Musculoskeletal Key

Patient completes the range of motion in side-lying position.

Grade 1 (Trace) and Grade 0 (Zero)

Position of Patient:

Supine:

Test limb supported by therapist under calf with hand behind knee (Figure 6-7).

Position of Therapist:

Standing at side of limb to be tested. Test limb is supported under calf with hand behind knee. Free hand palpates the muscle just distal to the inguinal ligament on the medial side of the sartorius (see Figure 6-7).

Instructions to Patient:

“Try to bring your knee up to your nose.”

Grading

Palpable contraction but no visible movement.

No palpable contraction of muscle.

Substitutions

• Use of the sartorius will result in external rotation and abduction of the hip. The sartorius, because it is superficial, will be seen and can be palpated along its entire length (Figure 6-8).

• If the tensor fasciae latae substitutes for the hip flexors, internal rotation and abduction of the hip will result. The tensor may be seen and palpated at its origin on the anterior superior iliac spine (ASIS).

Helpful Hint

The hip flexors are rather small muscles and therefore do not provide a lot of force, especially as compared with the quadriceps or gluteus maximus. Therefore a negative break test is rarely achieved if using a straight arm technique. This is why Figure 6-4 shows the therapist with a bent arm while providing resistance. Experience is necessary to appreciate what constitutes a normal level of resistance.

Hip Flexion, Abduction, and External Rotation with Knee Flexion

(Sartorius)

FIGURE 6-11 Arrow indicates level of cross section.

Range of Motion

Because this is a two-joint muscle, no specific range-of-motion value can be assigned solely to the sartorius.

Table 6-2

HIP FLEXION, ABDUCTION, AND EXTERNAL ROTATION

I.D.	Muscle	Origin	Insertion
195	Sartorius	Ilium (anterior superior iliac spine [ASIS])Iliac notch below ASIS	Tibia (shaft, proximal medial surface)Capsule of knee joint (via slip)Medial side fascia of leg
Others
Hip and knee flexors
Hip external rotators
Hip abductors

Grade 5 (Normal), Grade 4 (Good), and Grade 3 (Fair)

Position of Patient:

Short sitting with thighs supported on table and legs hanging over side. Arms may be used for support.

Position of Therapist:

Standing lateral to the leg to be tested. Place one hand on the lateral side of knee; the other hand grasps the medial-anterior surface of the distal leg (Figure 6-12).

Hand at knee resists hip flexion and abduction (down and inward direction) in the Grades 5 and 4 tests. Hand at the ankle resists hip external rotation and knee flexion (up and outward) in Grades 5 and 4 tests. No resistance for Grade 3 test.

Test:

Patient flexes, abducts, and externally rotates the hip and flexes the knee (see Figure 6-12).

Instructions to Patient:

Therapist may demonstrate the required motion passively and then ask the patient to repeat the motion, or the therapist may place the limb in the desired end position.

“Hold it! Don’t let me move your leg or straighten your knee.”

Alternate instruction: “Slide your heel up the shin of your other leg.”

Grading

Holds end point against maximal resistance.

Tolerates moderate to heavy resistance.

Completes movement and holds end position but takes no resistance (Figure 6-13).

Grade 2 (Poor)

Position of Patient:

Supine. Heel of limb to be tested is placed on contralateral shin (Figure 6-14).

Position of Therapist:

Standing at side of limb to be tested. Support limb as necessary to maintain alignment.

Test:

Patient slides test heel upward along shin to knee.

Grading

Completes desired movement.

Grade 1 (Trace) and Grade 0 (Zero)

Position of Therapist:

Standing on side to be tested. Cradle test limb under calf with hand supporting limb behind knee. Opposite hand palpates sartorius on medial side of thigh where the muscle crosses the femur (Figure 6-15). Therapist may prefer to palpate near the muscle origin just below the ASIS.

Test:

Patient attempts to slide heel up shin toward knee.

Instructions to Patient:

“Try to slide your heel up to your knee.”

Grading

Therapist can detect slight contraction of muscle; no visible movement.

Substitution by the iliopsoas or the rectus femoris results in pure hip flexion without abduction and external rotation.

No palpable contraction.

Substitution

Helpful Hint

The therapist is reminded that failure of the patient to complete the full range of motion in the Grade 3 test is not an automatic Grade 2. The patient should be tested in the supine position to ascertain whether the correct grade is Grade 2 or less.

Hip Extension

(Gluteus maximus and Hamstrings)

FIGURE 6-19 Arrow indicates level of cross section.

Range of Motion

0° to 20°

Some authors say as low as 0° to 5°.

Table 6-3

HIP EXTENSION

I.D.	Muscle	Origin	Insertion
182	Gluteus maximus	Ilium (posterior gluteal line)Iliac crest (posterior medial)	Femur (gluteal tuberosity)
		Sacrum (dorsal surface of lower part)Coccyx (side)Sacrotuberous ligamentAponeurosis over gluteus medius	Iliotibial tract of fascia lata
193	Semitendinosus	Ischial tuberosity (upper area, inferomedial impression via tendon shared with biceps femoris)Aponeurosis (between the two muscles)	Tibia (proximal medial shaft)Pes anserinus
194	Semimembranosus	Ischial tuberosity (superolateral impression)	Tibia (medial condyle, posterior aspect)Oblique popliteal ligament of knee jointAponeurosis over distal muscle (variable)
192	Biceps femoris (long head)	Ischial tuberosity (inferomedial impression via tendon shared with semitendinosus)Sacrotuberous ligament	Fibula (head)Tibia (lateral condyle)¹Aponeurosis
Others
181	Adductor magnus (inferior)
183	Gluteus medius (posterior)

Grade 5 (Normal), Grade 4 (Good), and Grade 3 (Fair) (Aggregate of all hip extensor muscles)

Position of Patient:

Prone. Arms may be overhead or abducted to hold sides of table. (Note: If there is a hip flexion contracture, immediately go to the test described for hip extension modified for hip flexion tightness [see page 216].)

Position of Therapist:

Standing at side of limb to be tested at level of pelvis. (Note: Figure 6-20 shows therapist on opposite side to avoid obscuring activity.)

The hand providing resistance is placed on the posterior leg just above the ankle. The opposite hand may be used to stabilize or maintain pelvis alignment in the area of the posterior superior spine of the ilium (see Figure 6-20). This is the most demanding test because the lever arm is longest.

Alternate Position:

The hand that gives resistance is placed on the posterior thigh just above the knee (Figure 6-21). This is a less demanding test. Optimal resistance cannot be applied because of the shorter lever arm and so this test is not recommended.

Test:

Patient extends hip through entire available range of motion. Resistance is given straight downward toward the floor. (No resistance is given in the Grade 3 test.)

Instructions to Patient:

“Lift your leg off the table as high as you can without bending your knee (see Figure 6-20).”

Grading

Patient completes available range and holds test position against maximal resistance.

Patient completes available range against strong to moderate resistance.

Completes range and holds the position without resistance (Figure 6-22).

Helpful Hints

Knowledge of the ranges of motion of the hip is imperative before manual tests of hip strength are conducted. If the therapist does not have a clear idea of hip joint ranges, especially tightness in the hip flexor muscles, test results will be inaccurate. For example, in the presence of a hip flexion contracture, the patient must be standing and leaning over the edge of the table to test hip extension strength. This position (described on page 216) will decrease the influence of the flexion contracture and will allow the patient to move against gravity through the available range. The supine hip extensor test can also be used (see page 218).

Grade 2 (Poor)

Position of Patient:

Side-lying with test limb uppermost. Knee straight and supported by therapist. Lowermost limb is flexed for stability.

Position of Therapist:

Standing behind patient at thigh level. Therapist supports test limb just below the knee, cradling the leg (Figure 6-23). Opposite hand is placed over the pelvic crest to maintain pelvic and hip alignment.

Test:

Patient extends hip through full range of motion.

Instructions to Patient:

“Bring your leg back toward me. Keep your knee straight.”

Grading

Completes range of extension motion in side-lying position.

Grade 1 (Trace) and Grade 0 (Zero)

Position of Therapist:

Standing on side to be tested at level of hips. Palpate hamstrings (deep into tissue with fingers) at the ischial tuberosity (Figure 6-24). Palpate the gluteus maximus with deep finger pressure over the center of the buttocks and also over the upper and lower fibers.

Test:

Patient attempts to extend hip in prone position or tries to squeeze buttocks together.

Instructions to Patient:

“Try to lift your leg from the table.” OR “Squeeze your buttocks together.”

Grading

Palpable contraction of either hamstrings or gluteus maximus but no visible joint movement. Contraction of gluteus maximus will result in narrowing of the gluteal crease.

• Because of the strength of the gluteus maximus, it is imperative that the therapist achieve an optimal position for himself or herself, such as using a straight arm technique to apply as much force as the muscle can bear. See hip extensor test to isolate the gluteus maximus on page 214.

No palpable contraction.

Helpful Hints

• The therapist should be aware that the hip extensors are among the most powerful muscles in the body, and most therapists will not be able to “break” a Grade 5 hip extension. Care should be taken not to overgrade a Grade 4 muscle.

• Care should be taken so that the patient does not rotate the trunk to increase motion or create added force production. Having the patient turn his or her head to the opposite side will help prevent trunk rotation.

• Be aware that isolating the hamstrings (page 240) may be a better indicator of hamstring strength.

Hip Extension Test to Isolate Gluteus Maximus

Grade 5 (Normal), Grade 4 (Good), and Grade 3 (Fair)

Position of Patient:

Prone with knee flexed to 90°. (Note: In the presence of a hip flexion contracture, do not use this test but refer to the test for hip extension modified for hip flexion tightness [see page 216].)

Position of Therapist:

Standing at the side to be tested at the level of the pelvis. (Note: The therapist in the illustration is shown on the wrong side to avoid obscuring test positions.) Hand for resistance is contoured over the posterior thigh just above the knee. The opposite hand may stabilize or maintain the alignment of the pelvis (Figure 6-25).

For the Grade 3 test, the knee may need to be supported in flexion (by cradling at the ankle).

Test:

Patient extends hip through available range, maintaining knee flexion. Resistance is given in a new straight downward direction (toward floor).

Instructions to Patient:

“Lift your foot to the ceiling.” OR “Lift your leg, keeping your knee bent.”

Grading

Completes available range of motion and holds end position against maximal resistance.

Limb position can be held against heavy to moderate resistance.

Completes available range of motion and holds end position but takes no resistance (Figure 6-26).

Grade 2 (Poor)

Position of Patient:

Side-lying with test limb uppermost. Knee is flexed and supported by therapist. Lowermost hip and knee should be flexed for stability (Figure 6-27).

Position of Therapist:

Standing behind the patient at thigh level. (Note: The therapist in the illustration is shown on the wrong side to avoid obscuring test positions.) Therapist cradles uppermost leg with forearm and hand under the flexed knee. Other hand is on pelvis to maintain postural alignment.

Test:

Patient extends hip with supported knee flexed.

Grading

Completes available range of motion in side-lying position.

Grade 1 (Trace) and Grade 0 (Zero)

This test is identical to the Grades 1 and 0 tests for aggregate hip extension (see Figure 6-24). The patient is prone and attempts to extend the hip or squeeze the buttocks together while the therapist palpates the gluteus maximus.

Helpful Hints

• Hip extension range is less when the knee is flexed because of tension in the rectus femoris. A diminished range may be observed, therefore, in tests that isolate the gluteus maximus.

• Often, cramping will occur when the patient contracts the hamstrings during this test. The authors have found that flexing the knee to 70° or applying resistance in the middle of the muscle belly during the test will decrease the likelihood of a cramp.

Hip Extension Tests Modified for Hip Flexion Tightness

Grade 5 (Normal), Grade 4 (Good), and Grade 3 (Fair)

Patient stands with hips flexed and places torso prone on the table (Figure 6-28). The arms are used to “hug” the table for support. The knee of the non-test limb should be flexed to allow the test limb to rest on the floor at the start of the test.

Position of Therapist:

Standing at side of limb to be tested. (Note: Figure 6-28 shows the therapist on the opposite side to avoid obscuring test positions.) The hand used to provide resistance is contoured over the posterior thigh just above the knee. The opposite hand stabilizes the pelvis laterally to maintain hip and pelvis posture (see Figure 6-25).

Test:

Patient extends hip through available range, but hip extension range is less when the knee is flexed. Keeping the knee in extension will test all hip extensor muscles; with the knee flexed, the isolated gluteus maximus will be evaluated.

Resistance is applied downward (toward floor) and forward.

Instructions to Patient:

“Lift your foot off the floor as high as you can.”

Grading

Completes available range of hip extension. Holds end position against maximal resistance.

Completes available range of hip extension. (Note: Because of the intrinsic strength of these muscles, weakened extensor muscles frequently are overgraded.) Limb position can be held against heavy to moderate resistance.

Completes available range and holds end position without resistance.

Grade 2 (Poor), Grade 1 (Trace), and Grade 0 (Zero)

Do not test the patient with hip flexion contractures and weak extensors (less than Grade 3) in the standing position. Position the patient side-lying on the table. Conduct the test as described for the aggregate of extensor muscles (see page 212) or for the isolated gluteus maximus (see page 214).

Helpful Hint

The modified hip extensor test is the preferred test for people who are not able or are unwilling to lay prone. This test may elicit a greater effort than the alternate supine hip extensor test.

Supine Hip Extension Test

An alternate hip extensor test is the supine hip extension test. This supine test may be substituted to eliminate change of patient position. Grades 5, 4, 3, and 2 have been validated in this position (n = 44 subjects) by measuring maximum hip extension torques recorded via a strain gauge dynamometer.²

Grade 5 (Normal), Grade 4 (Good), Grade 3 (Fair), and Grade 2 (Poor)

Position of Patient:

Supine with heels off end of table. Arms folded across chest or abdomen. (Do not allow patient to push into table with upper extremities.) The patient’s hip range should be measured to assure approximately 35 inches (approximately 65° of flexion). This is the distance the leg should be lifted during the test (Figure 6-29).

Position of Therapist:

Standing at end of table. Both hands are cupped under the heel (Figure 6-30). The therapist should be in a position to resist this typically very strong muscle.

Test:

Patient presses heel into therapist’s cupped hands, attempting to maintain full extension of the limb as the therapist raises the limb approximately 35 inches from the table. No instructions are given for the opposite leg except to relax.

Instructions to Patient:

“Don’t let me lift your leg from the table. Keep your hip locked tight.”

Grading

Hip locks in neutral (full extension) throughout this test. Pelvis and back elevate as one locked unit as the therapist raises the limb (Figure 6-31). The opposite limb will rise involuntarily, illustrating a locked pelvis.

Hip flexes before pelvis and back elevate and lock as the limb is raised by the therapist. Hip flexion should not exceed 30° before locking occurs (Figure 6-32). The other leg will rise involuntarily, but will have some hip flexion because the pelvis is not fully locked.

Full elevation of the limb to the end of straight-leg raising range (60° of hip flexion) with little or no elevation of the pelvis, demonstrated by the other leg remaining on the table. Therapist feels strong resistance throughout the test (Figure 6-33).

Hip flexes fully with only minimal resistance felt (therapist should check to ensure that the resistance felt exceeds the weight of the limb; see Figure 6-33).

Hip Abduction

(Gluteus medius and Gluteus minimus)

Range of Motion

0° to 45°

Table 6-4

HIP ABDUCTION

I.D.	Muscle	Origin	Insertion
183	Gluteus medius*	Ilium (outer surface between crest and anterior and posterior gluteal lines)Fascia (over upper part)	Femur (greater trochanter, lateral aspect)
184	Gluteus minimus	Ilium (outer surface between anterior and inferior gluteal lines)Greater sciatic notch	Femur (greater trochanter, anterolateral ridge)Fibrous capsule of hip joint
Others
182	Gluteus maximus (upper fibers)
185	Tensor fasciae latae
187	Obturator internus (thigh flexed)
189	Gemellus superior (thigh flexed)
190	Gemellus inferior (thigh flexed)
195	Sartorius

^*The greatest percentage of maximum voluntary contraction (MVC) in the gluteus medius was recorded during single limb stance when the subject was simultaneously abducting the opposite leg. This finding validates the gluteus medius as a pelvic stabilizer.3,4

Grade 5 (Normal), Grade 4 (Good), and Grade 3 (Fair)

Position of Patient:

Side-lying with test leg uppermost. Start test with the limb slightly extended beyond the midline and the pelvis rotated slightly forward (Figure 6-36). Lowermost leg is flexed for stability.

Position of Therapist:

Standing behind patient. Hand used to give resistance is contoured across the lateral surface of the knee. The hand used to palpate the gluteus medius is just proximal to the greater trochanter of the femur (see Figure 6-36). (No resistance is used in a Grade 3 test.)

To distinguish a Grade 5 from a Grade 4 result, first apply resistance at the ankle and then at the knee (Figure 6-37). Applying resistance at the ankle creates a longer lever arm, thus requiring more patient effort to resist the movement. If the patient cannot hold the limb in the test position with the resistance at the ankle but can at the knee, the grade is Grade 4. The therapist is reminded always to use the same lever in a given test sequence and in subsequent comparison tests.

Test:

Patient abducts hip through the complete available range of motion without flexing the hip or rotating it in either direction. Resistance is given in a straight downward direction.

Instructions to Patient:

“Lift your leg up in the air. Hold it. Don’t let me push it down.”

Grading

Completes available range and holds end position against maximal resistance.

Completes available range and holds against heavy to moderate resistance or with resistance given at the knee.

Completes range of motion and holds end position without resistance (Figure 6-38).

Grade 2 (Poor)

Position of Patient:

Supine.

Position of Therapist:

Standing on side of limb being tested. One hand supports and lifts the limb by holding it under the ankle to raise limb just enough to decrease friction. This hand offers no resistance, nor should it be used to offer assistance to the movement. On some smooth surfaces, such support may not be necessary (Figure 6-39). (Note: Figures 6-39 and 6-40 show therapist on opposite side of patient to avoid obscuring test positions.)

The other hand palpates the gluteus medius just proximal to the greater trochanter of the femur (Figure 6-40).

Test:

Patient abducts hip through available range.

Instructions to Patient:

“Bring your leg out to the side. Keep your kneecap pointing to the ceiling.”

Grading

Completes range of motion supine with no resistance and minimal to zero friction.

Grade 1 (Trace) and Grade 0 (Zero)

Position of Patient:

Supine.

Position of Therapist:

Standing at side of limb being tested at level of thigh. One hand supports the limb under the ankle just above the malleoli. The hand should provide neither resistance nor assistance to movement (see Figure 6-40). Palpate the gluteus medius on the lateral aspect of the hip just above the greater trochanter.

Test:

Patient attempts to abduct hip.

Instructions to Patient:

“Try to bring your leg out to the side.”

Grading

Palpable contraction of gluteus medius but no movement of the part.

• Tensor fasciae latae substitution: If the test is allowed to begin with active hip flexion or with the hip positioned in flexion, there is an opportunity for the tensor fasciae latae to abduct the hip.

No palpable contraction.

Substitutions

• Hip-hike substitution: Patient may “hike hip” by approximating pelvis to thorax using the lateral trunk muscles, which move the limb through partial abduction range (Figure 6-41). This movement may be detected by observing the lateral trunk and hip (move clothing aside) and palpating the gluteus medius above the trochanter.

• External rotation and flexion substitution: The patient may try to externally rotate during the motion of abduction (Figure 6-42). This could allow the oblique action of the hip flexors to substitute for the gluteus medius.

Helpful Hints

• The therapist should not be able to “break” a Grade 5 muscle (resistance applied at the ankle) and most therapists will not be able to “break” a Grade 4 muscle. A grade of 4 often masks significant weakness because of the intrinsic great strength of these muscles. Giving resistance at the ankle rather than at the knee is helpful in overcoming this problem. However, respect the long lever arm and apply resistance carefully, assessing whether the patient can adequately resist the movement through the long lever arm.

• Do not attempt to palpate contractile activity of muscle through clothing. (This is one of the cardinal principles of manual muscle testing.)

• When the patient is supine, the weight of the opposite limb stabilizes the pelvis. It is not necessary, therefore, to use a hand to manually stabilize the contralateral limb.

• A patient should be able to stand on one leg keeping the pelvis level with a muscle grade of 4 or 5.

Hip Abduction from Flexed Position

(Tensor fasciae latae)

FIGURE 6-45 Arrow indicates level of cross section.

Range of Motion

Two-joint muscle. No specific range of motion can be assigned solely to the tensor.

Table 6-5

HIP ABDUCTION FROM FLEXION

I.D.	Muscle	Origin	Insertion
185	Tensor fasciae latae	Iliac crest (outer lip)Fasciae latae (deep)Anterior superior iliac spine (lateral surface)	Iliotibial tract (between its 2 layers, ending 1/3 of the way down)
Others
183	Gluteus medius
184	Gluteus minimus

Grade 5 (Normal), Grade 4 (Good), and Grade 3 (Fair)

Position of Patient:

Side-lying. Uppermost limb (test limb) is flexed to 45° and lies across the lowermost limb with the foot resting on the table (Figure 6-46).

Position of Therapist:

Standing behind patient at level of pelvis. Hand for resistance is placed on lateral surface of the thigh just above the knee. Hand providing stabilization is placed on the crest of the ilium (Figure 6-47).

Test:

Patient abducts hip through approximately 30° of motion. Resistance is given downward (toward floor) from the lateral surface of the distal femur. No resistance is given for the Grade 3 test.

Instructions to Patient:

“Lift your leg and hold it. Don’t let me push it down.”

Grading

Completes available range; holds end position against maximum resistance.

Completes available range and holds against strong to moderate resistance.