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Orthopedic & Muscular System
Marks, Orthop Muscul Syst 2014, 3:4
http://dx.doi.org/10.4172/2161-0533.1000174
Volume 3 • Issue 4 • 1000174
Orthop Muscul Syst
ISSN: 2161-0533 OMCR, an open access journal
Open Access
Case Report
Hip Flexor and Knee Extensor Muscle Strength Characteristics of Community-
Dwelling Women with Recent Hip Fractures: A Case Study of Extent of
Persistent Inter and Intra-limb Strength Assymetries
Ray Marks*
Department of Health and Behavior Studies, Program in Health Education, Columbia University, Teachers College, and School of Health and Behavioral Sciences, New
York, USA
Abstract
Objectives: To examine the prole of hip exor and knee extensor strength measures among other factors in the
context of recovery from an acute hip fracture among a sample of six community dwelling otherwise healthy women.
Methods: Records of the hip exor and knee extensor strength of six women with right-sided hip fractures followed
up for six months were analyzed.
Results: All women presented with interlimb strength assymetries at all stages of their rehabilitation program, as
well as intralimb differences in recovery rates between the hip and knee muscles. While strength improved in most
cases, this was not consistent within or across subjects, and was signicant between 6 weeks and 6 months only for
the uninjured side (p<0.05). Those with better hip exor symmetry strength scores at six months had more rapid Get
Up and Go scores, (p=.008), number of walking laps competed was higher (p=.049). Hip exor muscle strength on the
uninjured side at 6 months independently predicted the subject’s ability to rise from a chair as rapidly as possible, and
knee strength on the uninjured side predicted walking distance (p<.05).
Conclusion: Hip exor and knee extensor strength decits of the affected leg are still evident among community
dwelling hip fracture cases at six months, regardless of whether subjects take part in intensive exercise interventions
or not. The presence of hip exor and knee extensor strength deciencies and assymetries from side to side which
prevail for an extended period after surgical repair inuences overall functional ability at 6 months. Implications:
Improving leg strength after hip fracture surgery requires careful baseline and ongoing periodic evaluations and
tailored prolonged interventions to avert the increased risk of falling and sustaining second hip fractures associated
with suboptimal muscle strength of the legs. Optimally reducing interlimb and intralimb discrepancies in hip exor and
knee extensor muscle strength can be expected to improve functional ability.
*Corresponding author: Ray Marks, Department of Health and Behavior Studies,
Columbia University, Teachers College, New York, Tel: 1 212 678 3445, Fax: 1 212
678 8259; E-mail: rm226@columbia.edu
Received September 02, 2014; Accepted October 30, 2014; Published
November 03, 2014
Citation: Marks R (2014) Hip Flexor and Knee Extensor Muscle Strength
Characteristics of Community-Dwelling Women with Recent Hip Fractures: A Case
Study of Extent of Persistent Inter and Intra-limb Strength Assymetries. Orthop
Muscul Syst 3: 174. doi:10.4172/2161-0533.1000174
Copyright: © 2014 Marks R. This is an open-access article distributed under the
terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and
source are credited.
Keywords: Fractures; Hip exors muscles; Hip fracture; Knee
extensor muscles; Rehabilitation; Strength
Introduction
Prevailing literature detailing hip fractures and their outcomes
continues to support the highly negative impact of this injury on
individual health, and personal independence [1-4]. In particular, if the
leg muscles remain weak aer hip fracture surgery, one can strongly
anticipate suboptimal functional recovery rates, plus higher healthcare
utilization and costs [5], despite vast improvements in recent surgical
strategies for treating this serious clinical condition. In addition, the
presence of poor or suboptimal recovery of lower limb strength, might
also explain why some hip fracture patients are more prone to post-
surgical complications than others who undergo similar surgery for
other conditions, such as hip arthritis. Weaker patients may also be a
greater risk for catastrophic declines in outdoor walking ability [6,7],
plus secondary falls than those with enhanced muscle strength who
can perform muscle-loading activities such as climbing stairs [4-8].
Moreover, if muscle strength is not symmetrically distributed from
side to side, balance as well as function could be compromised [9].
Conversely, those patients who are less prone to further injury aer
hip fracture surgery and recover independence may be those able to
generate muscles forces sucient to elicit protective reexes in a
timely way, regardless of perturbations that can cause falls and the later
development of secondary hip osteoarthritis.
However, early investigations of strength recovery rates even
among healthy robust patients, showed signicant dierences between
the injured and non-injured sides on discharge [9,10], and because
hip fractures occur in the elderly, who already may be weak, plus the
fact hip surgery entails cutting of nerves to the hip, the recovery rate
of muscles at the hip and possibly the knee may be impeded in their
recovery to some degree by related factors such as pain, or muscle
atrophy [7]. Further, there may be a gain in regional muscle fat content
in addition to a muscle mass loss post-surgery [11]. As well, due simply
to so tissue and muscular trauma, and its immediate consequences, a
patient who has sustained a hip fracture may have reduced leg strength
that is greater than that due to ageing [12-14], and may exhibit chronic
inammation [15], and/or thigh edema [16]. ey may also present
with signs of poor muscle coordination [17], impaired sensorimotor
function of their leg muscles [18], and excessive weakness if they
have comorbidities, such as hip osteoarthritis [19]. As indicated by
Kristenson et al. [20 ], a post-operative rehabilitation program which
does not account for the unique eects trauma, disease and surgery may
have on an individual patients overall leg strength, may consequently
fail to promote optimal functional outcomes for an individual patient
as alluded to by Munin et al. [21] and Sherrington and Lord [22].
Citation: Marks R (2014) Hip Flexor and Knee Extensor Muscle Strength Characteristics of Community-Dwelling Women with Recent Hip Fractures:
A Case Study of Extent of Persistent Inter and Intra-limb Strength Assymetries. Orthop Muscul Syst 3: 174. doi:10.4172/2161-0533.1000174
Page 2 of 5
Volume 3 • Issue 4 • 1000174
Orthop Muscul Syst
ISSN: 2161-0533 OMCR, an open access journal
with their upper limbs and recording the distance, and number of laps
recorded on a six minute self-paced walking test on an indoor walkway
were examined. e initial and nal strength scores for both limbs were
scanned to examine if the resultant imbalance was uniformly due to
weakness on the aected side.
e specic dependent variables chosen for analysis were:
1. e cohorts non-normalized uncorrected hip exor and
knee extensor strength scores of the injured leg relative and
uninjured leg as assessed bilaterally at 6 weeks, 3 months, and 6
months in response to the one repetition maximum test.
2. An asymmetry score, whereby the fractured leg strength score
for each muscle group was compared to the combined strength
score of both legs and symmetry or no assymetrical was taken
as a value of 50% according to Portegijs et al. [30]. Lower values
indicated an asymmetrical decit, and poorer strength in the
aected leg.
3. Strength change scores for each leg for each muscle group of
each individual over time.
4. Average time to stand up on three occasions as quickly as
possible from a seated position, number of laps recorded during
a six minute walk test, and number of centimeters recorded on
a functional reach test.
All subjects had been referred to the study by surgeons and
decisions regarding subject suitability for the study were made by the
investigator. All subjects had provided informed consent. ose who
exercised did so for 2-3 times a week for eight weeks using free weights,
according to 60 percent of their one–repetition maximum tested
at each exercise session for each muscle of each leg. In addition, the
knee exors and hip extensors of both legs were exercised in sitting
and standing with varied forms of resistance designed to increase leg
strength.
Once collected, the data were then entered into a computerized
database and analysed using descriptive and inferential statistics. e
statistical package SPSS version 17 for a personal computer was used
to examine the extent of selected relationships and dierences which
existed among the data, using standardized t-tests, and bivariate
correlations. Factors evaluated as independent predictors of outcome
included age, gender, type of fracture, reason for fracture, use of
vitamin D supplementation, body mass indices, body weight and
height. Signicance was set at p=.05.
Results
e key characteristics of the sample are presented in Table
1. All were relatively healthy community dwelling adults, with no
osteoporosis history, or current fractures at other sites, and all were
on vitamin D supplementation. Five of the six had inter-trochanteric
fractures and all had fallen prior to fracturing their hips. None were
complaining of pain which had decreased more than 70 percent
from baseline in all cases by the end of the six month period using a
subjective pain scale. Four had been actively participating in a hospital
based tailored eight week exercise program designed to strengthen the
leg muscles and improve their balance, while two had been following a
home exercise routine. All were right handed with right sided fractures.
In terms of strength recovery, there was evidence of greater
weakness on the uninjured side in two separate cases for the hip exor
muscles and knee extensor muscles, respectively. Only one subject
Hip fractures are one of the most serious health care problems
facing aging nations, and those who survive this injury may experience
permanent institutionalization, premature death, high morbidity rates,
and an associated increase in risk of a second fracture [23,24]. Some
degree of this increased morbidity appears due to the fact recovery
rates of muscle strength may not be uniform in all hip fracture cases
[25-27], there may be unanticipated muscle mass losses [28] and
persistent pain [29] that increases the tendency towards weakness.
e present case series was designed to examine the potential value of
careful evaluation of muscle strength capacity at baseline and during
the recovery period in key muscles of the lower leg on both sides,
regardless of injury side. It was also designed to highlight the possible
need for more extensive o targeted and tailored rehabilitation strategies
which focus on facilitating optimal strength recovery of both the hip
exors and the knee extensors in both the short-term and long-term
post fracture periods, as well as balance. While previously studied in
the context of the knee extensor muscles to some degree, recovery rates
of muscle strength at the hip, and related changes at the knee have
not been studied extensively in the related literature with respect to
community dwelling women who are in good general health and have
sustained fractures on their dominant side as a result of falls.
Objectives
Based on a review of the literature and the research questions under
consideration, this case study specically attempted to examine if:
1. Hip fracture patients either receiving intensive exercise
therapy or not receiving therapy experience prolonged muscle
imbalances from side to side with respect to the hip exor and
knee extensor muscles.
2. Hip exor and knee extensor muscle strength assymetries are
predictive of functional outcomes at six months.
3. If leg strength imbalances from side to side are inuenced by
age, body mass, whether the individual was receiving exercise
instruction or not, or whether they had a cervical fracture or an
inter trochanteric fracture.
Methodology
e strength records of six adult females with right sided hip
fractures who underwent surgical xation were reviewed at 6 weeks,
3 months, and 6 months aer surgery for the aected leg as well as the
unaected leg. e non-normalized strength values, as well as ratios of
leg strength of the aected hip exors and knee extensors with respect
to the hip exors and knee extensors of the aected and unaected
legs were computed. e six subjects selected were those who had
experienced an acute hip fractures preceded by a fall, were otherwise
healthy, and had agreed to be followed progressively to examine their
hip and knee strength proles over a six month post-operative period.
e strength testing protocol was conducted in a standard manner by
experienced tester in the seated position using a hand held strength
testing device and a one repetition maximum test with free weights
placed at the ankle to assess maximal force capacity of the hip exors
and knee extensors of both legs to the nearest kilogram. e participants
had to be free of cancer, cardiovascular, and neuromuscular diseases
as determined by their medical histories, ambulatory, with or without
aids, and living in the community. In addition to strength measures,
age, height, weight, and body mass index measures, reason for hip
fractures, timed Get Up and Go tests involving asking the patient to
stand up from a chair as fast as they could, Functional Reach scores,
recorded by asking subjects to stand and reach forward as far as possible
Citation: Marks R (2014) Hip Flexor and Knee Extensor Muscle Strength Characteristics of Community-Dwelling Women with Recent Hip Fractures:
A Case Study of Extent of Persistent Inter and Intra-limb Strength Assymetries. Orthop Muscul Syst 3: 174. doi:10.4172/2161-0533.1000174
Page 3 of 5
Volume 3 • Issue 4 • 1000174
Orthop Muscul Syst
ISSN: 2161-0533 OMCR, an open access journal
prior work to our knowledge has identied similar trends for the hip
exor muscles, which are key to functions such as walking, sitting to
standing functions, and stair climbing.
In a more extensive series of observations [26] we found the
observed strength decit aer hip fracture surgery did not seem related
to the side of the body injured, gender or age, and in this case series
we found similar trends when only females were studied, and the
side injured was their dominant side. Our observations for the knee
extensors which are very close to those of previous investigators in
exhibited symmetry between the two muscle groups from side to side,
in this case for the hip exors.
e overall trends in strength for the hip exors and knee extensors
are shown in Figures 1 and 2. e resultant asymmetry that existed
on average between the aected and unaected sides, regardless of
whether this was an injured or uninjured side is shown in Table 2 for
the two muscles studied. As depicted these were not uniform over
time, and between the muscle groups. e value reached in the case
of the hip exors and knee extensors suggests muscle strength in these
two groups were clearly not equal from side to side at six months.
In terms of correlations between the measures of strength across
time for the hip exors, Table 3 shows these tended to improve over the
study period, but did not approach unity in all cases. is was similar
for the knee extensor muscles but there was diminishing concordance
for this muscle group over time.
Table 4, depicting the intra-limb strength relationships for the
aected and the unaected side, shows these were generally more
concordant on the non-fracture side over time. In terms of correlations
between the functional variables, only the extent of hip symmetry at
six months predicted speed on the Get Up and Go Sit to Stand test
(r=-.96, p=.008) and number of laps completed on a six minute walk
test (r=.88; p=.049). Neither age, nor body mass index, nor whether the
patient exercises or not, appeared to inuence the functional outcomes
or hip asymmetry scores, and knee asymmetry scores were not related
to the functional measures in any way. Strength of the uninjured hip
exors and knee extensors at baseline were not correlated with walking
distance, functional reach or standing up from a chair as quickly as
possible. Hip exor strength of the uninjured side at six months
showed a positive trend as far as getting up from a chair as rapidly
as possible goes (r=-.85; p=.065). Knee strength of the uninjured leg
showed a positive trend as far as number of walking laps completed
were concerned (r=.95; p .075). Although the injured limb generally
displayed greater weakness than the uninjured limb for both muscles,
studied, this was not uniformly the case.
Discussion
is study series involved generally healthy older women 66-
85 years of age, who had fractured their hips as a result of a fall and
were living in the community. ey were assessed at dierent points
in time with respect to their maximal hip exor and knee extensor
strength capacity, as well as body weight, and standard functional
outcomes with a view to oering insight into the recovery process.
e present nding that hip fracture patients showed unequal levels
of strength between those of the aected side and unaected side, as
well as weakness of both the hip exors and knee extensors or both,
regardless of duration since injury, and regardless of whether they were
receiving therapy or not, may help to explain the functional declines,
as well as the proclivity for falls and further injury this group oen
exhibits While problems in the case of knee extensor muscles have been
identied by several authors post hip fracture injury, for example in
recent ndings of Sherrington et al. [22] and Madsen et al. [25], no
Mean S.D. Min Max
Age (yr) 77.8 8.5 68 92
Weight (kg) 57.0 7.6 45.4 63.5
Height (m) 1.6 0.1 1.37 1.68
BMI (kg/m2) 22.3 3.1 18.00 26.00
Table 1: Descriptive characteristics of the six initially acute hip fracture cohorts as
assessed at baseline 6 weeks after surgery.
0
5
10
15
20
25
6 weeks 3 months 6 months
kg
Time
Affected side
Unaffected side
Note: The strength differential between that recorded at 6 weeks and that
recorded at 6 months using a paired t-test was signicant only for the uninjured
side, p=.006
Figure 1: Hip exor strength differentials among the six hip fracture patients
in (kg) over time.
0
2
4
6
8
10
12
14
16
18
6 weeks 3 months 6 months
kg
Time
Affected side
Unaffected side
Note: The strength differential between that recorded at 6 weeks and that
recorded at 6 months using a paired t-test was p=.054 for the injured side; and
non-signicant for the uninjured side, p=.150
Figure 2: Knee extensor strength differentials among the six hip fracture
patients in (kg) over time.
6 weeks 3 months 6 months
Hip exor muscles 42.6 41.6 42
Knee extensor muscles 39 46 46
Table 2: Asymmetry scores with respect to the hip exor and knee extensor
strength ratios recorded over time for 6 hip fracture surgical cases showing less
than optimal recovery at 6 months, and where a score of 50=symmetry from side
to side.
Citation: Marks R (2014) Hip Flexor and Knee Extensor Muscle Strength Characteristics of Community-Dwelling Women with Recent Hip Fractures:
A Case Study of Extent of Persistent Inter and Intra-limb Strength Assymetries. Orthop Muscul Syst 3: 174. doi:10.4172/2161-0533.1000174
Page 4 of 5
Volume 3 • Issue 4 • 1000174
Orthop Muscul Syst
ISSN: 2161-0533 OMCR, an open access journal
terms of outcome and strength magnitudes (e.g. 27) suggest our data
are reliable despite a limited sample size. In addition to knee extensor
muscle weakness, which has been implicated in a number of studies as
an independent contributor to a hip fracture, the nding of hip exor
muscle weakness in all the present cohorts with acute fractures, even
aer they have returned home following standard rehabilitation, and
which was present at baseline to a greater degree on the uninjured side
in one subject, may imply a problem predating the injury, which is
compounded by surgery. e fact that strength of the uninjured leg
increased over time for both muscle groups, and this was signicant for
the hip exors on the uninjured side, but not the injured side, may not
only point to a preceding strength decit which aects both limbs, but
that this decit is compounded by the injury and surgical procedures,
regardless of whether the person undertakes exercise or not. Although
strength gains for the knee extensors were more marked for the injured
leg on average, which is consistent with ndings of others [27,28] the
intra-limb strength correlations shown in Table 4-strongly suggests
that the aected side has not yet matched the unaected side as a whole
in terms of extent of strength gains at six months.
As well as the resection of muscles at the hip which extend the knee,
muscle weakness in the rst year aer surgery [28] could explain the
slow rate of mobility recovery. At the same time, pain that persists aer
hip fracture, along with skeletal muscle weakness of the fractured leg
may contribute to further pain and less desire to be active [29,30] even
though the present subjects were not complaining overtly of pain at six
months. e presence of prolonged strength decits among fallers who
have fractured their hip could increase the risk for further falling in
the post fracture period [31]. e presence of prolonged weakness and
muscle imbalances may also increase the chances of adverse eects on
bone health, muscle mass [32,33] as well as optimal mobility recovery
[34].
Moreover, protective reexes against perturbations which depend
in part on appropriate timing of muscle contraction as well as the
physiological quality of force generating mechanism of the lower
limb may be impaired. Based on the present outcomes, it can also be
conjectured a persistent degree of leg strength asymmetry between the
hip exor strength measures from side to side over time, will hamper
walking endurance and the ability to rise from a chair unassisted. While
this asymmetry tended to improve over time, it did not fully disappear
as was observed by Portegijs et al. [30].
us, consistent with current literature that emphasizes the
importance of leg strength in preventing falls and in maintaining
functional ability, and that the complete recovery of lower extremity
function may take many months of recuperation time [34], and that
the recovery process may be quite variable [35], the present body of
ndings may indicate that treatments to specically enhance strength
recovery of the hip exors, along with the extensor muscles of hip
fracture cohorts, which are systematically applied, as indicated, for an
extended duration aer surgery are advocated. As well, educational
interventions and counseling that sensitizes patients and caregivers
to the possibility of patient’s incurring further dysfunction if exercise
compliance is poor, may be extremely important in promoting
long-term functional ability of these cohorts and in reducing some
unwarranted functional complications aer hip fracture surgery that
can prove so devastating.
A further related implication of the present observations is that:
as a potentially potent predictor of hip fracture surgery functional
outcomes, contrary to current practices, hip exor strength needs to be
carefully and consistently evaluated bilaterally and treated accordingly
post hip fracture surgery in order to promote functional independence
and optimize the extent of mobility recovery of elderly hip fracture
cohorts. Although all were presently taking vitamin D supplementation,
it is possible the outcomes of strength recovery would be even more
detrimental for those who are not taking supplements, as well as for
those who have additional health challenges.
To avert suboptimal outcomes for all hip fracture surgical cases,
routine baseline and follow up evaluations of hip exor muscle strength
along with knee extensor strength, followed by therapy tailored based
on these results are hence strongly recommended so that therapy can
be adjusted accordingly. Patients should continue to exercise until
there is adequate or optimal concordance between the strength values
generated for both muscles of both legs, as well as intra limb muscle
balances are optimally restored. Specic exercises to improve balance
capacity may be desirable, if non weight bearing exercise protocols do
not inuence balance capacity
In conclusion, despite the obvious limitations to the present
observations, including sample selection, sample size, the method
used to assess muscle strength, and the small numbers of outcome
measures documented, it appears muscle strength of the aected and
unaected sides of cases who have fallen and sustained hip fractures
are non-uniform between patients, and across sides and muscles, in
the present case the hip exors and knee extensors. Given that the
results comport favorably with current investigative results of others,
it is concluded they may be useful for directing future interventions
and especially for highlighting the need to implement more careful
initial evaluations, followed by tailored rehabilitation programs,
and progressive evaluations, in light of the high variability presently
observed in outcomes, which can clearly impact upon the individual
functional outcomes. Since suboptimal muscle strength may be an
important predictor of falls that lead to hip fractures, as well as adverse
outcomes post fracture, a consistent emphasis on acknowledging the
important role of muscle in both hip fracture prevention, and secondary
prevention, is likely to yield substantive societal and individual returns
on this investment.
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Table 4: Pearson (r) correlations of strength scores for selected variables.
Citation: Marks R (2014) Hip Flexor and Knee Extensor Muscle Strength Characteristics of Community-Dwelling Women with Recent Hip Fractures:
A Case Study of Extent of Persistent Inter and Intra-limb Strength Assymetries. Orthop Muscul Syst 3: 174. doi:10.4172/2161-0533.1000174
Page 5 of 5
Volume 3 • Issue 4 • 1000174
Orthop Muscul Syst
ISSN: 2161-0533 OMCR, an open access journal
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Citation: Marks R (2014) Hip Flexor and Knee Extensor Muscle Strength
Characteristics of Community-Dwelling Women with Recent Hip Fractures: A
Case Study of Extent of Persistent Inter and Intra-limb Strength Assymetries.
Orthop Muscul Syst 3: 174. doi:10.4172/2161-0533.1000174
