ORIGINAL CONTRIBUTION
The “iliacus test”: New information for the evaluation of hip extension dysfunction
DAVID C. ELAND, DO; TIFFANI N. SINGLETON, BS; ROBERT R. CONASTER, MS; JOHN N. HOWELL, PHD; ALFRED M. PHELEY, PHD;
MELYNDA M. KARLENE, DO; JOYNITA M. ROBINSON, DO
This study confirms the clinical value of investigating
the “iliacus complex” during evaluations of the low back.
A new “iliacus test” isolates this iliacus complex compo-
nent of limited hip extension. Designed for a single joint,
the test isolates motion across the hip joint. Study results
include the following: (1) in a comparison with the clin-
ical standard, the Thomas test, data show that the two
tests are significantly different in an asymptomatic pop-
ulation between the ages of 18 and 35 years; (2) with the
exception of the standard Thomas test, the data show no
statistical differences in range of motion when comparing
the left side with the right side; (3) examiner-added, end-
range pressure for assessment of range of motion when
compared with the standard gravity-dependent end range
of motion used in the Thomas test yields valuable new
information; and (4) data provide a basis for population
norms for each test—Thomas and iliacus—in gravity-
dependent and examiner-produced tissue-feel end ranges.
(Key words: hip extension, “iliacus,” iliacus com-
plex, low back pain, range of motion, Thomas test)
H ip extension is crucial in all activities involving human
locomotion. It is a component of motion as simple as a
change of position from seated to standing or a leisurely
stroll. Complex coordinated activities such as dribbling a
soccer ball down a field or dancing a waltz depend on ade-
quate hip extension as well. The hip joint functions in a coor-
dinated relationship with lower extremity, lumbopelvic,
and thoracolumbar structures in all such activity. The hip
joint is thus a significant component in dysfunction that
Dr Eland is an associate professor of osteopathic manipulative medicine in the
department of family medicine at Ohio University College of Osteopathic
Medicine in Athens, Ohio, and a researcher at the university’s Somatic Dys-
function Research Institute. Also at the Ohio University College of Osteo-
pathic Medicine, Ms Singleton is a fourth-year osteopathic medical student,
Mr Conaster a researcher at the university’s Somatic Dysfunction Research Insti-
tute, Dr Howell is an associate professor of physiology in the department of
biomedical sciences, and Dr Pheley is an associate professor of clinical research
in the department of social medicine. Dr Karlene is a resident in emergency
medicine at the Mount Clemens General Hospital in Mount Clemens, Mich.
Dr Robinson is at Cuyahoga Falls General Hospital in Cuyahoga Falls, Ohio.
Address correspondence to David C. Eland, DO, Somatic Dysfunction
Research Institute, Ohio University College of Osteopathic Medicine, 249
Grosvenor Hall, Athens, OH 45701-2979.
E-mail: eland@exchange.oucom.ohiou.edu
130 • JAOA • Vol 102 • No 3 • March 2002
contributes to patient complaints of pain in all of these struc-
tures. Because back problems rank second as a reason for
visits to primary care physicians’ offices,1 any advance in the
understanding of the genesis or maintenance of dysfunc-
tion contributing to such common musculoskeletal prob-
lems can have an immediate impact on diagnosis and treat-
ment.
The term iliacus complex refers in part to the iliac muscle,
the major single-joint muscle involved in flexion of the hip joint
and resistance to hip extension. Other significant single-joint
factors influence these motions. The iliofemoral ligament also
contributes significantly to limitation of range of motion
(ROM) in hip extension. The fascias associated with these
structures also play a significant role. Other single-joint mus-
culature and ligaments that cross the hip joint (eg, the pectineal
muscle and the ischiofemoral ligament, respectively) likely
play a lesser role in resistance to hip extension, but they
should not be ignored.
Therefore, for the purposes of this article, iliacus complex
refers to these anatomically related and interdependent struc-
tures, not to just the iliac muscle itself. This new descriptor—
a term not in use in the general medical literature—differen-
tiates the focus of inquiry in this study from that generally
associated with hip flexion (ie, the psoas muscles). The “iliacus
test,” which is described in the Methods section, is designed
to assess the stretch capacity of the iliacus complex.
Application of osteopathic principles in the clinical setting
and an exploration of the biomechanics of the region have led
to the recognition of the iliacus complex as a significant com-
ponent in many regional musculoskeletal problems. Extension
is only one of the possible motions at the hip joint. However,
this motion is more difficult to isolate with standard osteo-
pathic and orthopedic tests than are the motions of internal
and external rotation, abduction, and adduction. Such motions
do not occur along the primary plane of motion of the
sacroiliac and pubic joints. Each will induce little motion or
compensation through these joints. However, flexion and
extension at the hip do occur in unison with primary motion
in both sacroiliac joints (anterior-posterior rotation of the
innominate bones) and the pubic symphysis (superior-inferior
rotation/glide).2,3
Hip flexion results in a “loose pack” configuration for
the hip joint. Loose pack refers to the decreased compressive
force on the femoral head into the acetabulum as the capsule
Eland et al • Original contribution

and ligaments lose tension during the course of hip flexion.
Such positioning cannot readily initiate the femoral leverage
that can influence the other lumbopelvic structures unless
extreme contracture of the hamstring is present.
Hip extension results in a “close pack” configuration for
the joint as the strong capsular ligaments tighten. Close pack
refers to the increased compressive force on the femoral head
into the acetabulum as the capsule and ligaments gain ten-
sion during the course of hip extension. Thus, limitation of
hip extension establishes a source for other regional dysfunc-
tions.
Femoral leverage applied through this joint can then
rotate the innominate bone anteriorly (with associated func-
tional leg-length discrepancy). This rotation increases the
potential for a backward torsion of the sacrum (with the axis
to the contralateral side), and influences biomechanics through
the lumbosacral junction and further cephalad along the spine.
Testing hip extension without isolation of the hip joint from the
sacroiliac and pubic joints then applies a regional test rather
than a localized joint-specific test. This study identifies the
new information that a localized hip-joint–specific test yields.
The Thomas test is the standard for assessment of limited
hip extension and hip flexor contracture.4-7 (See Methods,
Range-of-motion testing procedures.) The Thomas test is a
regional test. It represents a multifactorial (multiple joints,
muscles, and tissues) ROM test that does not isolate the influ-
ence of the tissues that cross only the hip joint (ie, the iliacus
complex). With use of the Thomas test, change in pelvic posi-
tion at end ROM for hip extension is assessed by monitoring
the lumbar curve. The leverage of the thigh and femur via
the acetabular joint produces the close pack configuration as
the lower extremity is carried into extension. This configura-
tion increases pelvic tilt and thus can increase the lumbar
curve at end ROM.
Thus, the lumbar monitoring system for end ROM for
the Thomas test is several joints removed from direct objective
observation of localized hip joint motion. Multiple joints
(lumbar, sacroiliac, pubic, acetabular, and knee) are involved
in the performance and assessment of this test. As such, this
clinical test cannot assess the contribution of individual joints
and associated fascias/muscles for hip extension. Of particular
relevance is the inability of this approach to assess the contri-
bution of rotation of the innominate bone, or lack thereof, to the
degree of hip extension. If associated contracture of the ili-
acus complex exists, that contracture cannot be differentiated
from contracture of the psoas muscles determined with the
Thomas test.
These facts may account for the overall low reliability of
hip-extension testing7,8 and the variation in normative ranges
in the literature—from 9 degrees to 50 degrees.3,7 Additionally,
the methods for measuring hip extension reported in the lit-
erature vary considerably in approach from resource to
resource.9-12 This variation has complicated the picture with
regard to norms of hip extension.
Eland et al • Original contribution
ORIGINAL CONTRIBUTION
Related research
Because the term iliacus complex is new, the medical literature
has no information specific to it or its diagnostic and therapeutic
implications. The most closely related evidence is specific to the
iliac muscle and is cited in three separate studies published in
1995 and 1997 by a team of Swedish researchers.13-15 Their
research using fine-wire electromyography shows independent
iliac muscle activity.
Andersson et al13 found that the iliac muscle was selec-
tively recruited in the standing position with extension of the
contralateral leg. The researchers also found significantly
higher levels of activation in the iliac muscle when compared
with the psoas muscles in standing maximal ipsilateral abduc-
tion. This finding seems to speak to local pelvic control (ie,
preferential activation of involved single joint muscles) when
possible. Each of these findings confirmed the body’s ten-
dency toward efficient management and local control capacity.
A later study evaluated walking and running.14 This
research found the iliac muscle to be the main “switch muscle”
during low-speed walking (ie, the iliac muscle was key to
reversing lower extremity motion from extension to flexion).
The value of focused evaluation of the iliac muscle and asso-
ciated tissues (ie, the iliacus complex) was supported by these
findings—especially in relationship to individuals recovering
from an injury that affected gait.
In a final study, Andersson et al15 studied abdominal and
hip flexor activation during hip flexion, trunk flexion, and
spontaneous sit-ups and leg lifts. They noted that the iliac and
sartorius muscles performed a static function needed to pre-
vent a backward tilting of the pelvis during trunk flexion sit-
ups. With static leg lifts, there was more activation of these mus-
cles with increased elevation of the extremity (eg, 60 degrees
of leg lift showed strong activation, 10 degrees much less so).
Andersson et al15 also observed that a change in pelvic tilt
also influenced activation of the iliac and sartorius muscles
during a 10-degree leg lift. Backward pelvic tilt combined
with hypolordotic back decreased activation of these mus-
cles. Forward pelvic tilt combined with hyperlordotic back
increased activation of the sartorius and iliac muscles.
This information may have implications for individuals
with a chronic forward pelvic tilt and hyperlordosis in the
upright stance, suggesting that long-term activation and pos-
sible contracture of these muscles could come from the postural
habit alone. During quiet standing and during the gait cycle,
these individuals may have higher levels of electromyographic
activity for the iliac and sartorius muscles, which in turn has
implications for contracture of these muscles and for anterior
rotation of the innominate bone.
In their conclusion, Andersson et al15 alluded to the impor-
tance of the iliac muscle in rehabilitation and sports, but they
did not elaborate. With evolving methods of investigation,
such as the fine-wire electromyography, more information
relevant to the iliac muscle and hip flexion/extension is likely
to be reported in the near future.
JAOA • Vol 102 • No 3 • March 2002 • 131
ORIGINAL CONTRIBUTION
21.7 mm Hg 12.8 mm Hg
and 6.5 degrees and 16.1 degrees
Pressure
(mm Hg)
Right leg
angle
(degrees)
Time in seconds (5 seconds / division)
Figure 1. Thomas test. Digitized data showing pressure and angle
changes for a typical run of the protocol for the Thomas test.
Study goals
For the purposes of the current study, a new iliacus test local-
ized hip extension ROM to the hip joint to evaluate the hypoth-
esized independent contribution of the iliacus complex. The
goals of this study were fourfold:
 To confirm or refute that there was a measurable difference
between the iliacus test and the clinical standard, the Thomas
test.
 To compare the standard gravity-dependent end point for hip
extension with an examiner-pressure–produced end point.
 To establish a norm for the iliacus test for an asymptomatic
patient population.
 To determine whether significant differences existed in
ROM in side-to-side (left and right) hip extension for this
population.
Methods
Subjects
Volunteer subjects were recruited and screened from the first-
year and second-year classes of the Ohio University College of
Osteopathic Medicine in the spring, summer, and fall of 1998.
Inclusion criteria were age limited, 18 to 35 years of age. The
following relative exclusion criteria ensured an asymptomatic
study population:
 Familiarity with and performance of the iliac muscle stretch
on a regular basis within the past 6 months;
 Consistent low back pain or recent injury (within the past 6
months);
 Pelvic pain or injury (within the past 6 months);
132 • JAOA • Vol 102 • No 3 • March 2002
 Leg pain or injury (within the past 6 months); and/or
 Current medical illness—particularly illness that was
impairing function at the time the ROM test was to be done.
No chronic cardiac, endocrine, neurologic, gastrointestinal,
or genitourinary disease was exclusionary by itself.
The Ohio University institutional review board approved
study protocols. Each subject signed an informed consent
agreement before the test sequence. Complete confidentiality
applied to consent forms and maintenance of all records of
assessment collected.
Inclusion criteria symptom-rating system
For those individuals included, a symptom rating system was
used to categorize the subjects as follows:
 Symptom rating 0: Individuals who completely fit the cri-
teria, including those who had done the iliac muscle stretch
only in an osteopathic manipulative medicine class, and
those who had old ankle or knee complaints that no longer
were symptomatic.
 Symptom rating 1: Individuals who noted that intermit-
tent excessive exercise or prolonged sitting produced tem-
porary low back pain or those who noted premenstrual
pelvic pain that was not of a debilitating nature.
 Symptom rating 2: Individuals who noted two sources of
intermittent low back pain (eg, pain at the end of the day,
pain with prolonged sitting, or intermittent pelvic pain).
 Symptom rating 3: Individuals who reported having chronic
intermittent/mild low back pain.
Subject preparation
Each subject was instructed to inform the examiner if dis-
comfort in the back, pelvis, or lower extremity was present at
any time before, during, or after the procedure. Whether the
Thomas test (Part 1) or the iliacus test (Part 2) was performed
first, the subject’s position was supine with hips at the bottom
edge of the table. A removable stand supported the lower
extremities. Each lower extremity was tested independently.
The center point of the greater trochanter was aligned
with the axis of motion for the goniometer. A Velcro strap
attached the free goniometer arm to the lower extremity to
be tested. Alignment of the free end of the goniometer arm with
the middle of the lateral epicondyle of the tested extremity
maintained consistency for goniometer arm placement.
Underneath the middle of the subject’s back and centered
at the third lumbar vertebrae, an air bladder connected to a
pneumatic pressure transducer monitored lumbar lordotic
response to ROM testing.
Definition of terms
Figure 1 shows the relationship of terms to data recording.
 Preangle: The angle of hip extension in the gravity-
dependent position; allowed to remain stable for 3 to 5 sec-
onds before further intervention (Figure 2, left, and Figure 3,
top right).
Eland et al • Original contribution
 ORIGINAL CONTRIBUTION

Figure 2. Left: Thomas test for right hip extension: The left lower extremity is held in a position at the hip and the knee is comfortably flexed
to maintain a flattened lordotic curve. Gravity is allowed to carry the extremity to an end point of hip extension. This end point is designated
the “Thomas preangle measurement position” for the purposes of this study.
Right: Thomas test for right hip extension (continued): After the gravity-dependent end point has been established (Figure 2, left), the exam-
iner adds pressure to the right lower extremity via suprapatellar contact to induce further hip extension. The amount of extension is limited
by palpatory feedback guided by tissue tension and resistance. This end point is designated the “Thomas postangle measurement position.”

 Postangle: The angle of hip extension at the end-point posi-
tion obtained by examiner-applied pressure on the involved
knee; allowed to remain stable for 3 to 5 seconds before
further intervention (Figure 2, right, and Figure 3, bottom
left).
 Prepressure and postpressure: The pressure in millimeters
of mercury measured at the third lumbar vertebrae for the
previously cited positions.
Range-of-motion testing procedures
Description of the right hip test illustrates the procedure for the
right and the left sides. The testing required approximately 10
minutes. Performance of the ROM assessment was the same
for every subject; one examiner did all the tests. The iliacus test
variation used in the clinical setting takes less than 1 minute.
Thomas test for right hip extension
The Thomas test for right hip extension (Figure 2) was per-
formed as follows:
(1) The examiner directed the subject to flex the left hip and
knee, bringing the left knee toward the chest as far as was
comfortable. The subject then grasped the left knee with
both hands to hold this position.
This position maintained a flattened lumbar spine
against the table and prevented most lumbosacral and
pelvic motion.
(2) The examiner grasped the subject’s right lower extremity
by contacting behind the knee, then the lower extremity
support was removed.
(3) The examiner directed the subject to let the right lower
extremity relax, allowing the knee to bend during the
ROM assessment. Tension or contracture of the musculus
rectus femoris was indicated if the knee did not bend pas-
sively to near 90 degrees.
The test was discontinued if such tension or contrac-
ture existed. Gravity was allowed to carry the extremity to
an end point of hip extension, designated the Thomas pre-
angle measurement position (Figure 2, left).
(4) The gravity-dependent position was passively maintained
for 3 to 5 seconds before the examiner carried the right
thigh into further extension, but no further than the end of
comfortable motion. This step rarely required more than an
estimated 3 to 5 pounds of pressure at the point of con-
tact, 2 inches above the patella.
Assessment of the end point was by the tissue-feel/end-
range resistance defined by the examiner’s contact with
the knee. This end point was designated the Thomas postangle
measurement position (Figure 2, right). The subject continued
to relax while the examiner maintained the palpable end
point for another 3 to 5 seconds.
(5) Finally, the examiner returned (lifted) the thigh to neutral
supported position for 10 to 15 seconds before proceeding
directly to the iliacus test for right hip extension.

Eland et al • Original contribution JAOA • Vol 102 • No 3 • March 2002 • 133

ORIGINAL CONTRIBUTION
Iliacus test for right hip extension
The key element differentiating the iliacus test from the Thomas
test was the localization accomplished by stabilization of the
innominate bone through physical contact with the anterior
superior iliac spine (ASIS).
The iliacus test for the right hip extension (Figure 3) was
performed as follows:
(1) The examiner instructed the subject to maintain the left
hip and knee flexion with the left knee near the chest in the
same comfortable position used for the Thomas test.
(2) The examiner then contacted the subject’s right ASIS with
his or her left palm (Figure 3, top left). By using only enough
pressure to maintain the position of the ASIS during exten-
134 • JAOA • Vol 102 • No 3 • March 2002
Figure 3. Top left: Iliacus test for right hip extension: Localization of
extension to the hip joint is accomplished by stabilizing the innom-
inate bone through palmar contact with the inferior surface of the
anterior superior iliac spine. The vector of force through this contact
is superior and slightly posterior. Just enough force is used to coun-
terbalance leg weight and its leverage. This counterbalance prevents
anterior rotation of the innominate bone during hip extension.
Top right: Iliacus test for right hip extension (continued): For this
test, right innominate position is maintained by anterior superior
iliac spine contact (Figure 3, top left) while the right lower extremity
is allowed to extend to a gravity-dependent end point. This end
point is designated the “iliacus preangle measurement position.”
Bottom left: Iliacus test for right hip extension (continued): After
the gravity-dependent end point has been established (Figure 3, top
right), the examiner adds pressure to the right lower extremity via
suprapatellar contact to induce further hip extension. The amount of
extension is limited by palpatory feedback guided by tissue tension
and resistance. This end point is designated the “iliacus postangle mea-
surement position.”
sion of the right lower extremity, the examiner prevented
anterior rotation of the right innominate bone.
The pressure on the ASIS required to prevent rotation
of the innominate bone was only that which was necessary
to counterbalance the weight and leverage of the lower
extremity and the downward force applied by the exam-
iner at the knee.
The examiner individualized this ASIS pressure for
each subject. Pressure changes, as described in the Results
section, showed that consistency was possible with this
approach.
(3) The lower extremity being treated was held by the exam-
iner until the subject let the lower extremity relax and drop
Eland et al • Original contribution
 ORIGINAL CONTRIBUTION

Table 1 Table 2
Thomas Test Done First—Population Demographics (N  40)* Part 1 of the Study: Thomas Test Done First
Followed Immediately by the Iliacus Test (N  40)

Variable Subjects Pearson 2 tests*

Age, mean (SD), y 26 (3.5) Component Hand Symptom

and test Gender dominance Age rating
Gender
Male 25 (62.5)
Left, preangle†
Female 15 (37.5)
Thomas test .475 .920 .504 .596
Hand dominance Iliacus test .470 .974 .222 .164
Right 34 (85.0)
Left, postangle‡
Left 6 (15.0)
Thomas test .420 .952 .552 .517
Inclusion criteria symptom rating Iliacus test .248 .841 .344 .452
Symptom rating 0 23 (57.5)
Right, preangle
Symptom rating 1 7 (17.5)
Thomas test .566 .304 .230 .470
Symptom rating 2 8 (20.0)
Iliacus test .296 .368 .469 .223
Symptom rating 3 2 (5.0)
Right, postangle
*Values are number (percentage) unless otherwise indicated. Thomas test .377 .062 .131 .357
Iliacus test .211 .089 .555 .062

toward the floor, allowing the knee to bend.
The examiner again monitored for involvement of the
musculus rectus femoris. Gravity carried the lower
extremity to its end point of hip extension, designated the
iliacus preangle measurement position (Figure 3, top right).
(4) Following passive maintenance of this gravity-dependent
position for 3 to 5 seconds, the examiner carried the right
thigh into further extension—but no further than the end
of comfortable ROM as assessed by tissue-feel/end-range
resistance defined by the examiner’s contact with the
knee.
This end point was designated the iliacus postangle mea-
surement position (Figure 3, bottom left). The position of the
innominate bone was maintained by continued contact
with the ASIS.
The subject continued to relax while the examiner main-
tained the palpable end point for another 3 to 5 seconds.
(5) Finally, the examiner returned (lifted) the thigh to neu-
tral, supported position. The examiner proceeded to test left
hip extension following the same protocol.
Measures
A calibrated electrogoniometer measured the angle in degrees
with horizontal at 0 (supine standard anatomic position).
Motion toward the ceiling was recorded as negative, denoting
less hip extension ROM; motion toward the floor was recorded
as positive, denoting increasing ROM further toward hip
extension from the horizontal. The pneumatic pressure trans-
ducer (Lafayette Instrument Co, Lafayette, Ind) measured
the pressure in the mid-lumbar region in millimeters of mer-
cury. Sampled at 200 Hz, digitized and collected by use of the
*No influence on any of the eight tests was noted at the .05 significance
level for gender, hand dominance, age, or inclusion criteria symptom rating.
†Preangle, the angle of hip extension in the gravity-dependent position;
allowed to remain stable for 3 to 5 seconds before further intervention.
‡Postangle, the angle of hip extension at the end-point position obtained by
examiner-applied pressure on the involved knee; allowed to remain stable
for 3 to 5 seconds before further intervention.
Enhanced Graphics & Analysis program (Version 3.5, RC
Electronics, Golita, Calif), the data generated continuous ROM
and pressure curves. All measurements were recorded to the
nearest tenth of a degree, although practical limits of accuracy
for hip extension ROM were to the nearest degree. Each ROM
end point was measured once. The level portion of the angle
measurement curve was the source for the angle recorded at
the end of the ROM for each test. The simultaneous pressure
was also recorded at that same point (Figure 1).
Statistical analysis
The SPSS statistical analysis program (Version 9.0, SPSS Sci-
ence, Chicago, Ill) provided results. We used paired t tests and
Wilcoxon signed rank tests to analyze the measurement data,
and Pearsons 2 tests for the demographic data.
Results
Differences between the Thomas and iliacus tests
Part 1: Thomas test first—The primary question posed was:
“Is there a measurable difference between the Thomas test (the
clinical standard) and the iliacus test?” In the clinical setting,
the ROM for hip extension was always less for the iliacus
test than for the Thomas test. Therefore, the initial study
design minimized any differences between the two tests by

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ORIGINAL CONTRIBUTION

Table 3 Table 4
Part 1 of the Study: Thomas Test Done First Iliacus Test Done First—Population Demographics (N  58)*
Followed Immediately by the Iliacus Test (N  40)*
Variable Subjects
Component Degrees,
and test mean (SD) 2-Tailed t test Age, mean (SD), y 26 (3.6)

Left, preangle† Gender

Thomas test 6.4 (9.9) Male 27 (47.0)
Iliacus test 1.7 (9.0) P.001 Female 31 (53.0)

Left, postangle‡ Hand dominance

Thomas test 18.2 (8.2) Right 55 (95.0)
Iliacus test 9.8 (7.1) P.001 Left 3 (5.0)

Right, preangle Inclusion criteria symptom rating

Thomas test 10.3 (8.8) Symptom rating 0 38 (65.5)
Iliacus test 4.2 (8.9) P.001 Symptom rating 1 17 (29.3)
Symptom rating 2 3 (5.2)
Right, postangle Symptom rating 3 0 (0)
Thomas test 18.7 (8.3)
Iliacus test 12.0 (7.9) P.001
*Values are number (percentage) unless otherwise indicated.

*Statistically significant differences between the two tests (Thomas and

iliacus) are noted for each of the four comparisons (2-tailed t test;
significant at P.001).
†Preangle, the angle of hip extension in the gravity-dependent position;
allowed to remain stable for 3 to 5 seconds before further intervention.
‡Postangle, the angle of hip extension at the end-point position obtained by
examiner-applied pressure on the involved knee; allowed to remain stable
for 3 to 5 seconds before further intervention.
performance of the Thomas test first followed by the iliacus
test. Because each test had the potential to be therapeutic,
any stretching that occurred during the first ROM test would
potentially increase the ROM for the second test.
The procedure as described in the Methods section was
done on 40 subjects. Demographics are given in Table 1. We
used Pearson’s 2 tests to assess each of the eight tests (eg, the
Thomas test with the gravity-dependent end point [preangle] on
the right lower extremity) for the influence of age, gender, hand
dominance, or symptom rating (see Methods section) on the
angle measurements. These four variables produced no signif-
icant differences with respect to the mean for angle measurement
of the eight investigated ROM tests (Table 2 and Table 3).
Analysis of the data revealed a significant difference
(P  .001) in ROM for the two tests—Thomas and iliacus,
for the right and the left lower extremity whether using the
preangle (the gravity-dependent end point) or postangle (end
point by examiner-induced pressure on the knee; tissue-
feel/end-range resistance) ROM results (Table 4).
Part 2: Iliacus test first—Given the results of Part 1, we repeated
the same protocol with a second group of 58 subjects, but we
did the iliacus test first, followed by the Thomas test (Table
5). Again, Pearson’s 2 tests showed no significant influences
on the eight variables of interest with respect to age, gender,
hand dominance, or symptom rating (Table 5 and Table 6).
Analysis of these data also suggested a significant dif-
ference (P  .001) in ROM for the two tests—Thomas and ili-
acus, for the right and for the left lower extremity whether
using the preangle (the gravity-dependent end point) or
postangle (end point by examiner-induced pressure on the
knee) ROM results (Table 7).
Direct comparison of the Thomas and iliacus tests—We used
the Wilcoxon signed rank test to compare the Thomas test
ROM data from Part 1 of the study (N  40) with the iliacus
test ROM data from Part 2 of the study (N  58).
This data analysis showed a significant difference (P  .05)
in ROM for the two tests, with the means of the iliacus test
always showing significantly less ROM than the means of the
Thomas test for right and left lower extremity (Table 7), whether
using the preangle (the gravity-dependent end point) or
postangle (end point by the examiner-induced pressure on
the knee) ROM results. The results clearly demonstrated a
measurable difference between the iliacus test and the clinical
standard, the Thomas test.
Test differences: Preangle versus postangle
Were there differences in the preangle (the gravity-dependent
end point) and postangle (end point by the examiner’s applying
pressure on the knee; tissue-feel/end-range resistance) ROM
approaches to testing hip extension? We compared them in the
same manner as the Thomas and iliacus tests, but with the
paired-samples t test.
This analysis of results also clearly demonstrated a mea-
surable difference between the standard gravity-dependent
end point and the examiner-induced knee pressure end point
(P  .001; Table 8).

136 • JAOA • Vol 102 • No 3 • March 2002 Eland et al • Original contribution

 ORIGINAL CONTRIBUTION

Table 5 Table 6
Part 2 of the Study: Iliacus Test Done First Part 2 of the Study: Iliacus Test Done First
Followed Immediately by the Thomas Test (N  58) Followed Immediately by the Thomas Test (N  58)*

Pearson 2 tests* Component Degrees,

and test mean (SD) 2-Tailed t test
Component Hand Symptom
and test Gender dominance Age rating Left, preangle†
Iliacus test 4.4 (10.3)
Left, preangle† Thomas test 14.9 (10.9) P.001
Iliacus test .563 .664 .267 .072
Thomas test .385 .487 .239 .886 Left, postangle‡
Iliacus test 17.0 (9.2)
Left, postangle‡ Thomas test 26.7 (9.9) P.001
Iliacus test .489 .688 .386 .721
Thomas test .519 .216 .427 .157 Right, preangle
Iliacus test 6.8 (9.9)
Right, preangle
Thomas test 17.0 (7.7) P.001
Iliacus test .561 .976 .169 .785
Thomas test .419 .679 .606 .765
Right, postangle
Right, postangle Iliacus test 16.5 (7.7)
Iliacus test .216 .412 .335 .603 Thomas test 24.9 (7.0) P.001
Thomas test .696 .395 .929 .802
*Statistically significant differences between the two tests (iliacus and
Thomas) are noted for each of the four comparisons (2-tailed t test;
*No influence on any of the eight tests was noted at the .05 significance level significant at P.001).
for gender, hand dominance, age, or inclusion criteria symptom rating.
†Preangle, the angle of hip extension in the gravity-dependent position;
†Preangle, the angle of hip extension in the gravity-dependent position; allowed to remain stable for 3 to 5 seconds before further intervention.
allowed to remain stable for 3 to 5 seconds before further intervention.
‡Postangle, the angle of hip extension at the end-point position obtained
‡Postangle, the angle of hip extension at the end-point position obtained by by examiner-applied pressure on the involved knee; allowed to remain
examiner-applied pressure on the involved knee; allowed to remain stable for stable for 3 to 5 seconds before further intervention.
3 to 5 seconds before further intervention.

Table 7
Iliacus Test and Thomas Test
Mean Angle Comparisons*

Iliacus test Thomas test

Test Degrees, Degrees, Wilcoxon

component mean (SD) 95% CI† mean (SD) 95% CI signed rank test

Preangle‡
Left 4.4 (10.3) 1.7 to 7.0 6.4 (9.9) 3.4 to 9.5 P.032
Right 6.8 (9.9) 4.2 to 9.3 10.3 (8.8) 7.5 to 13.0 P.004

Postangle§
Left 17.0 (9.2) 14.6 to 19.3 18.2 (8.2) 15.7 to 20.8 P.044
Right 16.5 (7.7) 14.5 to 18.5 18.7 (8.3) 16.1 to 21.2 P.006

*Statistically significant differences between the two tests (iliacus and Thomas mean range of motion)
are noted for each of the four comparisons (2-tailed t test; significant at P.05).
†CI  confidence interval
‡Preangle, the angle of hip extension in the gravity-dependent position; allowed to remain stable
for 3 to 5 seconds before further intervention.
§Postangle, the angle of hip extension at the end-point position obtained by examiner-applied pressure
on the involved knee; allowed to remain stable for 3 to 5 seconds before further intervention.

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Table 8
Thomas Test and Iliacus Test
Preangle and Postangle Mean Angle Comparisons*

Preangle,† degrees Postangle,‡ degrees

Test Mean (SD) Mean (SD) 2-Tailed t test

Thomas test
Left 6.4 (9.9) 18.2 (8.2) P.001
Right 10.3 (8.8) 18.6 (8.3) P.001

Iliacus test
Left 4.4 (10.3) 17.0 (9.2) P.001
Right 6.8 (9.9) 16.5 (7.7) P.001

*Statistically significant differences between the two tests (preangle and postangle) are noted
for each of the four comparisons (2-tailed t test; significant at P.001).
†Preangle, the angle of hip extension in the gravity-dependent position; allowed to remain stable
for 3 to 5 seconds before further intervention.
‡Postangle, the angle of hip extension at the end-point position obtained by examiner-applied pressure
on the involved knee; allowed to remain stable for 3 to 5 seconds before further intervention.

Table 9
Iliacus Test and Thomas Test
Mean Pressure Change Comparisons*

Iliacus test (N  58), Thomas test (N  40), Wilcoxon

Side mean (SD) mean (SD) signed rank test

Left, pressure change

(mm Hg) 16.5 (15.0) 21.7 (13.0) P.368

Right, pressure change

(mm Hg) 8.4 (12.9) 20.9 (12.3) P.559

*No statistically significant differences in pressure change from preangle to postangle were noted
between the iliacus and Thomas tests (Wilcoxon signed rank test; not significant at P.05).

Variability of findings Right and left range-of-motion differences

The study’s design allowed for data collection and analysis
for another question: “Does added pressure on the knee
increase the variability of the findings compared with the
standard gravity-dependent end point?”
 Variability of angle measurements: Table 8 shows the mean
and SD for each of the tests, pairing the preangle (the gravity-
dependent end point) and postangle (end point by examiner-
induced pressure on the knee) tests. This data analysis sug-
gests that added pressure on the knee slightly, but
consistently, decreased the variability for end-range mea-
surement of angle as expressed by the SD.
 Variability of pressure measurements: Table 9 shows
pressure changes in millimeters of mercury from preangle
(the gravity-dependent end point) to postangle (end point
by examiner-induced pressure on the knee) were consis-
tent between the Thomas and iliacus tests.
One of the clinical observations associated with symptomatic
patients has been a side-to-side (left-to-right) difference in hip
extension ROM, particularly with use of the iliacus test. Table
10 provides results relating to an associated question: “Is there
a significant difference in side-to-side ROM in a ‘normal,’
asymptomatic population?”
Analysis revealed a significant difference in ROM for left
versus right hip extension only for the standard (gravity-
dependent end point) Thomas test (P  .05).
Test norms for hip extension range of motion
Given the lack of significant difference between the right and
the left ROM means for all but the Thomas test preangle mea-
surement (Table 10), we averaged the left and right means to
generate a single preangle ROM norm and a single postangle
ROM norm for each test, iliacus test and Thomas test (Table 11).

138 • JAOA • Vol 102 • No 3 • March 2002 Eland et al • Original contribution

 ORIGINAL CONTRIBUTION

Table 10
Iliacus Test and Thomas Test
Left Versus Right Mean Angle Comparisons*

Left Right

Test Degrees, Degrees,

component mean (SD) 95% CI† mean (SD) 95% CI 2-Tailed t test

Preangle‡
Iliacus test 4.4 (10.3) 1.7 to 7.0 6.8 (9.9) 4.2 to 9.3 P.064
Thomas test 6.4 (9.9) 3.4 to 9.5 10.3 (8.8) 7.5 to 13.0 P.024
Postangle§
Iliacus test 17.0 (9.2) 14.6 to 19.3 16.5 (7.7) 14.5 to 18.5 P.642
Thomas test 18.2 (8.2) 15.7 to 20.8 18.7 (8.3) 16.1 to 21.2 P.787

*Statistically significant differences between right and left lower extremity ranges were noted only with
the standard (preangle) Thomas test (2-tailed t test; significant at .05 level).
†CI  confidence interval
‡Preangle, the angle of hip extension in the gravity-dependent position; allowed to remain stable
for 3 to 5 seconds before further intervention.
§Postangle, the angle of hip extension at the end-point position obtained by examiner-applied pressure
on the involved knee; allowed to remain stable for 3 to 5 seconds before further intervention.

We used the 95% confidence intervals to establish meaningful
norms from this study’s data for the preangle and postangle
ROM for the iliacus test and for the Thomas test (Table 11).
Comparison of this study’s Thomas preangle measurement
norm was made with the norms noted in the introduction.
Those standards did not distinguish between right and left
sides. The range of values reported from those sources for the
standard Thomas test (preangle) were between 9 degrees and
50 degrees. The Thomas test preangle norm from this study
was 8.3 degrees (mean).
Discussion
This study’s design provided a basis for assessing whether
the iliacus test was a refinement for the evaluation of an indi-
vidual’s hip extension capacity. The statistical analysis of the
results confirmed that the test did provide information dif-
ferent from that provided by the Thomas test. The data showed
that the iliacus test yielded consistently less hip extension than
the Thomas test (Table 7). From a clinical perspective, this dif-
ference made sense, given that the iliacus test was testing
motion limited to a single joint, the hip joint. Therefore, there
was no summation of motions that occur across multiple joints
such as occurs with the Thomas test.
Each test has its inherent value, while the combined infor-
mation from doing both tests provides a better overview of the
function of the region than either test by itself can provide. Used
together, these tests can differentiate the contribution of the iliac
muscle from that of the psoas muscles. If the Thomas and ili-
acus tests are done with the result that the same amount of
restriction is noted in both tests, contracture of the psoas mus-
cles is as great or greater than that of the iliac muscle. If both
tests are done, but the iliacus test shows more restriction, iliac
muscle contracture is the dominant element. Biomechanical
analysis dictates these conclusions:
During the Iliacus test the innominate is fixed in position via
the contact with the ipsilateral ASIS. This effectively fixes the
origin of the iliacus. This is not the case for the origins of the
psoas. Therefore, during the Iliacus test, compensations for a
tight psoas can occur through the sacroiliac and lumbar joints.
Its influence on end-range resistance is thus diminished, leaving
the iliacus complex as the primary influence on end-range
resistance during the Iliacus test, even if significant psoas tight-
ness is present. If the psoas is sufficiently tight to limit end
range during the Iliacus test, no appreciable influence from
fixing the ASIS in place will be noted and thus no appreciable
difference will be seen between the Iliacus and Thomas test.16
Previously, no normative data have been collected for
the iliacus testing approach to evaluation of hip extension.
Therefore, establishing a norm for an asymptomatic popula-
tion was important for future evaluation of the stretch capacity
of the iliac muscle as a contributing factor in spinal, pelvic, or
lower extremity dysfunction. The results of Part 2 of the study
(N  58) provided the basis for establishing a ROM norm for
iliacus testing (Table 11).
The norms for the Thomas test (Table 11) were at the
lower end of the ROMs cited in Van Deusen and Brunt,7 who
described and pictured the Thomas test for assessment of hip
extension. However, all sources for this measurement cited in
Van Deusen and Brunt used a prone hip extension ROM test.
Those ranges cited that used passive ROM testing10,11 (9.5
degrees and 15 degrees, respectively) were still consistent
with the results from the Thomas test in our study (8.3

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ORIGINAL CONTRIBUTION

Table 11
Iliacus Test and Thomas Test
Preangle and Postangle Normal Range Comparisons*

Iliacus test (N  58) Thomas test (N  40)

Test Degrees, Degrees,

component mean (SD) 95% CI† mean (SD) 95% CI

Preangle‡ 5.6 (8.9) 3.2 to 8.0 8.3 (7.8) 5.9 to 10.7

Postangle§ 16.7 (7.5) 14.8 to 18.6 18.4 (6.7) 16.2 to 20.6

*The normal range for each range of motion test is defined by the 95% confidence interval (CI).
†CI  confidence interval
‡Preangle, the angle of hip extension in the gravity-dependent position; allowed to remain stable
for 3 to 5 seconds before further intervention.
§Postangle, the angle of hip extension at the end-point position obtained by examiner-applied pressure
on the involved knee; allowed to remain stable for 3 to 5 seconds before further intervention.

degrees). It seemed logical that the prone position used in
those studies did not allow for similarly precise control for lum-
bopelvic motion and would have had a slightly greater range
of hip extension for their norms.
Those studies using an active ROM (patient initiated and
controlled) reported 22 degrees or greater hip extension. The
most recent study, by Roach and Mills,12 suggested that the
“effort-dependent nature” of active ROM may have con-
tributed to the variability seen in such measurements.
For asymptomatic individuals, the common clinical prac-
tice assumption has been to expect relative equivalence when
comparing extension motion on the right side with that on
the left. Absence of equivalence has been a basis for confir-
mation of dysfunction on one side or the other, as Ekstrand et
al17 noted:
Similar amplitudes of right and left joints is in accordance
with Boone and Azen who concluded that joint motions of a
patient’s “healthy limb” could routinely be used for compar-
ison with the affected side in the presence of disease or lesion.
The data of Roaas and Andersson11 confirmed this observation
as well.
The norms established in the current study tended to
agree with the findings of Boone and Azen,18 Ekstrand et al,17
and Roaas and Andersson.11 The current study’s norms were
found to be representative of both right and left lower extrem-
ities, except for the standard Thomas test (Thomas preangle 2-
tailed significance, P  .024; Table 10).
A review of the data from the seven subjects that partic-
ipated in Part 1 and Part 2 of the study did not support the left-
right difference in means for the standard Thomas test (2-
tailed t test, P  .100). However, a larger number of subjects
participating in both Part 1 and Part 2 testing sequences might
have revealed the same trend toward significant difference
that was apparent in the current study’s large-group data.
This small-group data analysis supported the rest of the sta-
tistical analysis reported in the Results section.
The side-to-side difference in range for the standard
Thomas test may well have been due to its multiple-joint char-
acter. Many people are right lower extremity dominant.6 The
cumulative effect of lower extremity dominance across multiple
joints influencing the lower extremities may have explained the
right-to-left difference noted. The addition of an examiner-
induced pressure end point eliminated that difference (Thomas
postangle 2-tailed significance, P  .787; Table 10). The change
in pressure from preangle to postangle measurements was
not significantly different from left to right sides (Table 9). This
finding suggested consistency of application of the technique
which helped to rule out variability as a source of error.
Given that our subjects were, in fact, a normal, asymp-
tomatic population, lower extremity dominance could have
played a minor role in local, single-joint ROM differences—as
evidenced by the near significance of the iliacus preangle test
(2-tailed significance, P  .064). Any influence of lower
extremity dominance was lost with the postangle approach to
testing (iliacus postangle 2-tailed significance, P  .642).
The Thomas test classically utilized patient relaxation in
response to gravity for end-range determination. Clinical
experience suggested that the tissue-feel/end-range end point
yielded more information and more consistent information
than a gravity-dependent end point. The examiner gained
additional clinical information by assessing end-range end
point with suprapatellar contact, adding extension pressure
to evaluate end-feel end point as end-range end point was
approached. Therefore, we compared both the Thomas and
the iliacus tests using the traditional relaxation/gravity (pre-
angle) end point and examiner palpatory pressure (tissue-
feel/end-range resistance; postangle) end point. Preangle and
postangle SDs were comparable with the postangle SDs being
slightly, but consistently smaller values (Table 8).

140 • JAOA • Vol 102 • No 3 • March 2002 Eland et al • Original contribution


Because the examiner was able to tell when the patient was
guarding excessively and could feel the difference between
spasm and fascial contracture using the tissue-feel end point,
the added information was worth the change from traditional
(gravity-dependent end point) Thomas testing procedures.
The comparative equality in variability of end-range angles and
pressure changes (Table 9) suggested added value to utilization
of this palpatory-controlled end point.
In both tests, significant differences were eliminated
using this examiner-induced pressure. This examiner-induced
pressure provided a means for decision making relating to the
clinical significance of gravity-dependent end point left-to-right
differences. A hypothesis consistent with the data suggested
that elimination of the difference, given examiner-induced
pressure, indicated a “normal” resilient dominance pattern had
been identified with the standard Thomas test.
Clinical experience suggests that the iliacus test is more sen-
sitive to side-to-side variations in symptomatic patients than the
Thomas test. This difference in sensitivity seems to be due to
the iliacus test’s single-joint nature and the iliacus complex’s
strong participation in upright and ambulatory activities.14
Future studies with symptomatic patients will determine
whether clinical observations of definite side-to-side differ-
ences in ROM for hip extension for these populations are accu-
rate and significant. They may provide more insight into the
mechanism as well.
Mean pressure changes were consistent for all tests (Table
9). This finding reinforced the clinical observation that consis-
tency could be readily obtained with examiner-produced pres-
sure end point.
Our study’s population was recruited from osteopathic
medical students in the 20- to 35-year-old age group. It was
therefore not necessarily a representative norm for all age
groups, and the norm may not be generalized to the whole age
group. Roach and Miles12 compared the 25- to 39-year-old age
group at 22 degrees of hip extension and the 60- to 74-year-old
age group at 17 degrees of hip extension. They noted a differ-
ence of 20% in active ROM. Their analysis found hip extension
to be the only motion tested showing such a large range dif-
ference with age. This was a secondary analysis of data collected
by the National Center for Health Statistics in the National
Health and Nutrition Examination Survey conducted from
1971 to 1975. Of the 1892 subjects involved, 433 were in the 25-
to 39-year-old age group, and 523 were in the 60- to 74-year-
old group.12
Future normative work could add data for norms in
other age ranges by use of passive-motion testing methods.
The approach could randomize subject assignment to the
first of the two tests, with 24 hours lapsing before the second
test was administered, eliminating, or at least minimizing,
the influence of one test on the other. The subjects would
perform no strenuous activity in the interim between tests. It
would be important to continue to assess both tests on each
subject so that the relationship of the tests in asymptomatic
Eland et al • Original contribution
ORIGINAL CONTRIBUTION
subjects and symptomatic subjects could be compared.
Given this study’s confirmation of the independent nature
of the iliacus test, future study could direct attention toward dif-
ferences in symptomatic and asymptomatic populations. Some
previous studies have addressed issues of intraexaminer and
interexaminer reliability, which may deserve repeating for this
approach as well.
Comments
The results of the current study suggest the role of the iliacus
complex, as evaluated by the discrete single-joint iliacus test,
can provide valuable new information relevant to common
clinical musculoskeletal complaints.
It also demonstrates the tissue-feel (postangle) end point
is at least as consistent as the gravity-dependent (preangle)
end point.
The findings of the current study do not diminish the
value of the Thomas test, but do suggest that there is other
information about hip extension and hip flexion contracture
that the iliacus test provides. If the ROM determined by the
Thomas test ROM equals the ROM determined by the iliacus
test, then the resistance of the psoas muscles is greater than or
equal to that of the iliacus complex. If, on the contrary, the
ROM measured by the iliacus test is less than that measured
by the Thomas test, then the iliacus complex resistance is
greater than that of the psoas muscles.
The iliacus test norms provide one more piece to the diag-
nostic and therapeutic puzzle with which physicians and
patients alike find themselves dealing. Because the iliacus test
can be readily adapted to any primary care or specialty prac-
tice, office treatment can be readily provided with concurrent
prescription of home exercises for the iliacus complex.
Acknowledgments
This study was supported by the Office of Research of the Ohio Uni-
versity College of Osteopathic Medicine.
References
1. Wipf JE, Deyo RA. Low back pain. Med Clin North Am 1995;79:231:321-246.
2. Mitchell FL. Structural pelvic function. Academy of Applied Osteopathy Year-
book 1958;75-76:79.
3. Heinking K, Jones JM III, Kapler RE. Pelvis and sacrum. In: Ward RC, ed. Foun-
dations for Osteopathic Medicine. Baltimore, MD: Williams & Wilkins;
1997:607,617-618,625.
4. American Medical Association. Guides to the Evaluation of Permanent
Impairment. 4th ed. Chicago, Ill: American Medical Association; 1993:90.
5. Day JW, Smidt GL, Lehmann T. Effect of pelvic tilt on standing posture. Phys
Ther 1984;64:510-516.
6. Magee DJ. Orthopedic Physical Assessment. 3rd ed. Philadelphia, Pa: WB
Saunders Co; 1997:482,773.
JAOA • Vol 102 • No 3 • March 2002 • 141
ORIGINAL CONTRIBUTION
7. Van Deusen J, Brunt D. Assessment in Occupational Therapy and Physical
Therapy. Philadelphia, Pa: WB Saunders Co; 1997:65-66.
8. Ashton BB, Pickles B, Roll JW. Reliability of goniometric measurements of
hip motion in spastic cerebral palsy. Develop Med Child Neurol 1978;20:87-
94.
9. Esch D, Lepley M. Evaluation of joint motion: methods of measurement and
recording. Minneapolis, Minn: University of Minnesota Press; 1974.
10. Gerhardt J, Russe O. International SFTR Method of Measuring and
Recording Joint Motion. Bern-Bümpliz, Switzerland: Hans Huber Publishers;
1975:62.
11. Roaas A, Andersson GB. Normal range of motion of the hip, knee, and
ankle joints in male subjects, 30-40 years of age. Acta Orthopaed Scand
1982;53:205-208.
12. Roach KE, Miles TP. Normal hip and knee active range of motion: the rela-
tionship to age. Phys Ther 1991;71:658.
13. Andersson E, Oddsson L, Grundstrom H, Thorstensson A. The role of the
psoas and iliacus muscles for stability and movement of the lumbar spine, pelvis
and hip. Scand J Med Sci Sports 1995;5:10-16.
142 • JAOA • Vol 102 • No 3 • March 2002
14. Andersson EA, Nilsson J, Thorstensson A. Intramuscular EMG from the hip
flexor muscles during human locomotion. Acta Physiolog Scand 1997;161:361-
370.
15. Andersson EA, Nilsson J, Zhijia M, Thorstensson A. Abdominal and hip
flexor muscle activation during various training exercises. Eur J Appl Physiol
1997;75:115-123.
16. Eland DC. A model for (focused) osteopathic evaluation of “iliacus” func-
tion and dysfunction. Am Acad Osteopathy J 2001;11:15-39. Available at:
http://www.academyofosteopathy.org/summer2001.pdf. Accessed February
20, 2002.
17. Ekstrand J, Wiktorsson M, Oberg B, Gillquist J. Lower extremity goniometric
measurements: a study to determine their reliability. Arch Phys Med Rehabil
April 1982;63:171-175.
18. Boone DC, Azen SP. Normal range of motion in male subjects. J Bone Joint
Surg Am 1979;61:756-759.
Eland et al • Original contribution