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Strength and torque consistency of the hip and knee flexors and extensors: A
comparative study of elderly and young individuals

Article  in  Isokinetics and Exercise Science · March 2015

DOI: 10.3233/IES-140563

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Isokinetics and Exercise Science 23 (2015) 45–51 45
DOI 10.3233/IES-140563
IOS Press

Strength and torque consistency of the hip and

knee flexors and extensors: A comparative
study of elderly and young individuals
Viviane Santos Borgesa , João Marcos Dominguesa, Rosângela Corrêa Diasa ,
Patrícia Azevedo Garciaa and Zeevi Dvirb,∗
a
Department of Physical Therapy, Universidade Federal of Minas Gerais, Belo Horizonte, Brazil
b
Department of Physical Therapy, Sackler Faculty of Medicine, Tel Aviv University, Israel

Received 1 August 2014

Accepted 8 October 2014

Abstract.
OBJECTIVES: To assess the strength of the flexors and extensors of the knee and hip joints in elderly and in young individuals.
METHODS: A group of elderly women (N = 47) and men (N = 44) aged 65 and older and a group of young women (N = 15)
and men (N = 15) aged between 20 and 30 years were tested for the isokinetic strength of the hip and knee flexors and extensors.
RESULTS: A typical age-related decrease in the strength of all tested muscles was observed but the decline in hip muscles
strength, compared to those of the knee, was significantly lower, by about 10%. Moreover, women presented a significantly
better strength preservation than men. The consistency of performing the repeated isokinetic efforts was higher, in some instances
significantly so, in the older (range: 4.4–11%) than in the younger (3.5–6.3%) individuals but the differences do not seem to
convey any clinical significance.
CONCLUSION: These findings enable clinicians to set valid rehabilitation goals, particularly with respect to hip dysfunction in
the elderly. Furthermore, healthy elderly individuals perform maximal isokinetic tests with substantially similar degree of gross
motor control compared to that of young individuals.

Keywords: Muscle strength, hip, knee

1. Introduction the as the muscles of the lower extremities are con-

One of the major implications of the continuous
increase in life expectancy is the greater prevalence
in, and incidence of, chronic degenerative diseases [1,
2]. Muscles are adversely affected by old age, a phe-
nomenon that is expressed by deterioration in the mus-
cle mechanical output. This acquired/adaptive weak-
ness, associated with a loss and a reduced in muscle
mass (sarcopenia) is of particular concern as far as
∗ Corresponding author: Zeevi Dvir, Department of Physical Ther-
apy, Sackler Faculty of Medicine, Tel Aviv University, 69971, Is-
rael. Tel.: +972 528364476; Fax: +972 36409223; E-mail: zdvir@
post.tau.ac.il.
cerned as it may eventually lead to difficulties in gait
and maintenance of balance [3,4]. Thus, availability of
reference strength values in the elderly is crucial for
assessing muscular status and change due to interven-
tion [5,6].
Among the major muscle groups comprising the
lower extremity, the knee extensors have attracted most
attention. Conspicuously less attention was given to
the muscles comprising the hip and ankle complex, as
for the hip muscles, those operating substantially in
the sagittal plane have a special significance in gait
and balance. The hip flexors are essential for initiating
the swing phase in gait and contribute to hip strategy
in preventing forward falling while the hip extensors

ISSN 0959-3020/15/$35.00 
c 2015 – IOS Press and the authors. All rights reserved
46 V.S. Borges et al. / Hip and knee strength in old and young people
synergize with the knee extensors in the execution of
‘closed kinetic chain’ actions [7,8]. However a litera-
ture survey revealed a clear dearth in terms of the effect
of age on the strength of these muscles.
Another aspect that is relevant to muscle force pro-
duction is the consistency of its reproduction upon re-
peated contractions. Inconsistency can be quantified
by the coefficient of variation: CV = (SD/Mean)*100
where the mean refers to the mean value of a number of
repeated contractions obtained within one test session.
The CVs of strength scores derived from various dy-
namometric techniques have been calculated, all indi-
cating that a normal measure of consistency is between
2–10% [9,10]. Values higher than that may indicate the
involvement of factors such as fatigue, pain, cognitive
impairment and/or reduced compliance but age may be
another factor.
Therefore, the objective of this study was twofold:
first, to examine the extent of absolute and relative
weakness of the knee and hip flexors and extensors
in elderly compared to young individuals, using isoki-
netic dynamometry. The other objective was to find out
whether the consistency of performing a set of maxi-
mal effort contractions was impaired in elderly com-
pared to young individuals.
2. Method
2.1. Subjects
Two groups, one consisting of apparently healthy,
elderly individuals (47 women and 44 men, Group-
O), and another consisting of apparently healthy young
individuals (15 women and 15 men, Group-Y) took
part in the study. Group-O participants were conve-
niently sampled from the community. The eligibility
criteria included: age > 65 years, community residents
and able to ambulate without assistive devices. Sub-
jects were excluded if they had uncontrolled cardiores-
piratory diseases, neurological diseases, balance prob-
lems, disabling musculoskeletal disorders, referred hip
or knee pain, limitation of range of motion in the hip
and/or knee joints, presence of cognitive impairment
assessed by the Mini-Mental State Exam [11] or hav-
ing undergone surgery in the lower limbs or lumbar
spine. Group-Y participants were conveniently sam-
pled from staff and students of the Universidade Fed-
eral de Minas Gerais. The eligibility criteria included:
healthy subjects aged between 20 and 30 years. The
exclusion criteria for this group were the same as those
applied for the elderly except for the cognitive screen-
ing. This study was approved by the Universidade Fed-
eral de Minas Gerais Ethics Committee (ETIC 647/08).
All participants gave written informed consent.
2.2. Instrumentation
A Biodex System 3 Pro R
(Biodex Medical Systems
Inc., Shirley, NY, USA) isokinetic dynamometer was
used for the strength analysis.
2.3. Procedure
Warm-up preceded all isokinetic tests and consisted
of at least 5-min of level walking at the subject’s pre-
ferred comfortable speed on a treadmill. Testing started
with the knee muscles with the subject positioned in
sitting and the back inclined at 95◦ relative to the seat.
The test range of motion was adjusted to cover 85◦ :
5◦ to 90◦ of knee. Prior to the test, participants per-
formed a familiarization bout of three submaximal rep-
etitions at the test angular speed. The test was then ini-
tiated with the dominant side. Five reciprocal repeti-
tions of concentric knee extension-flexion movements
were first assessed at 60◦ /s. Following a 2-min inter-
speed break the test was repeated at 180◦ /s using 15 re-
ciprocal repetitions. During the tests, standardized ver-
bal encouragement was given to ensure maximal coop-
eration [12].
Testing of the hip flexors and extensors then fol-
lowed taking place in the functional standing, weight-
bearing position and using a dedicated adjustable sta-
bilization frame [12,13]. For alignment of the mechan-
ical axis of the dynamometer, hip joint axis was con-
sidered to pass through the greater trochanter. The test
range of motion was adjusted to cover 60◦ : 0◦ (upright
standing) to 60◦ (hip flexion). Similar familiarization
bouts were allowed. Testing comprised reciprocal flex-
ion and extension movements at 60◦ /s (5 repetitions)
and at 120◦ /s (15 repetitions).
2.4. Data analysis
The values of the peak torque (PT) were expressed
as mean(SD) in Nm. The statistical analysis was per-
formed using SPSS, Version 15.0. The normality of
distribution was assessed using the Shapiro-Wilk test.
Independent t tests and Mann-Whitney U-Test were
used to assess the differences between groups. The
Wilcoxon Test was used to evaluate the differences be-
tween the hip and knee muscles within the same group.
Significance was accepted at α = 0.05.
 V.S. Borges et al. / Hip and knee strength in old and young people 47

Table 1
Group characteristics according to gender
Characteristic Old group (n = 91) Young group (n = 30)
Women (n = 47) Men (n = 44) Women (n = 15) Men (n = 15)
Age (yr) 74.4 (7.3) 74.8 (6.4) 23.6 (2.9) 22.9 (2.2)
Body Mass (kg) 65.8 (12.2) 74.2 (12.6) 62 (11.2) 76.6 (11.9)
BMI (Kg/m2 ) 27.5 (4.6) 26.7 (3.7) 23.5 (3.3) 24.2 (2.8)
Values expressed as mean (SD).

Table 2
Mean (SD) of the Peak Torque (in Nm) for men and women divided by group
Old group (n = 91) Young group (n = 30)
Peak torque (PT) Women (n = 47) Men (n = 44) Women (n = 15) Men (n = 15)
K-E 60◦ /s 83.2 (24.0) 127.0 (35.2) 134.2 (25.0)∗ 244.7 (48.2)∗
K-F 60◦ /s 37.5 (11.6) 56.3 (19.0) 59.0 (16.0)∗ 113.6 (21.7)∗
K-E 180◦ /s 51.0 (14.4) 82.2 (22.0) 83.0 (15.0)∗ 157.9 (29.8)∗
K-F 180◦ /s 38.0 (9.3) 54.6 (13.9) 51.3 (11.4)∗ 90.76 (11.9)∗
H-F 60◦ /s 70.8 (23.8) 99.7 (28.8) 94.7 (15.8)∗ 161.9 (30.0)∗
H-E 60◦ /s 54.3 (25.2) 85.5 (34.8) 83.6 (30.5)∗ 155.0 (40.0)∗
H-F 120◦ /s 68.3 (21.8) 103.6 (30.2) 91.0 (20.5)∗ 147.8 (22.7)∗
H-E 120◦ /s 54.2 (22.2) 79.5 (31.2) 72.0 (18.4)† 143.0 (36.5)∗
Abbreviations: K-knee, H-hip, F-flexion, E-extension. ∗ Denotes significant difference at P = 0.000
and † denotes significant difference at P = 0.005 using Mann Whitney test.

Table 3
3. Results Percent reduction in strength in the old vs. the young group

Group-O consisted of individuals residing in the city Women Men

of Belo Horizonte. The majority was retired and mar- K-E 60◦ /s 38 (18) 48 (14)∗
K-F 60◦ /s 37 (20) 50 (17)∗
ried. Most of the participants in this group were not K-E 180◦ /s 39 (17.3) 48 (14)∗
involved in any regular physical activity. Participants’ K-F 180◦ /s 29 (13.6) 40 (15)∗
characteristics are outlined separately for gender and H-F 60◦ /s 25 (25) 38 (18)∗
group in Table 1. H-E 60◦ /s 35 (30) 45 (22.4)
Table 2 outlines the respective PT values for the H-F 120◦ /s 25 (24) 30 (20.4)
H-E 120◦ /s 25 (31) 44 (22)∗
groups. The tests revealed that the knee and hip mus-
Values expressed as mean (SD). ∗ Denotes significant difference at
cles of the younger subjects were significantly stronger P = <0.02 using Mann Whitney test.
in all test conditions compared to their older counter-
parts. The extent of the difference between the groups
4. Discussion
is also highlighted in relative terms (Table 3) where
for each test condition the relative reduction was cal-
The fact that muscle strength in old individuals is
culated from the data in Table 2 using the formula
significantly lower than that of young individuals is not
(‘woman’ stands also for a ‘man’): 100- [(PT of an in-
dividual O woman)/mean PT of Y women)]*100. The new; past research has repeatedly supported this find-
highly significant inter-group difference (p = 0.002) ing using different muscle groups [14,15], contraction
indicates that elderly Brazilian women suffer less from modes [16,17], strength indicators and testing tech-
strength loss of lower extremity muscles (approxi- niques [8,13,18].
mately 32%) compared to their male counterparts (ap- However since the current study is basically a com-
proximately 43%) It is also evident that the strength of parative one, an essential step in interpreting the find-
the hip muscles was better preserved than that of the ings was to ensure that the values obtained were indeed
knee muscles, by a gender symmetrical margin of 9%. compatible with previous studies in order to render the
This finding was significant in both women and men results as generalized as possible. This comparison was
(p = 0.00). easier to carry out with respect to knee flexors and ex-
Table 4 relates to the consistency of performance. tensors but much more limited as far as their hip coun-
Considering the 16 gender-conditions pairs, the CVs in terparts were concerned. In terms of knee muscles,
14 were higher in the elderly compared to the young a reliable source is a study which tested non-athletic
participants. women and men with an age span of 20–70 y [19].
48 V.S. Borges et al. / Hip and knee strength in old and young people

Table 4
CV scores by group/gender and pooled gender (in %)
Test Group O Group Y
Women Men Pooled Women Men Pooled
K-E 60◦ /s 4.4 (2.7) 4.8 (2.9) 4.6 (2.8) 4.4 (1.8) 4.1 (1.8) 4.2 (1.7)
K-F 60◦ /s 7.3 (5.8) 5.9 (3.9) 6.6 (4.9) 5.5 (3.8) 3.8 (1.5) 4.7 (3.0)
K-E 180◦ /s 6.0 (2.4) 6.2 (2.7) ND 6.2 (1.8) 4.8 (1.5)* ND
K-F 180◦ /s 8.3 (5.5) 7.5 (4.9) 7.9 (5.2) 5.2 (2.2) 4.9 (2.9) 5.1 (2.5)‡
H-F 60◦ /s 6.2 (3.6) 4.8 (3.9)† ND 4.7 (1.8) 3.5 (1.4) ND
H-E 60◦ /s 8.9 (6.5) 10.7 (7.2) 9.8 (6.8) 6.3 (2.5) 5.9 (3.3) 6.1 (2.9)‡
H-F 120◦ /s 5.8 (3.7) 5.4 (2.7) 5.6 (3.1) 4.9 (1.9) 3.8 (1.8) 4.4 (1.9)§
H-E 120◦ /s 9.3 (5.8)† 11.1 (4.9)† ND 5.7 (2.2) 6.3 (2.1) ND
∗ Denotes significant difference within group/between gender differences at P = 0.05, † P = 0.02 and ‡ denotes significant difference between
group at P = 0.01 and at § P = 0.05 using Mann Whitney and Independent t tests. ND (no data).

The test velocities comprised a nearly isometric mode
(12◦ /s) as well as the mid-spectrum of 90 and 150◦ /s.
Using the 90◦ /s to compare with the present study
60◦ /s, the mean PT for KE in third decade women and
men was 143 and 231 Nm, respectively while for KF
the respective PTs were 68 and 122 Nm. Extrapolat-
ing these values could increase by some 5–10% as in-
dicated by the 20+% increase in scores derived from
the tests performed at 12◦ /s. The respective mean PTs
for the test conducted at 150◦/s were 74, 180, 49, and
96 Nm. Given the variations (dynamometer, test ve-
locities etc.) the current results are very similar to the
above scores.
Testing of hip flexion and extension strength in the
standing position has been reported in an often quoted
study [13]. For young subjects (21–40 y) the mean
PT in flexion at 30 and 90◦ /s were 152 and 126 Nm,
respectively, for men and 91 and 76 Nm for women.
For extension, the respective values were 177, 163, 110
and 97 Nm, respectively. In terms of flexion strength
the findings for the lower velocities correlate well with
the present results. Extension strength values were
lower in the present study, by some 10–20%, possi-
bly reflecting the correction to gravitational effect and
thus the net moment. In a recent study of male ath-
letes, the standing position was used for testing 4 hip
muscle groups [20]. The mean PT in flexion at 30 and
90◦ /s were 172 and 151 Nm whereas those for exten-
sion were 155 and 130 Nm, respectively. Intrapolating
for 60◦ /s these values are in close agreement with the
current values.
Focusing on the elderly population, there is a num-
ber of studies relating to knee musculature. Of partic-
ular relevance to the current investigation is the one by
Goodpaster et al. (2001) in which knee extension con-
centric isokinetic strength was measured at 60◦ /s in an
elderly cohort (70–79 y) comprising 1342 women and
1285 men [21]. The mean PT for all women was 81 Nm
while for all men it was 132 Nm. In a later study some
1800 elderly (70–79 y) individuals were tested using
the same strength measurement protocol, the mean PTs
were 83 Nm in women and 135.6 Nm in men [22].
In another study which tested knee extension at 60◦ /s,
the mean PTs for men 60–69 yr (N = 278) and 70+
(N = 273) were 144 and 109 Nm, respectively while
for women the respective values were 87 (N = 263)
and 79 Nm (N = 252) [16]. As the age groups were
roughly of the same size, the mean value for the men’s
group was 126 Nm and for women 78 Nm. The present
mean PT scores for concentric KE at 60◦ /s were 83 and
127 Nm in women and men, respectively.
Knee flexion strength has been studied far less thor-
oughly in older population. One study that is of rele-
vance, related to a cohort of 47 women (mean age 65
y) [23]. The mean PT was 52 Nm which should be
compared with the current score of 37.5 (11.6) Nm.
Also, the rise in KF/KE ratio from around 0.45 to 0.8
is very consistent with the literature [12].
Regarding hip flexors (HF) and extensors (HE)
strength in elderly individuals, an important study
where the testing was conducted in the upright position
is by Cahalan et al. [13]. For subjects aged 41–80 y,
and hence somewhat closer to the present study’s ‘old’
group, the mean flexion PT at 30 and 90◦ /s were 113
and 84 Nm, respectively, for men and 67 and 46 Nm
for women. For extension, the respective values were
157, 132, 101 and 70 Nm. Intrapollating between 30
and 90◦ /s the estimated PT for flexion in men could be
around 99 Nm and for women around 56 Nm. For ex-
tension, these values could respectively be around 144
and 85 Nm, for men and women. The large discrepan-
cies, particularly in hip extension strength could be due
to the gravitational correction procedure than was not
performed in the Cahalan et al. study and is quite con-
siderable given the weight of the lower extremity. On
the other hand there is a very good compatibility with
 V.S. Borges et al. / Hip and knee strength in old and young people
the flexion PT in men although the present finding in
women were about 20% higher than those mentioned
in the above study. To conclude this part of the Discus-
sion, both the old and young participants who took part
in this study had knee and hip flexion and extension
strength scores that are well within the reported range
of strength scores in terms of their age group and thus
the findings are externally validated.
This study joins a long series of previous studies
attesting to a significant decline of muscle strength
with age, a phenomenon that has been related to sar-
copenia coupled with increasing disuse. Various rates
of strength decline/decade have been reported, relat-
ing specifically to knee extensor function. One study
has suggested a 12–15%/decade reduction in knee ex-
tension PT relative to a plateau that has been reached
around the fifth decade [24] while in another study, the
fourth decade served as the reference while the rate of
decline was 8–10%/decade [25]. Using the age of 20
as a baseline reported a linear decline of knee muscles
strength with a rate of 12%/decade for knee flexors and
extensors in men and 8% for women, respectively, had
been reported [26]. Of note, as far as the concentric
strength is considered, women and men presented with
nearly identical relative decline in strength of around
33%.
The findings related to the decline in hip muscles
strength can be compared to those derived by Caha-
lan et al. [13]. In this study, the separation between
young and old was not acute; the age groups (young
and old) touched each other at 40. For the concentric
hip flexion strength the decline in women and men (ve-
locities pulled) was the same – 30%. However, much
smaller rates were reported for hip extension strength:
18% and 16%, in women and men respectively. In the
present study, these rates were largely similar in flex-
ion: 25% and 34% in women and men, respectively, but
somewhat higher in extension: 30% (w) and 45% (m).
Since the decline in flexion strength is largely symmet-
rical in the two studies, and as both investigations have
used standing as the test position, the poor age separa-
tion and failure to incorporate a correction procedure
for gravitational effect could play a role in the former
study’s outstandingly low rates of decline.
Apart from exploring the issue of age-related streng-
th decline, this study sheds some light on the gender-
related difference in muscle action. The present find-
ings reveal that the participating women were signifi-
cantly less impaired with muscle weakness than men
as reflected by a pooled (knee + hip muscles at both
velocities) deficit of 32% in the former vs. 43% in the
49
latter. Akima et al. [26] have looked into the age vari-
ations of both the absolute and relative isometric and
isokinetic PT of the KE and KF. It was reported that
for all tested velocities, the percentage decline in men
and women was respectively 12% and 8% for KE and
11% and 8% for KF. Lindle et al. [25] have indicated
that women tended to better preserve muscle quality
with age for the eccentric PT. Women were also distin-
guished by having an enhanced capacity to store and
utilize elastic energy compared with men of similar
age. In a later study elderly men were reported to suffer
as much as twice loss of KE strength compared to el-
derly women [22]. On the other hand no gender differ-
ences were indicated in another study [15] where KE,
KF and plantar flexion strength were measured in 4
decade groups (40–80). In the current study is in agree-
ment with the above studies.
On the other hand, the differential strength decline
in the knee vs. hip muscles is an interesting issue that
was not accorded direct attention. This study reveals
that the strength of the hip muscles was significantly
better preserved than that of the knee muscles, by a
gender symmetrical margin of 9%. The lesser decline
in hip flexion may well be interpreted in terms of the
role these muscles play in ambulation and the resis-
tance they have to overcome. It is well known that the
hip flexors act as prime movers of the lower extremity
in initiating the swing phase in gait [27]. It should also
be borne in mind that hip flexors strength was mea-
sured using dynamic concentric contraction with a typ-
ical short acceleration phase. This proximity, between
function and testing, could account for the apparent hip
flexion strength scores.
In this study we have also looked into the question
of torque consistency (steadiness), an issue which has
been examined with regards to various lower extrem-
ity muscles [28,29]. The interest in this issue reflects
the notion that lesser torque steadiness on repeated ef-
forts could adversely affect maintenance of balance
and functional performance such as gait. Interestingly,
the results of the present study are in good agreement
with the abovementioned studies in terms of elderly
vs. young individuals performance. In other words, al-
though elderly individuals present with lower torque
steadiness, it is particularly true for hip muscles; for
knee muscles the findings were similar with CVs of
around 4–6% save in the higher velocity at knee flex-
ion (180◦/s). The latter finding may be interpreted in
terms of familiarity: the hamstring rarely operate at
this speed and torque steadiness could be compromised
with higher velocities. However, torque maintenance
50 V.S. Borges et al. / Hip and knee strength in old and young people
was less steady with respect to hip muscles but this
tendency was apparent in both group and amounted to
an extra 2–3% compared with that of knee muscles.
The lesser torque steadiness associated with hip mus-
cles activity may be due to the higher demand put on
these muscles during isokinetic testing. Subjects are
required to develop maximal torque against maximal
resistance, a situation that is very rarely met as far as
these muscles are concerned. Thus whereas knee ex-
tensors are often challenged with significant resistance,
e.g. in stair climbing and descent, rendering them more
familiar with heavy loads, this is not the case with hip
muscles.
However, the main question is whether this differ-
ence is of clinical significance. It should be borne in
mind that the elderly (as well as the young) participants
did not suffer from known neurological diseases, bal-
ance problems or disabling musculoskeletal disorders.
It is therefore reasonable to assume that for this par-
ticular cohort, the significant, albeit very limited, inter-
group differences in torque steadiness, could not con-
stitute a risk factor in terms of balance or gait chal-
lenges. On the other hand, this conclusion should be
put in the correct context of the study: maximal rather
than submaximal and dynamic rather than static ef-
forts, examined in apparently healthy individuals.
In terms of study limitations one should conceded
the absence of a thorough investigation of the lifestyle
and the level of physical activity of the elderly partic-
ipants. On the other hand, the strength ratios: old vs.
young and women vs. men are so clear and self evi-
dent that they more than compensate for the limitation.
The unequal size of the ‘old’ and ‘young’ samples may
be another limitation but again, the results speak for
themselves.
Conflict of interest
Authors disclaim any conflict of interest or financial
benefits.
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