 2”.
- Therapist Position and Grasps: Same as for “Grade 2” but the proximal hand is palpating
deeply for muscle contraction behind the greater trochanter.
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Effects of weakness of hip lateral rotators:
Usually, weakness of the lateral rotators of the hip will produce a medial rotation of the
femur accompanied by pronation of the foot and a tendency toward knock-knee position.
Effects of contracture in the lateral rotators of the hip:
a) The contracture of the lateral rotators of the hip is usually occurring in an abducted position of
the hip.
b) The range of motion of medial rotation will, then, be limited and in the standing position the
toes are outwardly directed.
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MANUAL MUSCLE TESTING FOR HIP EXTERNAL ROTATION
Grade 3: Fair Strength
Grade 4, 5: Good &Normal Strength
Grade 2: Poor Strength
Grade 1, 0: Trace and Zero Strength
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HIP INTERNAL ROTATION
 Muscles Tested:
1. Gluteus Minimus:
Please refer to the abductor muscles of the hip for description.
2. Tensor Fasciae Latae:
- Origins:
a) Anterior part of external lip of iliac crest.
b) Outer surface of anterior superior iliac spine.
- Insertion: Into ilio-tibial tract at the junction of proximal and middle third of thigh.
- Nerve Supply: Superior gluteal nerve (L4, L5, S1).
- Actions:
a) Medially rotates, abducts and flexes the hip joint.
b) It may assist in knee extension by tensing the ilio-tibial tract.
 Accessory Muscles
1. Gluteus Medius.
2. Semitendinosus.
3. Semimembranosus.
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Range of Motion:
The medial rotation of the hip with the knee flexed is of 45o. It will be of somewhat less
amplitude when performed with the knee extended. The range of motion may be limited by:
1. Tension in the ilio-femoral ligament when the hip is extended.
2. Tension in the ischio-capsular ligament when the hip is flexed.
3. Tension of hip lateral rotator muscles.
Test Procedures:
* Grade 3 “ Fair Strength”:
- Patient Starting Position: Sitting with legs over the edge of the table. Patient grasps the edge of
the examination table to stabilize the pelvis. Place a towel under the thigh and knee.
- Therapist Position and Grasps: Standing in front of the patient on the side of the affected leg.
The proximal hand applies a counter pressure above the knee joint to prevent adduction and
flexion of the hip.
- Command: “Bring your foot to the outer side, keeping your thigh in contact with the table,
RELAX”.
* Grade 4 “Good Strength”:
- Patient Starting Position: Same as for “Grade 3”; short sitting at the edge of table.
- Therapist Position and Grasps: Same as for “Grade 3”; the distal hand is placed proximal to
the ankle joint (on the lateral side) to give resistance.
- Resistance: Moderate leading resistance is given in a form of pressing downward and medially,
directly opposing the line of motion.
- Command: Same as for “Grade 3”.
* Grade 5 “Normal Strength”:
- Patient Starting Position: Same as for “Grade 4”.
- Therapist Position and Grasps: Same as for “Grade 4”.
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- Resistance: Maximum leading resistance is given in a form of pressing down and medially,
directly opposing the line of motion, plus hold position at the end of range of motion.
- Command: Same as for “Grade 4”, plus hold at the end of the range of motion.
* Grade 2 “Poor Strength”:
- Patient Starting Position: Back lying, the affected leg is away from the therapist and is in
external rotation.
- Therapist Position and Grasps: The therapist is standing beside the table, with the proximal
hand stabilizing pelvis.
- Command: “Turn your leg inward through full range of motion, RELAX”.
* Grade 1 and 0 “Trace and Zero Strength”:
- Patient Starting Position: Same as for “Grade 2”
- Therapist Position and Grasps: Same as for “Grade 2”; the proximal hand palpates the
contraction of tensor fasciae latae near its origin, posterior and distal to anterior superior spine of
ilium. The distal hand grasps around the ankle.
- Command: “Try to turn your leg inward, RELAX”.
Effect of weakness of hip medial rotators:
Weakness of the hip medial rotators results in lateral rotation of the lower extremity in
standing and walking.
Special consideration while testing the hip medial rotator muscles:
If the test is performed in the supine position, the pelvis will tend to tilt anteriorly if much
resistance is applied but this is not a substitution movement. Due to its anatomical attachments,
the tensor fasciae, when contracting to maximum, pulls forward on the pelvis as it medially
rotates the leg.
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MANUAL MUSCLE TESTING FOR HIP INTERNAL ROTATION
Grades 3,4,5: Fair, Good and Normal Strength
Grade 2: Poor Strength
Grade 1- 0: Trace and Zero Strength
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HIP FLEXION, ABDUCTION AND EXTERNAL ROTATION WITH KNEE FLEXION
(SARTORIUS)
 Muscle Tested:
1. Sartorius:
- Origins:
a) Anterior superior iliac spine.
b) Superior half of notch just distal to spine.
- Insertion: Proximal part of medial surface of tibia near anterior border.
- Nerve Supply: Femoral nerve: L2, L3.
- Actions:
a) Flexes, laterally rotates, and abducts the hip joint.
b) Flexes and assists in medial rotation of the knee joint.
 Accessory Muscles
1. Hip and knee flexors
2. Hip external rotators
3. Hip abductors
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Range of motion:
Combined joint action, ranges of motion (hip flexion, abduction and external rotation) is
incomplete.
Test Procedures:
* Grade 3 “Fair Strength”:
- Patient Starting Position: Sitting with legs over side of the table, heel of affected limb to be
tested in front of opposite ankle.
- Therapist Position and Grasps: Standing beside the patient, with the proximal hand stabilizing
the pelvis.
- Command: “Raise your heel up to knee with flexion, abduction, and lateral rotation of hip and
flexion of knee, RELAX”.
* Grade 4 and 5 “Good and Normal Strength”:
- Patient Starting Position: Same as for “Grade 3”.
- Therapist Position and Grasps: Same as for “Grade 3” plus proximal hand is above the knee
joint to resist hip flexion and abduction. The distal hand is above ankle joint to resist hip lateral
rotation.
Note: If sitting position is contraindicated, all tests can be given in back lying with slight
resistance for the fair grade.
* Grade 2 “Poor Strength”:
- Patient Starting Position: Back lying with heel of limb to be tested on opposite ankle.
- Therapist Position and Grasps: Therapist stands beside the patient with proximal hand fixing
the pelvis.
- Command: Slide your heel along leg to knee with flexion, abduction and lateral rotation of hip
and flexion of knee.
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* Grade 1 and 0 “Trace and Zero Strength”
- Patient Starting Position: Same as for “Grade 2” with hip flexed and laterally rotated.
- Therapist Position and Grasps: Same as for “Grade 2” with distal hand supporting leg under
knee and proximal hand palpating near the origin of Sartorius muscle just below anterior
superior iliac spine of ilium.
- Command: “Try to pull your thigh towards you flexing hip joint, RELAX”.
Substitution
Substitution of iliopsoas or rectus femoris in this movement is evidenced by straight hip
flexion without abduction and lateral rotation.
Effects of Weakness:
Weakness decreases strength of hip flexion, abduction, and lateral rotation. It also
contributes to antero-medial instability of the knee joint.
Effect of Contracture:
Contracture leads to flexion, abduction and lateral rotation deformity of the hip, with
flexion of the knee. The position of the leg, as illustrated, resembles the Sartorius test position in
its flexion, abduction, and lateral rotation. However, the ability to hold this position is essentially
a function of the hip adductors and requires little assistance from the sartorius.
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MANUAL MUSCLE TESTING FOR SARTORIUS
(Hip flexion, Abduction and External rotation with Knee Flexion)
Grade 3: Fair Strength
Grade 4, 5: Good & Normal Strength
Grade 2: Poor Strength
Grade 1 & 0: Trace and Zero Strength
34
HIP ABDUCTION FROM FLEXED POSITION
(TENSOR FASCIAE LATAE)
 Muscles Tested:
Tensor Fasciae Latae:
- Origin: Anterior part of external lip of iliac crest, outer surface of anterior superior iliac spine
and deep surface of fasciae latae.
- Insertion: Into ilio-tibial tract of fascia latae, at junction of proximal and middle thirds of thigh.
- Nerve Supply: Superior gluteal nerve (L4, L5, S1).
- Actions:
a) Flexes, medially rotates and abducts the hip joint.
b) Tenses the fasciae latae.
c) May assist in knee extension.
 Accessory Muscles:
1. Gluteus medius.
2. Gluteus minimus.
Range of Motion:
Combined joint action (hip flexion, abduction and internal rotation), ranges of motion are
not complete. On asking patient to abduct hip, range of motion is approximately 30o.
35
Test Procedures
* Grade 3 “Fair Strength”:
- Patient Starting Position: Side lying with lower knee slightly flexed for balance, limb to be
tested is flexed 45o at hip joint and internally rotated.
- Therapist Position and Grasps: Therapist stands behind the patient with the proximal hand
fixing the pelvis “over grasp”.
- Command: “Raise your leg up, RELAX”.
* Grade 4 and 5 “Good and Normal Strength”:
- Patient Starting Position: Same as for “Grade 3”.
- Therapist Position and Grasps: Same as for “Grade 3” plus apply resistance with the distal
hand at the lateral aspect of the thigh and proximal to knee joint.
- Resistance:
a) Grade 4: Moderate leading resistance in the form of pressing down directly opposing line of
raising the leg up.
b) Grade 5: Maximum resistance through full range of motion, plus a “Hold” position is kept at
the end of the range of motion.
- Command: Same as for “Grade 3”, plus “Hold” at the end of ROM when testing for grade 5.
* Grade 2 “Poor Strength”:
- Patient Starting Position: Sitting on table with knee extended. Trunk at a 45o to the table and
supported by patient’s arms behind back.
- Therapist Position and Grasps: Therapist stands beside the patient with the proximal hand
stabilizing the pelvis.
- Command: “Move your leg laterally (to approximately 30o), RELAX”.
36
* Grade 1 and 0 “Trace and Zero Strength”:
- Patient Starting Position: Same as for “Grade 2”.
- Therapist Position and Grasps: Same as for “Grade 2” with palpating below the origin of
muscle and at fascial insertion on lateral side of knee joint.
- Command: “Try to move your leg laterally”.
Effect of Weakness:
In standing, there is a thrust in the direction of a bow-leg position and the extremity tends
to rotate laterally from the hip.
Effect of Shortness:
The effect of a shortness of the tensor fasciae latae in standing depends upon whether the
tightness is bilateral or unilateral:
a) If bilateral, there is an anterior pelvic tilt, and sometimes bilateral knock-knee.
b) If unilateral, the abductors and fasciae latae are tight along with the tensor fasciae latae and
there is an associated lateral pelvic tilt, low on the side of tightness. The knee on that side will
tend forward a knock-free position. If the tensor fasciae latae muscle is tight as a hip flexor, there
is an anterior pelvic tilt and a medial rotation of the femur, as indicated by the position of the
patella.
Effects of Contracture:
a) Hip flexion.
b) Knock-free position.
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MANUAL MUSCLE TESTING FOR TENSOR FASCIAE LATAE
(Hip abduction from flexed position)
Grade 3: Fair Strength
Grade 4, 5: Good and Normal Strength
Grade 2: Poor Strength
Grade 1, 0 - Trace and zero Strength
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