Hip Muscle Imbalances and Their Effects

Muscles function through habit. Faulty mechanics

from inadequate or excessive length and an imbalance
in strength cause hip, knee, or back pain.116 Overuse
syndromes, soft tissue stress, and joint pain develop in
response to continued abnormal stresses. The related
muscle imbalances due to postural impairments are
summarized in Box 20.2. Common muscle lengthstrength
imbalances include the following.
Shortened iliotibial (IT) band with shortened tensor fasciae
latae (TFL) or gluteus maximus. Postural impairments
often associated with a shortened TFL or gluteus
maximus include an anterior pelvic tilt posture, slouched
posture, or flat back posture (see Chapter 14).
Dominance of the two-joint hip flexor muscles (TFL, rectus
femoris, sartorius) over the iliopsoas. This imbalance
may cause faulty hip mechanics or knee pain from overuse
of these muscles as they cross the knee.

Anterior Pelvic Tilt Posture

• Short TFL and IT band
• General limitation of hip external rotation
• Weak, stretched posterior portion of the gluteus medius
and piriformis
• Excessive medial rotation of the femur during the first
half of stance phase of gait with increased stresses on the
medial structures of the knee
• Associated lower extremity compensations including
medial rotation of the femur, genu valgum, lateral tibial
torsion, pes planus, and hallux valgus
Slouched Posture
• Shortened rectus femoris and hamstrings
• General limitation of hip rotators
• Weak, stretched iliopsoas
• Weak and shortened posterior portion of the gluteus
medius
• Weak, poorly developed gluteus maximus
• Associated lower extremity compensations including hip
extension, sometimes medial rotation of the femur, genu
recurvatum, genu varum, and pes valgus
Flat Back Posture
• A shortened rectus femoris, IT band, and gluteus
maximus
• Variations of the above two postures

Dominance of the TFL over the gluteus medius. This

imbalance leads to lateral knee pain from IT band tension
or medial rotation of the femur with medial knee
stresses from an increased bowstring effect.
Dominance of hamstring muscles over the gluteus maximus.
The gluteus maximus becomes short and the range
of hip flexion decreases; compensation occurs with
excessive lumbar spine flexion whenever the thigh is
flexed. Limited mobility in the gluteus maximus also
causes increased tension on the IT band with associated
trochanteric or lateral knee pain. Overuse of the hamstring
muscles causes decreased flexibility as well as
muscle imbalances with the quadriceps femoris muscle
at the knee. The hamstrings dominate the stabilizing
function by pulling posteriorly on the tibia to extend the
knee in closed-chain activities. This alters the mechanics
at the knee and may lead to overuse syndromes in the
hamstring tendons or anterior knee pain from imbalances
in quadriceps pull.
Use of lateral trunk muscles for hip abductors. This
results in excessive trunk motion and increased stress
in the lumbar spine.

THE HIP AND GAIT

During the normal gait cycle, the hip goes through a ROM
of 40_ of flexion and extension (10_ extension at terminal
stance to 30_ flexion at midswing and initial contact).
There is also some lateral pelvic tilt and hip abduction/
adduction of 15_ (10_ adduction at initial contact, 5_ abduction
at initial swing); and hip internal/external rotation
along with pelvic rotation totaling 15_ transverse plane
motion (peak internal rotation at the end of loading, peak
external rotation at the end of pre-swing). Loss of any of
these motions affects the smoothness of the gait pattern.105
Hip Muscle Function During Gait
Hip Flexors
The hip flexors control hip extension at the end of stance,
then contract concentrically to initiate swing.105 With loss
of flexor function, a posterior lurch of the trunk to initiate
swing is seen. Contractures in the hip flexors prevent complete
extension during the second half of stance; the stride
is shortened. To compensate, a person increases the lumbar
lordosis or walks with the trunk bent forward.
Hip Extensors
The hip extensors control the flexor moment at initial foot
contact, and the gluteus maximus initiates hip extension.105
With loss of extensor function, a posterior lurch of the
trunk occurs at foot contact to shift the center of gravity
of the trunk posterior to the hip. With contractures in the
gluteus maximus, some decreased range occurs in the terminal
swing as the femur comes forward, or the person
may compensate by rotating the pelvis more forward. The
lower extremity may rotate outward because of the external
rotation component of the muscle, or the gluteus maximus
may place greater tension on the iliotibial band through its
attachment, leading to irritation along the lateral aspect of
the knee with excessive activity.
Hip Abductors
The hip abductors control the lateral pelvic tilt during
swinging of the opposite leg.105 With loss of function of
the gluteus medius, lateral shifting of the trunk occurs over
the weak side during stance when the opposite leg swings.
This lateral shifting also occurs with a painful hip because
it minimizes the torque at the hip joint during weight bearing.
The tensor fasciae latae also functions as an abductor
and may become tight and affect gait with faulty use.
Effect of Musculoskeletal Impairments on Gait
Bony and joint deformities change alignment of the lower
extremity and therefore the mechanics of gait. Painful conditions
cause antalgic gait patterns, which are characterized
by minimum stance on the painful side to avoid the stress
of weight bearing.
REFERRED PAIN AND NERVE INJURY
The hip is innervated primarily from the L3 spinal level;
hip joint irritation is usually felt along the L3 dermatome
reference from the groin, down the front of the thigh to
the knee.35,72 For a detailed description of referred pain
patterns and peripheral nerve injuries in the hip and buttock
region, see Chapter 13.
Major Nerves Subject to Injury or Entrapment
Sciatic nerve. Entrapment may occur when the sciatic
nerve passes deep to the piriformis muscle (occasionally
it passes over or through the piriformis).
Obturator nerve. Isolated injury is rare, although uterine
pressure and damage during labor may occur.
Femoral nerve. Injury may result from fractures of the
upper femur or pelvis, during reduction of congenital
dislocation of the hip, or from pressure during a forceps
labor and delivery.
Common Sources of Referred Pain
in the Hip and Buttock Region
If painful symptoms are referred to the hip and buttock
region from other sources, primary treatment must be
directed to the source of the irritation. Common sources
of referred pain into the hip and buttock region include:

THE ANKLE/FOOT
COMPLEX AND GAIT
During the normal gait cycle, the ankle goes through a
ROM of 32_ to 35_. Approximately 7_ of dorsiflexion
occurs at the end of midstance as the heel begins to rise,
and 25_ of plantarflexion occurs at the end of stance
(toe off).78
Function of the Ankle and
Foot Joints During Gait
The shock-absorbing, terrain-conforming, and propulsion
functions of the ankle and foot include the following.
70,78,80
During the loading response (heel strike to foot flat),
the heel strikes the ground in neutral or slight supination.
As the foot lowers to the ground, it begins to
pronate to its loose-packed position. The entire lower
extremity rotates inward, which reinforces the loosepacked
position of the foot. With the foot in a lax
position, it can conform to variations in the ground
contour and absorb some of the impact forces as the
foot is lowered.
Once the foot is fixed on the ground, dorsiflexion
begins as the tibia comes up over the foot. The tibia
continues to rotate internally, which reinforces pronation
of the subtalar joint and loose-packed position
of the foot.
During midstance and continuing through terminal
stance, the tibia begins to rotate externally, which
initiates supination of the hindfoot and locking of
the transverse tarsal joint. This brings the foot into its
close-packed position, which is reinforced as the heel
rises and the foot rocks up onto the toes, causing toe
extension and tightening of the plantar aponeurosis
(windlass effect). This stable position converts the
foot into a rigid lever, ready to propel the body
forward as the ankle plantarflexes from the pull of
the gastrocnemius–soleus muscle group.
Muscle Control of the Ankle
and Foot During Gait70,78,80
Ankle dorsiflexors. The ankle dorsiflexors function during
the initial foot contact and loading response (heel strike to
foot flat) to counter the plantarflexion torque and to control
the lowering of the foot to the ground. They also function
during the swing phase to keep the foot from plantarflexing
and dragging on the ground. With loss of the dorsiflexors,
foot slap occurs at initial foot contact, and the hip and knee
flex excessively during swing (otherwise the toe drags on
the ground).
Ankle plantarflexors. The ankle plantarflexors function
eccentrically early in stance to control the rate of forward
movement of the tibia. Then at around 40% of the cycle
(midstance) there is a burst of concentric activity to initiate
plantarflexion of the ankle for push off. Loss of function
results in a slight lag of the lower extremity during terminal
stance with no push-off.
Ankle evertors. Contraction of the peroneus longus muscle
late in the stance phase facilitates transfer of weight from
the lateral to the medial side of the foot. It also stabilizes
the first ray and facilitates the pronation twist of the tarsometatarsal
joints as increased supination occurs in the
hindfoot.
Ankle inverters. The tibialis anterior helps control the
pronation force on the hindfoot during the loading
response of gait.
Intrinsic muscles. The intrinsic muscles support the transverse
and longitudinal arches during gait.