Patient: Sitting on a table, with the knees bent over the side and the subject holding on to the table.
Fixation: The weight of the trunk stabilizes the patient during this test. Stabilization is also given in the form of counterpressure, as described below under Pressure.
Test: Lateral rotation of the thigh, with the leg in a position of completion of the inward arc of motion.
Pressure: With one hand, the examiner applies counter-pressure at the lateral side of the lower end of the thigh. With the other hand, the examiner applies pressure to the medial side of the leg, above the ankle, pushing the leg outward in an effort to rotate the thigh medially.
Weakness: Usually, medial rotation of the femur accompanied by pronation of the foot and a tendency toward a knock-knee (or valgus) position.
Contracture: Lateral rotation of the thigh, usually in an abducted position.
Shortness: The range of medial rotation of the hip will be limited. (Frequently, excessive range of lateral motion is noted.) In the standing posture, a lateral rotation of the femur and out-toeing are observed.
Origin: External surface of the ilium, between the anterior and inferior gluteal lines and margin of the greater sciatic notch.
Insertion: Anterior border of the greater trochanter of the femur and hip joint capsule.
Action: Abducts, medially rotates and may assist in flexion of the hip joint.
Nerve: Superior gluteal, LA, 5, SI.
Fixation: The examiner stabilizes the pelvis. (See Note.)
Test: Abduction of the hip in a position neutral between flexion and extension and neutral in regard to rotation.
Pressure: Against the leg, in the direction of adduction and very slight extension.
Weakness: Lessens the strength of medial rotation and abduction of the hip joint.
Contracture and Shortness: Abduction and medial rotation of the thigh. In standing, lateral pelvic tilt, low on the side of shortness, plus medial rotation of femur.
Note: In tests of the gluteus minimus and medius, or of the abductors as a group, stabilization of the pelvis is necessary but often difficult. It requires a strong fixation by many trunk muscles, aided by stabilization on the part of the examiner. Flexion of the hip and knee of the underneath leg aids in stabilizing the pelvis against anterior or posterior tilt. The examiner's hand attempts to stabilize the pelvis to prevent the tendency to roll forward or backward, the tendency to tilt anteriorly or posteriorly, and ifpossible, any unnecessary hiking or dropping of the pelvis laterally. Any one of these six shifts in position of the pelvis may result primarily from trunk weakness; alternatively, such shifts may indicate an attempt to substitute anterior or posterior hip joint muscles or lateral abdominals in the movement ofleg abduction. When the trunk muscles are strong, it is not very difficult to maintain good stabilization of the pelvis, but when trunk muscles are weak, the examiner may need the assistance of a second person to hold the pelvis steady.
Origin: External surface of the ilium, between the iliac crest and posterior gluteal line dorsally and the anterior gluteal line ventrally and gluteal aponeurosis.
Insertion: Oblique ridge on the lateral surface of the greater trochanter of the femur.
Action: Abducts the hip joint. The anterior fibers medially rotate and may assist in flexion of the hip joint; the posterior fibers laterally rotate and may assist in extension.
Nerve: Superior gluteal, LA, 5, SI.
Patient: Side-lying, with the underneath leg flexed at the hip and knee and the pelvis rotated slightly forward to place the posterior gluteus medius in an antigravity position.
Fixation: The muscles of the trunk and the examiner stabilize the pelvis. (See Note on facing page.)
Test (Emphasis on Posterior Portion): Abduction of the hip, with slight extension and slight external rotation. The knee is maintained in extension. Differentiating the posterior gluteus medius is very important. Hip abductors, when tested as a group, may be normal in strength, even though a precise test of the gluteus medius may reveal appreciable weakness.
When external rotation of the hip joint is limited, do not allow the pelvis to rotate backward to obtain the ap
pearance of hip joint external rotation. With backward rotation of the pelvis, the tensor fasciae latae and gluteus minimus become active in abduction. Even though pressure may be applied properly, in the right direction, against the gluteus medius, the specificity of the test is greatly diminished. Weakness of the gluteus medius may become apparent immediately because of the subject's inability to hold the precise test position, the tendency for the muscle to cramp, or an attempt to rotate the pelvis backward to substitute with the tensor fasciae latae and the gluteus minimus.
Pressure: Against the leg, near the ankle, in the direction of adduction and slight flexion; do not apply pressure against the rotation component. The pressure is applied against the leg for the purpose of obtaining a long lever. To determine normal strength, strong force is needed, and this force can be obtained by the examiner with the added advantage of a long lever. There is relatively little danger of injuring the lateral knee joint, because it is reinforced by the strong iliotibial tract. (See p. 425.)
Weakness: See the following two pages regarding weakness of the gluteus medius and abductors.
Contracture and Shortness: An abduction deformity that, in standing, may be seen as a lateral pelvic tilt, low on the side of tightness, along with some abduction of the extremity.
Paralysis or Marked Weakness of Right Gluteus Medius: With paralysis or marked weakness of the glu-teus medius, a gluteus medius limp will occur in walking. This consists of displacement of the trunk laterally, toward the side of weakness, shifting the center of gravity in such a way that the body can be balanced over the extremity with minimal muscular support at the hip joint.
Hip Joint Abduction: Actual abduction of the hip joint is accomplished by the hip abductors, with normal fixation by the lateral trunk muscles, as shown in Figure A. When the hip abductors are weak, apparent abduction may occur by substitution action of the lateral trunk muscles. In this case, the leg drops into adduction, the pelvis is hiked up laterally, and the leg is raised upward from the table, as shown in Figure B.
The normal range of hip joint abduction is approximately 45° and that of adduction approximately 10°. When abductors are too weak to raise the leg in abduction against gravity in a side-lying position, avoid exercises in that position. A subject can learn to substitute by hiking the pelvis up laterally and bringing the leg into apparent abduction, but doing so actually stretches and strains the abductors rather than shortening and strengthening them. Substitution also can take place in the supine position, but can be prevented and an appropriate exercise can be done.
On a table or firm bed, the unaffected leg is moved in abduction to completion of the range of motion. This position will block any effort to hike the pelvis up on the affected side, thereby preventing substitution. Movement of the thigh in abduction will require true hip joint motion—not just a sideways movement of the extremity. Whatever assistance is appropriate may be used: Manually assist, or assist with some apparatus or adaptive measures, such as a smooth or powdered board or roller skate.
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