Manual Muscle Testing: Hip Flexion

Original Editor - Claire Knott

Top Contributors - Whitney Wagganer, Kaitlyn Carroll, Tony Varela, Claire Knott, Lucinda hampton, Kim Jackson and Wanda van Niekerk  

Welcome to Arkansas Colleges of Health Education School of Physical Therapy Musculoskeletal 1 Project. This space was created by and for the students at Arkansas Colleges of Health Education School in the United States. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!

Introduction

An assessment of muscle strength is typically performed as part of a patient's objective assessment and is an important component of the physical exam that reveals any strength discrepancy between the involved hip and the uninvolved hip. Manual Muscle Testing is used to evaluate weakness and can be effective in differentiating true weakness from imbalances or poor endurance. Strength testing helps the physical therapist come up with a specific patient goal to restore the strength of the involved hip to equal that of the uninvolved hip. See Muscle Strength Testing

Muscles Involved

Image 1: Anterior hip/thigh muscles.

There are three main muscles that flex the hip. There are two-joint muscles which are the Sartorius, Tensor Fasciae Latae, and Rectus Femoris. These muscles cross both the knee and the hip. Conversely, there is only a single one-joint muscle, known as the Iliopsoas, which only crosses at the hip.

• Iliopsoas
• Tensor Fasciae Latae
• Sartorius
• Rectus femoris

MMT Grading Scale

This table is a breakdown the the Manual Muscle Test grading system and the explanation behind each grade.

Grade	Description	Explanation of Grade
0	Zero	Contraction isn't visible or felt when palpated.
1	Trace	Contraction is visible or felt when palpated.
2-	Poor-	Patient is tested in gravity eliminated position with partial AROM(active range of motion).
2	Poor	Patient is tested in gravity eliminated position with full AROM.
2+	Poor+	Patient is tested in gravity eliminated position with full AROM along with some resistance from therapist.
3-	Fair-	Patient slowly comes out of testing position.
3	Fair	Patient can hold against gravity without resistance.
3+	Fair+	Patient can hold against gravity with slight resistance (1-24% of the therapist's force).
4-	Good-	Patient can hold against gravity with slight to moderate resistance (25-49% of the therapist's force).
4	Good	Patient can hold against gravity with moderate resistance (50-74% of the therapist's force).
4+	Good+	Patient can hold against gravity with moderate to strong (75-95% of the therapist's force).
5	Normal	Patient can hold against gravity with strong resistance (>95% of the therapist's force) or therapist was unable to break the patient out of the testing position.

Patient Positioning

• Patient will be in a seated position for a gravity resistance test and if they are able to actively flex the hip. This will automatically put the test grade between 3- to 5.
• If patient is unable to to actively flex the hip in the seated position, the test will continue in a side-lying position for a gravity eliminated test. This will automatically put the test grade between 0 to 2+.

Physical Therapist Position

• The Physical Therapist stands next to test side closest to the hip that is being tested.
• 

  Image 2: Cross-Over Method for Therapist Position. Arrow 1: Therapist's arm is used to stabilize the patient's shoulder. Arrow 2: Therapist's arm is used for direct of force to put the hip into extension.
  The Physical Therapist should adjust the height of the table or seat to avoid any future injures to therapist. The therapist body is important too, especially for the physical therapist who plans on doing this for years to come. Protect your body by learning what you can control. The ability to examine, treat and help others is limited by the physical therapists who can't protect their own body.
• The Physical Therapist will cross their arms to perform the test by placing one hand on the patient's shoulder to stabilize the trunk and by placing the other hand on the distal femur to apply force directly against the hip flexor. The cross-over method with help protect the therapist's shoulders and posture. See image 2 for example.

To Test

• Start with the patient in a seated position on a treatment table or chair that doesn't have arm rests.
• Have the patient put hands on the table. Do not allow the patient to grip the table, which could allow the patient to compensate and alter the test results. Have the patient's feet not touching the floor to avoid any possible compensations as well.
• For optimal test position, the 2 joint muscles are tested at mid range while the 1 joint muscles are tested at end range to put the 2 joint muscles on active insufficiency, which isolates the 1 joint muscle being tested.
• To test the hip flexors as a whole, therapist will bring the patient's tested leg into hip flexion at mid range and ask the patient to perform that motion without assistance. To test Iliopsoas only, the physical therapist will bring the patient's tested leg into hip flexion at end range and ask the patient to perform that motion without assistance.
• If the patient can perform the motion against gravity, continue the test in the seated position. If the patient was unable to perform the motion against gravity, put the patient in side-lying for a gravity eliminated position to test the hip flexors.
• Apply resistance over the distal femur in a direction opposite to flexion. The Physical Therapist will cross their arms, one hand on the patient's shoulder (same side as the tested hip) that will stabilize the patient and the other hand at the distal femur that will be used to apply the force against the hip flexors. See image 2.
• The grading will depend on the amount of force the physical therapist demonstrates to break the patient out of testing position.
• To satisfy grade 5 'normal muscle' performance criteria, the patient must have the ability to move through complete range of motion (active resistance testing) OR maintain an end point range (break testing) against maximum resistance.