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DAVID M. SELKOWITZ, PT, PhD, OCS, DAAPM1 • GEORGE J. BENECK, PT, PhD, OCS2 • CHRISTOPHER M. POWERS, PT, PhD, FAPTA3
A
bnormal hip kinematics and impaired hip muscle and hip joint pathol-
performance have been associated with various ogy.18,26 For example,
several studies have
musculoskeletal disorders, such as patellofemoral
Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
cises are best for activating the gluteus medius significantly (P<.05) more active than the TFL
apparent association between hip dys-
and the superior portion of the gluteus maximus, in unilateral and bilateral bridging, quadruped function and lower extremity injury, there
while minimizing activity of the tensor fascia lata hip extension (knee flexed and extending), the has been an increased focus on hip mus-
(TFL). clam, sidestepping, and squatting. The gluteal- cle strengthening as part of rehabilitation
TTBACKGROUND: Abnormal hip kinematics (ie, to-TFL muscle activation index ranged from 18 to protocols.14,17,28,35,48,49
excessive hip adduction and internal rotation) has 115 and was highest for the clam (115), sidestep The primary muscle actions at the hip
been linked to certain musculoskeletal disorders. (64), unilateral bridge (59), and both quadruped are well known. The middle portion of
The TFL is a hip abductor, but it also internally exercises (50).
the gluteus medius (GMED) is an abduc-
TTCONCLUSION: If the goal of rehabilitation
rotates the hip. As such, it may be important to
select exercises that activate the gluteal hip abduc- tor and the gluteus maximus (GMAX) is
tors while minimizing activation of the TFL. is to preferentially activate the gluteal muscles an extensor and external rotator.36 How-
while minimizing TFL activation, then the clam,
TTMETHODS: Twenty healthy persons participat- sidestep, unilateral bridge, and both quadruped
ever, the superior portion of the GMAX
ed. Electromyographic signals were obtained from (SUP-GMAX) also acts as a hip abductor
hip extension exercises would appear to be the
the gluteus medius, superior gluteus maximus, during gait.27 As such, enhancing per-
most appropriate. J Orthop Sports Phys Ther
and TFL muscles using fine-wire electrodes formance of the GMED and GMAX has
2013;43(2):54-64. Epub 16 November 2012.
as subjects performed 11 different exercises. been recommended to control excessive
doi:10.2519/jospt.2013.4116
Normalized electromyographic signal amplitude
TTKEY WORDS: EMG, gluteus maximus, gluteus
hip adduction and internal rotation dur-
was compared among muscles for each exercise,
using multiple 1-way repeated-measures analyses medius, hip ing weight-bearing activities.12
Recent studies have sought to de-
1
Department of Physical Therapy Education, Western University of Health Sciences, Pomona, CA. 2Department of Physical Therapy, California State University, Long Beach, Long
Beach, CA. 3Jacquelin Perry Musculoskeletal Biomechanics Research Laboratory, Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles,
CA. This study was approved by the Institutional Review Boards of the Western University of Health Sciences and the University of Southern California. The authors certify that
they have no affiliations with or financial involvement in any organization or entity with a direct financial interest in the subject matter or materials discussed in the manuscript.
Address correspondence to Dr David M. Selkowitz, 365 Lincoln Avenue, Pomona, CA 91767-3929. E-mail: dselkowitz@westernu.edu t Copyright ©2013 Journal of Orthopaedic
& Sports Physical Therapy
54 | february 2013 | volume 43 | number 2 | journal of orthopaedic & sports physical therapy
ity), and sidelying hip abduction.1,2,6,15,29 of exercises using fine-wire EMG. In ad- muscle.33 Disposable 25-gauge needles
A limitation of these studies is that all dition, no study specifically investigated were used as cannulas to place the elec-
of them used surface electromyography the SUP-GMAX. As such, the purpose trodes within the muscles of interest.
(EMG) to assess muscle activity. The use of the current study was to investigate
of surface electrodes to detect muscle ac- hip abductor muscle activation using Procedures
tivity has the potential to contaminate the fine-wire EMG for a selected number The skin over the lateral hip and buttock
desired muscle’s EMG signal with that of of therapeutic exercises. In particular, of the dominant lower extremity (that
nearby muscles (ie, cross-talk). Fine-wire we sought to determine which exercises used to kick a ball) was cleaned with
electrodes limit cross-talk because, unlike would best activate the GMED and SUP- rubbing alcohol. Fine-wire electrodes
surface electrodes, which are applied to GMAX while minimizing TFL activity. were then inserted into the SUP-GMAX,
the overlying skin, they are inserted di- Information gained from this study may GMED, and TFL muscles. Electrode lo-
rectly into the target muscle.45 Bogey et be useful for planning therapeutic exer- cations for these muscles were based on
Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
al4 reported that the EMG signal detected cise programs specific to certain lower the recommendations of Delagi and Pe-
using fine-wire electrodes was specific to extremity musculoskeletal disorders. rotto11 and Lyons et al.27 Briefly, the elec-
the target/sampled muscle, and that the trode insertion for the SUP-GMAX was
normalized intramuscular signal was METHODS superior and lateral to the midpoint of a
representative of the entire muscle. line drawn between the posterior supe-
T
A second limitation of the studies that wenty healthy volunteers (10 rior iliac spine and the posterior greater
have evaluated GMED and GMAX activ- men and 10 women) between the trochanter. The GMED electrode was in-
ity during various therapeutic exercise ages of 18 and 50 years (mean SD serted 2.5 cm distal to the midpoint of the
programs is that, with the exception of age, 27.9 6.2 years) participated. Sub- iliac crest (ie, middle portion). The TFL
Journal of Orthopaedic & Sports Physical Therapy®
2 studies,9,29 they did not simultaneously jects were recruited from the University electrode was inserted distal and slightly
quantify tensor fascia lata (TFL) activity. of Southern California (Los Angeles, CA) lateral to the anterior superior iliac spine
The TFL, in addition to being an abduc- and Western University of Health Sci- and medial and superior to the greater
tor, is an internal rotator of the hip. The ences (Pomona, CA) communities. Sub- trochanter. The reference electrode was
TFL can also exert a lateral force on the jects were excluded if they reported any placed over the C7 spinous process.
patella via connections to the iliotibial musculoskeletal disorders of the trunk The electrode wires were taped to the
band, which is connected to the patella or lower extremities, or any neurologi- skin, with a loop of wire created at the
and the lateral patellar retinaculum.24,30,31 cal conditions. Prior to participation, all insertion site to prevent accidental dis-
Excessive hip internal rotation and lateral subjects were given a detailed explana- lodging during movements. 33 The free
patellar displacement have been linked to tion of the study and signed an informed ends of the wire electrodes were stripped
conditions such as patellofemoral pain.40- consent form approved by the Institu- of insulation using fine sandpaper, where
42,46
In addition, atrophy of the GMAX tional Review Boards of the University they were attached to metal terminals
muscle relative to the TFL has been ob- of Southern California and Western Uni- connecting the rest of the detection sys-
served in persons with degenerative hip versity of Health Sciences. The rights of tem. The metal terminals were taped to
joint pathology.18 For certain conditions, subjects were protected. the skin of the lateral thigh. The wire
therefore, it would appear appropriate electrodes were inserted by a physical
to design rehabilitation programs using Instrumentation therapist who was receiving certification
therapeutic exercises that promote activ- EMG data were collected using an MA- in kinesiological EMG in the state of Cali-
ity of the GMED and GMAX while mini- 300-16 EMG system (Motion Lab Sys- fornia. This individual was supervised by
mizing recruitment of the TFL. tems, Inc, Baton Rouge, LA), with a 2 other physical therapists who had a
A review of the literature revealed that common-mode rejection ratio of greater combined 50 years of experience as cer-
3 studies have performed direct statisti- than 110 dB at 65 Hz, MA-416 discrete tified kinesiological EMG practitioners.
cal comparisons of EMG signal ampli- preamplifiers, a gain of 1 kHz × 20% Confirmation of electrode placement in
tudes among hip muscles for different 1%, and an input impedance of greater the appropriate muscle was made using
journal of orthopaedic & sports physical therapy | volume 43 | number 2 | february 2013 | 55
for each muscle, maximum voluntary ing (QKE), hip extension in quadruped of the EMG signal was obtained by de-
isometric contractions (MVICs) of 5 sec- on elbows with knee flexed (QKF), for- riving the root-mean-square (RMS) of
onds’ duration were performed for each ward lunge with erect trunk (LUNGE), the signal over a 75-millisecond moving
muscle in random order. One MVIC squat (SQUAT), sidestep with elastic window, resulting in full-wave rectifica-
trial was performed for each muscle. resistance around thighs in a squatted tion and smoothing of the raw signal.
The EMG signal collected during MVIC position (SIDESTEP), hip hike (HIKE), For statistical comparisons, the normal-
testing was used to normalize the EMG and forward step-up (STEP-UP). De- ized EMG signal amplitude during the
signal for each muscle. The highest EMG scriptions of each exercise can be found exercises was expressed as a percentage
signal amplitude was used for each mus- in the APPENDIX. Prior to data collection, of EMG obtained during the MVIC. The
cle, regardless of the MVIC test position/ subjects were familiarized with the test- highest EMG signal amplitude obtained
activity in which it was obtained. ing protocol and received instruction for each muscle during any MVIC test-
Neither the functional differentiation in and practiced the exercises to ensure ing procedure described above was used
Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
of the GMAX nor the best position for proper performance. On rare occasion, for normalization purposes. The highest
eliciting its maximum activity has been an exercise had to be repeated because of EMG signal was defined as the highest
well established; therefore, multiple test a “false start” or lack of synchronization mean RMS obtained over a consecutive
positions were used for MVIC testing of between the subject and the examiners or 1-second period of the MVIC test.
the SUP-GMAX. For 1 of the tests, maxi- metronome. The primary dependent variable of
mal hip extension was resisted using a A metronome was set at 40 beats per interest was the mean RMS (% MVIC)
strap across the distal posterior thigh, minute to pace the exercises, with the from each muscle for each exercise rep-
with the upper body prone on a treat- exception of the SIDESTEP, which was etition. After obtaining the mean RMS
ment table and the hip at an angle of 45° paced at 80 beats per minute. Five rep- for each repetition of a given exercise, the
Journal of Orthopaedic & Sports Physical Therapy®
of flexion and the knee at 90° of flexion. etitions of each exercise were performed, mean of the repetitions was used in the
The SUP-GMAX also was tested, such with the exception of the SIDESTEP, in statistical analysis. Intrarater reliability
that hip extension was resisted with the which 3 sets of 2 strides (APPENDIX) were of obtaining the mean RMS of each mus-
subject lying fully prone, with the knee completed in each direction. For each cle of interest using the visual estimation
flexed to 90°. The MVIC for the GMED exercise, the concentric and eccentric of contraction time (as described above)
was obtained during resisted hip abduc- phases of the repetitions each comprised was assessed by reanalyzing a portion of
tion while subjects were sidelying on 1 metronome beat, and there was 1 beat the data set on a second occasion (5 sub-
the treatment table on the side opposite of rest between each repetition. An event jects, 2 exercises, 5 repetitions). Using the
to that being tested, with the posterior marker was manually triggered during intraclass correlation coefficient (model
pelvis and scapulae back against an ad- each exercise. This was used, along with 3,1), reliability was found to be excel-
jacent wall. Subjects exerted maximal ab- visual inspection of the recorded signal, lent for the SUP-GMAX (0.99), GMED
duction force against a strap across the which was the reference standard,21 to (0.99), and TFL (0.99).
distal lateral leg, in a position of 30° of assist in determining the beginning and The signal-to-noise ratio was calcu-
hip abduction, with the hip and knee at end of each repetition. A rest of at least 2 lated from a portion of the collected EMG
0° of flexion. The MVIC for the TFL was minutes was given between each exercise. data, based on the following equation:
obtained in the same sidelying position 20log10(signalRMS/noiseRMS), where signal
used for the GMED, except that the hip EMG Analysis is the mean over the time course of the
was positioned in 45° of flexion and 30° Raw EMG signals were imported into contraction and noise is the baseline ac-
of abduction. Subjects exerted a maxi- MATLAB software (The MathWorks, Inc, tivity. Based on these data, the signal-to-
mal force against the strap in a diagonal Natick, MA) for processing. EMG data noise ratio was determined to be 20.2 dB.
plane, about 45° between the sagittal and were band-pass Butterworth filtered at
coronal planes. Manual resistance was 35 to 750 Hz. The use of the high-cut/ Statistical Analysis
added to the strap to help ensure that the low-pass boundary of the filter (750 Hz) A 3-way analysis of variance (ANOVA)
subjects were achieving a maximal effort. followed recommended guidelines32; (sex by exercise by muscle) was initially
56 | february 2013 | volume 43 | number 2 | journal of orthopaedic & sports physical therapy
T
of Each Muscle for Each Exercise* ABLE 1 provides the normalized
mean EMG amplitudes for each
Exercise Tensor Fascia Lata Gluteus Medius Superior Gluteus Maximus muscle for each exercise, and iden-
Sidelying hip abduction 32.3 13.1 43.5 14.7 (P = .012)† 23.7 15.3 (P = .033)‡ tifies any significant differences among
Bilateral bridge 8.2 7.4 15.0 10.5 (P = .011)† 17.4 11.9 (P = .008)† the muscles in each exercise, based on
Downloaded from www.jospt.org at China Medical University on January 19, 2016. For personal use only. No other uses without permission.
‡
Significantly less than tensor fascia lata (P<.05). .135, respectively).
For all of the exercises in which the
ANOVA was significant, with the excep-
performed to determine if there was a compared to the TFL for each exercise. tion of ABD and HIKE, contrast test re-
difference in muscle activation across the Specifically, the GTA index used the mean sults revealed that both the GMED and
various exercises and muscles between normalized EMG values to create relative SUP-GMAX had significantly higher
men and women. This analysis revealed activation ratios of both the SUP-GMAX normalized EMG amplitudes than the
that there were no main effects or inter- and GMED compared to the TFL (ie, TFL. For ABD, the contrast tests revealed
action effects with regard to sex. As such, SUP-GMAX/TFL and GMED/TFL). The that the normalized EMG amplitude for
Journal of Orthopaedic & Sports Physical Therapy®
data from both sexes were combined for relative activation ratio for each gluteal the GMED was significantly greater than
all analyses. muscle was multiplied by that muscle’s the TFL (P = .012); however, the SUP-
Based on our research question, 1-way mean normalized EMG value, summed, GMAX was significantly less than the
repeated-measures ANOVAs were used and then divided by 2 to provide the TFL (P = .033). For HIKE, the contrast
to compare the EMG signals among the GTA index: {[(GMED/TFL) × GMED] + tests revealed that the normalized EMG
muscles of interest for each exercise. [(SUP-GMAX/TFL) × SUP-GMAX]}/2. amplitude for the GMED was not signifi-
As the purpose of this study was to as- The GTA index is similar in principle cantly different from the TFL (P = .196);
sess the difference between each of the to activation indexes created for other however, the SUP-GMAX was signifi-
gluteal muscles and the TFL within muscle combinations to assess muscle cantly less than the TFL (P = .001).
each exercise, specific paired compari- activation relationships (eg, cocontrac- Five exercises demonstrated a GTA
sons among the muscles were planned a tion of muscles crossing the knee during index of at least 50: CLAM, SIDESTEP,
priori. Therefore, if the 1-way ANOVAs running and cutting maneuvers3). Given UniBRG, QKE, and QKF. In contrast, the
revealed a significant difference in EMG the GTA index equation, an exercise with 6 remaining exercises exhibited a GTA
signal among the muscles for a given ex- a high GTA index would be one in which index of less than 40: ABD, STEP-UP, Bi-
ercise, simple contrast tests were used to there were high normalized EMG ampli- BRG, SQUAT, HIKE, and LUNGE. The
analyze the paired comparisons, with the tudes of both gluteal muscles, and both of ranking of exercises using the GTA index
TFL as the reference for comparison (ie, these amplitudes were higher compared is displayed in TABLE 2.
each gluteal muscle was compared to the to the TFL amplitude. In contrast, an
TFL). The alpha level was .05 for all tests exercise could produce higher EMG am- DISCUSSION
of significance. plitudes of the gluteal muscles relative
T
The gluteal-to-TFL muscle activation to the TFL but at the same time produce he purpose of the current in-
(GTA) index, a novel descriptive analysis, relatively low EMG amplitudes overall. vestigation was to compare the
was performed to quantify the combined In this instance, the GTA index would be EMG signal amplitudes of the hip
relative activation of the gluteal muscles considerably lower. abductor muscles during selected thera-
journal of orthopaedic & sports physical therapy | volume 43 | number 2 | february 2013 | 57
skeletal disorders in which excessive hip EMG amplitudes of the TFL also were recommendations is the actual normal-
internal rotation may be a contributing observed during both of these exercises. ized EMG amplitude levels of the muscles
factor. During ABD, the GMED was significantly during the different exercises. Of the 7
The results of the ANOVA and con- more active than the TFL; however, there exercises in which both gluteal muscles
trast tests demonstrated that the majority was no statistically significant differ- showed significantly greater EMG am-
of the exercises evaluated preferentially ence between these 2 muscles for HIKE. plitude than the TFL, the BiBRG and
activated the gluteal muscles while limit- Nonetheless, activity of the TFL was sig- SQUAT produced relatively low normal-
ing recruitment of the TFL. These exer- nificantly greater than that of the SUP- ized EMG amplitudes of both the GMED
cises included the QKF, QKE, UniBRG, GMAX in both exercises. Our findings for and SUP-GMAX. For example, the nor-
BiBRG, SQUAT, SIDESTEP, and CLAM. the ABD exercise are also in agreement malized EMG amplitude levels of all the
All of these exercises produced greater with the surface EMG study of McBeth tested muscles in the BiBRG exercise
than 50% higher normalized EMG am- et al,29 who reported that the GMED had were approximately half of those in the
plitudes for both gluteal muscles com- significantly greater activity than the TFL UniBRG. During the SQUAT exercise,
pared to the TFL. During ABD, only the and that the TFL had significantly greater the gluteal muscles demonstrated even
GMED exhibited significantly greater activity than the GMAX. lower normalized EMG amplitudes. As
normalized EMG amplitude than the The normalized EMG amplitude such, we developed the GTA index to bet-
TFL. For the STEP-UP, LUNGE, and for the SUP-GMAX was highest in the ter characterize exercises based on their
HIKE, normalized EMG amplitudes of CLAM exercise and second highest in ability to preferentially activate the glu-
the gluteal muscles and the TFL were UniBRG. This finding may be attributed teals relative to the TFL, while exhibiting
not statistically different, with the excep- to the fact that these exercises incor- high normalized EMG amplitudes.
tion of the SUP-GMAX, which exhibited porate greater amounts of hip external Of the exercises examined, the CLAM,
lower normalized EMG amplitude com- rotation and extension compared to the SIDESTEP, UniBRG, QKE, and QKF ex-
pared to the TFL during HIKE. other exercises evaluated. Both the SUP- ercises had GTA index values of 50 or
The greatest normalized EMG am- GMAX and the GMED had significantly greater (TABLE 2). These exercises would,
58 | february 2013 | volume 43 | number 2 | journal of orthopaedic & sports physical therapy
of the parametric statistical testing (ex- ing activation of the TFL. means of rating exercises based on rela-
cept for the 2 exercises with high relative The BiBRG and SQUAT exercises tive gluteal-to-TFL muscle activity un-
activation ratios but low signal ampli- would have been considered favorable less it has been calculated only for those
tudes and, therefore, low GTA indexes). based on the results of the ANOVAs exercises in which both gluteal muscles
In addition, these 5 exercises produced and contrast tests, as well as the relative demonstrated a normalized EMG ampli-
EMG signal amplitudes greater than activation ratios of the gluteals to the tude significantly greater than that of the
25% MVIC for each of the gluteals and TFL. However, these exercises were in TFL. Based on the framework presented
less than 20% MVIC for the TFL. the lower tier of the GTA index ranking earlier, a desirable exercise would be one
The CLAM had the highest SUP- (TABLE 2). This was the result of low nor- in which the normalized EMG ampli-
GMAX normalized EMG amplitude and malized EMG amplitudes of the gluteal tude of both the GMED and SUP-GMAX
one of the lowest TFL amplitudes of all muscles during these exercises. The rela- muscles was greater than that of the TFL.
the exercises examined. These factors tively low GTA index values for each of A limitation of the current study is
Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
contributed to its having the highest GTA these 2 exercises call into question their that the CLAM and SIDESTEP exercises
index. This finding is consistent with the usefulness for rehabilitation purposes used elastic resistance that was not quan-
fact that the CLAM requires more hip when the training favors higher activa- tified in absolute or relative terms. Also,
external rotation and abduction than the tion levels. If the BiBRG and SQUAT it is possible that without the added re-
other exercises. In addition, it was 1 of 2 were performed with greater resistive sistance, these exercises would have had
exercises performed with external resis- loads, it is likely that their GTA indexes lower normalized EMG amplitudes and
tance (elastic tubing). The SIDESTEP would increase, as would the activity GTA indexes. However, as with BiBRG
had one of the lowest TFL normalized levels of all of the muscles with greater and SQUAT, it appears that any exercises
EMG amplitudes, which contributed to resistive loads; however, the relative ac- that were beneficial, based on the relative
Journal of Orthopaedic & Sports Physical Therapy®
its having the second highest GTA index. tivation ratios would not be expected activation of the gluteal muscles to the
The SIDESTEP was performed in a squat to change as long as the exercises were TFL, but had a less desirable GTA index
position with elastic tubing around the properly performed. Such an increase in because of overall low actual activation
distal thighs, and both the position and activation of the gluteal muscles with no might become desirable (achieve higher
resistance might have augmented acti- change in relative activation ratios would, GTA indexes) by increasing the applied
vation of the gluteals. Cambridge et al9 by definition (see equation), cause the resistance. It should also be noted that
studied a similar exercise and reported GTA index to increase. this study was performed on a sample of
that the TFL had lower surface EMG TABLE 2 presents the tested exercises healthy, uninjured individuals. Whether
signal amplitude than the GMED but in descending order of magnitude of the findings may be generalized to specific
greater amplitude than the GMAX. This the GTA index, illustrating how the patient populations remains to be seen. In
is contrary to our findings, in which the GTA index could be used to make rec- addition, we did not quantify activation of
TFL had significantly lower EMG signal ommendations for therapeutic exercise the gluteus minimus, which represents ap-
amplitudes than both the GMED and prescription. However, the GTA index proximately 20% of the total hip abductor
SUP-GMAX. However, Cambridge et al9 should be used with caution and in com- cross-sectional area. Based on its origin
did not perform statistical comparisons bination with the results of the inferen- and insertion, however, there is no reason
among the muscles, nor did they specifi- tial statistics, as well as an assessment to suspect that activation of the gluteus
cally assess the SUP-GMAX. Thus, it is of the relative activation of both gluteal minimus for any of the exercises evaluated
not possible to accurately determine the muscles to the TFL. The reason for this would differ from that of the GMED.
nature of the relationships among the qualification is that the GTA index can
muscles in their study and compare the be artificially high even if the TFL EMG CONCLUSIONS
2 studies. signal amplitude is relatively high. This
I
The ABD, STEP-UP, HIKE, and could be so if the EMG amplitude of one f the goal of rehabilitation is to
LUNGE exercises produced GTA indexes of the gluteal muscles were low while that preferentially activate the gluteal mus-
less than 40 (TABLE 2). In addition, these of the other were high relative to the am- cles while minimizing TFL activation,
journal of orthopaedic & sports physical therapy | volume 43 | number 2 | february 2013 | 59
jospt.2005.2066 19. Heinert BL, Kernozek TW, Greany JF, Fater DC.
KEY POINTS 7. Bolgla LA, Uhl TL. Reliability of electromyo- Hip abductor weakness and lower extremity
FINDINGS: The GMED and SUP-GMAX graphic normalization methods for evaluating kinematics during running. J Sport Rehabil.
muscles were significantly more active the hip musculature. J Electromyogr Kinesiol. 2008;17:243-256.
2007;17:102-111. http://dx.doi.org/10.1016/j. 20. Hewett TE, Myer GD, Ford KR, et al. Biomechani-
than the TFL in UniBRG and BiBRG,
jelekin.2005.11.007 cal measures of neuromuscular control and val-
QKF and QKE, CLAM, SIDESTEP, and 8. Boudreau SN, Dwyer MK, Mattacola CG, Lat- gus loading of the knee predict anterior cruciate
SQUAT. The GTA index was highest for termann C, Uhl TL, McKeon JM. Hip-muscle ligament injury risk in female athletes: a prospec-
the CLAM, SIDESTEP, UniBRG, and activation during the lunge, single-leg squat, tive study. Am J Sports Med. 2005;33:492-501.
and step-up-and-over exercises. J Sport Rehabil. http://dx.doi.org/10.1177/0363546504269591
both quadruped exercises.
2009;18:91-103. 21. Hodges PW, Bui BH. A comparison of computer-
IMPLICATIONS: If the goal of rehabilitation 9. Cambridge ED, Sidorkewicz N, Ikeda DM, McGill based methods for the determination of onset
is to preferentially activate the gluteal SM. Progressive hip rehabilitation: the effects of of muscle contraction using electromyogra-
muscles while minimizing TFL activa- resistance band placement on gluteal activation phy. Electroencephalogr Clin Neurophysiol.
Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
ACKNOWLEDGEMENTS: We thank Dr Lucinda Variation of rotation moment arms with hip flex- kinematics and contact pattern. J Orthop Res.
Baker, PT, PhD, for her consultation on the ion. J Biomech. 1999;32:493-501. 2000;18:101-108. http://dx.doi.org/10.1002/
EMG analysis, and Mr Jess Lopatynski for his 13. Dierks TA, Manal KT, Hamill J, Davis IS. Proximal jor.1100180115
and distal influences on hip and knee kinemat- 25. Leinonen V, Kankaanpää M, Airaksinen O, Hän-
assistance with the photography.
ics in runners with patellofemoral pain during ninen O. Back and hip extensor activities during
a prolonged run. J Orthop Sports Phys Ther. trunk flexion/extension: effects of low back pain
2008;38:448-456. http://dx.doi.org/10.2519/ and rehabilitation. Arch Phys Med Rehabil.
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MSS.0000043608.79537.AB jospt.2010.3028 runners. J Athl Train. 2012;47:15-23.
4. Bogey RA, Perry J, Bontrager EL, Gronley JK. 17. Fukuda TY, Rossetto FM, Magalhães E, Bryk FF, 30. Merican AM, Amis AA. Anatomy of the lat-
Comparison of across-subject EMG profiles Lucareli PR, de Almeida Aparecida Carvalho N. eral retinaculum of the knee. J Bone Joint
using surface and multiple indwelling wire Short-term effects of hip abductors and lateral Surg Br. 2008;90:527-534. http://dx.doi.
electrodes during gait. J Electromyogr Kinesiol. rotators strengthening in females with patel- org/10.1302/0301-620X.90B4.20085
2000;10:255-259. lofemoral pain syndrome: a randomized con- 31. Merican AM, Amis AA. Iliotibial band tension af-
60 | february 2013 | volume 43 | number 2 | journal of orthopaedic & sports physical therapy
@ MORE INFORMATION
clinbiomech.2007.07.001 dx.doi.org/10.2519/jospt.2007.2439
Journal of Orthopaedic & Sports Physical Therapy®
38. Perry J. The contribution of dynamic electromy- 45. Solomonow M, Baratta R, Bernardi M, et al.
ography to gait analysis. In: DeLisa JA, ed. Gait Surface and wire EMG crosstalk in neighbouring WWW.JOSPT.ORG
APPENDIX
journal of orthopaedic & sports physical therapy | volume 43 | number 2 | february 2013 | 61
the tested limb on top of the other limb. The subject’s back
and plantar surface of the foot were placed against the wall for
control of position and movement. The subject raised the tested
limb’s knee up off the other limb, such that the hip was in 30° of
abduction, before returning to the starting position while keep-
ing both heels in contact with each other and the wall. Subjects
performed this activity with blue-colored Thera-Band (The Hy-
genic Corporation, Akron, OH) tubing around the distal thighs,
with no stretch or slack on the tubing prior to raising the limb.
The elastic resistance was used because the motion involved is
a multiplanar arc that is only minimally resisted by gravity.
Bilateral bridge Starting position was hook-lying with the knees at 90° of flexion,
hips at 45° of flexion, 0° of rotation and abduction, trunk in
Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
neutral, and feet flat on the table. The subject then pushed both
feet into the table to raise the pelvis until a position of 90° of
knee flexion was achieved bilaterally before returning to the
starting position. The hips remained at 0° of rotation and ab-
duction during the exercise, with the trunk in neutral.
Unilateral bridge Starting position was unilateral hook-lying, as that described
for the bilateral bridge, except that the nontested lower limb
remained on the table (0° at the hip and knee). The subject
then pushed with the tested limb’s foot into the table to raise
the pelvis until a position of 90° of knee flexion was achieved
ipsilaterally, before returning to the starting position. The non-
Journal of Orthopaedic & Sports Physical Therapy®
tested lower limb moved up and down with the pelvis, without
changing the positions of its joints. The hips remained at 0° of
rotation and abduction during the exercise, with the pelvis and
trunk in neutral.
Hip extension in quadruped Starting position was quadruped, with the upper body supported
on elbows with knee by the elbows and forearms, and the knees and elbows at ap-
extending proximately 90° of flexion. The subject then lifted the tested
lower limb up and backward, extending the hip and knee to 0°,
and then returned to the starting position.
Hip extension in quadruped This exercise was performed in the same manner as described for
on elbows with knee quadruped with knee extending, except that the subject main-
flexed tained the knee in 90° of flexion throughout the exercise.
62 | february 2013 | volume 43 | number 2 | journal of orthopaedic & sports physical therapy
Squat Starting position was standing with the knees and hips at 0° in the
sagittal plane, with slight hip external rotation, such that the
feet/toes pointed laterally from midline approximately 15°. The
Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
distance between the feet in the coronal plane was two thirds
of the length from the greater trochanter to the floor (measured
in the erect standing position), so that the hips were in slight
abduction. Subjects then squatted so that the knees and hips
were at approximately 90° of flexion, with the knees moving in
a direction parallel to the toes (ie, over the second toe of the
ipsilateral limb).
Journal of Orthopaedic & Sports Physical Therapy®
Sidestep with elastic resis- Starting position was in a squatted position, as described above
tance around the thighs for the squat. The subject then stepped to the side with one
in a squatted position limb, followed in the same direction by the other limb, both step
lengths approximately 50% of the starting-position distance
between the feet (see squat). Knees were kept aligned with the
ipsilateral second toe. If a sidestep with each limb in succession
was considered a stride, then the subject performed a total of 2
strides in one direction, followed by 2 strides in the opposite di-
rection to return to the starting position. This activity cycle was
performed a total of 3 times. The same method of elastic resis-
tance was used in this exercise as in the clam exercise, because
there was otherwise little resistance to the sideways movement.
journal of orthopaedic & sports physical therapy | volume 43 | number 2 | february 2013 | 63
Forward step-up Starting position was with the foot of the tested limb on a step, at
Journal of Orthopaedic & Sports Physical Therapy®
64 | february 2013 | volume 43 | number 2 | journal of orthopaedic & sports physical therapy
1. Bryan Heiderscheit, Shane McClinton. 2016. Evaluation and Management of Hip and Pelvis Injuries. Physical Medicine
and Rehabilitation Clinics of North America 27, 1-29. [CrossRef]
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4. Simon Lack, Christian Barton, Oliver Sohan, Kay Crossley, Dylan Morrissey. 2015. Proximal muscle rehabilitation is
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Isometric Hip Contraction on Gluteus Medius and Tensor Fasciae Latae Activity During Squat Exercises. Physical Therapy
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Weakness and Healthy Subject. Journal of the Korean Society of Physical Medicine 10, 71-82. [CrossRef]
11. Adam I. Semciw, Rachel Neate, Tania Pizzari. 2014. A comparison of surface and fine wire EMG recordings of gluteus
medius during selected maximum isometric voluntary contractions of the hip. Journal of Electromyography and Kinesiology
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12. Natalie Sidorkewicz, Edward D.J. Cambridge, Stuart M. McGill. 2014. Examining the effects of altering hip orientation on
gluteus medius and tensor fascae latae interplay during common non-weight-bearing hip rehabilitation exercises. Clinical
Biomechanics 29, 971-976. [CrossRef]
13. Edward P. Mulligan, Emily F. Middleton, Meredith Brunette. 2014. Evaluation and management of greater trochanter
pain syndrome. Physical Therapy in Sport . [CrossRef]
14. So-Young Kim, Suhn-Yeop Kim, Hyun-Jeong Jang. 2014. Effects of Manual Postural Correction on the Trunk and Hip
Muscle Activities During Bridging Exercises. Physical Therapy Korea 21, 38-44. [CrossRef]
15. Yun-Chan Oh, Heon-Seock Cynn, Chung-Hwi Yi, Hye-Seon Jeon, Tae-Lim Yoon. 2014. Effect of Hip External Rotation
Angle on Pelvis and Lower Limb Muscle Activity During Prone Hip Extension. Physical Therapy Korea 21, 1-10.
[CrossRef]
16. Ji-hyun Lee, Heon-Seock Cynn, Oh-Yun Kwon, Chung-Hwi Yi, Tae-Lim Yoon, Woo-Jeong Choi, Sil-Ah Choi. 2014.
Different hip rotations influence hip abductor muscles activity during isometric side-lying hip abduction in subjects with
gluteus medius weakness. Journal of Electromyography and Kinesiology 24, 318-324. [CrossRef]
17. Melinda M Franettovich Smith, Sonia S Coates, Mark W Creaby. 2014. A comparison of rigid tape and exercise, elastic tape
and exercise and exercise alone on pain and lower limb function in individuals with exercise related leg pain: a randomised
controlled trial. BMC Musculoskeletal Disorders 15, 328. [CrossRef]
18. A. Rambaud, R. Philippot, P. Edouard. 2013. La prise en charge rééducative globale de patients présentant un syndrome
fémoro-patellaire : la lutte contre l’effondrement du membre inférieur par le renforcement du moyen fessier. Journal de
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19. Philip Malloy, Molly Malloy, Peter Draovitch. 2013. Guidelines and pitfalls for the rehabilitation following hip arthroscopy.
Current Reviews in Musculoskeletal Medicine 6, 235-241. [CrossRef]
20. Emma L. Willcox, Adrian M. Burden. 2013. The Influence of Varying Hip Angle and Pelvis Position on Muscle
Recruitment Patterns of the Hip Abductor Muscles During the Clam Exercise. Journal of Orthopaedic & Sports Physical
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Downloaded from www.jospt.org at China Medical University on January 19, 2016. For personal use only. No other uses without permission.
Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Journal of Orthopaedic & Sports Physical Therapy®