220

C OPYRIGHT  2010

BY

T HE J OURNAL

OF

B ONE

AND J OINT

S URGERY, I NCORPORATED

Current Concepts Review

Assessment of Hip and Knee Muscle Function

in Orthopaedic Practice and Research
By Nicola A. Maffiuletti, PhD
Investigation performed at the Neuromuscular Research Laboratory, Schulthess Clinic, Zurich, Switzerland

Isometric evaluation of hip and knee muscle strength can be a useful objective assessment tool in the clinic and
may be preferred over other forms of dynamic muscle testing, such as isokinetic assessment or variable-resistance
weight-lifting.

Assessment of isometric strength with use of a handheld dynamometer requires little skill and is easily administered, relatively inexpensive, valid, reliable, and functional; thus, it could be easily integrated into routine clinical
examinations.

Surface electrical stimulation, electromyography, and ultrasonography can be used in conjunction with isometric
muscle testing for the identification of neuromuscular factors influencing muscle force generation.

Further research is warranted to investigate the neural and/or muscular impairments associated with hip and knee
muscle weakness in orthopaedic populations, with the ultimate goal of improving rehabilitation strategies.

The time course of functional changes following lower-limb

surgery and immobilization, as assessed with self-report questionnaires, is well known. However, performance-based functional assessments, which consist of evaluations of physical
function (i.e., the ability to perform daily activities) and muscle
function (strength and power), are not typically performed
in orthopaedic practice1,2. Besides the evaluation of physical
function (e.g., stair-climbing, walking, and timed up and go
[rising from a chair and walking]), which may have limited
reproducibility and validity 3, the systematic implementation of
hip and knee muscle-function assessments in modern orthopaedic practice would be extremely useful to both surgeons
and rehabilitation therapists to improve patient care.
Information about hip and knee muscular performance is
of paramount importance for most clinical applications in orthopaedic practice and research4e.g., to diagnose specific
disorders such as acetabular dysplasia5 or arthrogenous muscle
inhibition6 (muscle activation failure), to prospectively assess
the impact of an operative7 and/or therapeutic6,8,9 intervention
(including physiotherapy exercise), to investigate the mechanisms that account for muscle weakness2, and to detect any

predisposing factors that may lead to injury10. For instance,

careful evaluation of hip muscle function soon after an operation would allow iatrogenic lesions such as nerve injury to be
excluded as a potential cause of impairment11,12. More importantly, reduced muscle strength (quadriceps strength in particular), which is frequently observed in orthopaedic patients, has
been suggested to be a surrogate marker for the progression of
osteoarthritis in some patients13,14 as well as one of the single
most important predictors of functional disability15. Quadriceps
strength is related to both subjective knee scores and functional
test outcomes1,16 both before and after anterior cruciate ligament
surgery or total knee arthroplasty. These facts illustrate the
critical importance of accurate quantification of hip and knee
muscle function in orthopaedic practice and research.
Measured general muscle-function outcomes mainly include muscle strength and power4, which are tested with use of
different methodologies, ranging from manual muscle testing,
which is the simplest but is imprecise, to the most complex but
expensive isokinetic assessments. Muscle strength is commonly
measured in one of three ways: (1) as the maximum force that
can be produced during an isometric contraction, (2) as the

Disclosure: The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of
his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

J Bone Joint Surg Am. 2010;92:220-9

doi:10.2106/JBJS.I.00305

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TABLE I Important Factors for the Assessment of Isometric Muscle Strength

Factors

Outcomes

Type of muscle action

Single-joint (open chain)
Multiple-joint (closed chain)
Joint angle
Angle of peak force for movement of interest
Angle of peak force for muscle tested
Body position
Validity of assessment (body stabilization)
Contribution of biarticular muscles
Intensity of contraction
Maximal

Maximal voluntary contraction strength, rate-of-force-development variables

Submaximal

Accuracy, steadiness (Fig. 2)

Type of contraction
Voluntary only

Maximal voluntary contraction strength, rate-of-force-development variables

Stimulated only
Voluntary with superimposed stimulation

M-wave and contractile properties (Fig. 3, B)

Muscle activation (Fig. 3, A)

Testing mode
Manual muscle testing
Handheld (stabilized) dynamometer (Fig. 1)
Isometric dynamometry
Isokinetic dynamometry
Additional techniques
Electrical stimulation
Electromyography
Ultrasound
Experimental recommendations
Familiarization and practice
Visual feedback of performance
Standardized verbal encouragement
Clear instructions
Several repeat trials
Negligible pretension
Other factors to control
Device calibration
Gravity correction
Time-of-day effect
Residual fatigue effect
Test-retest reliability
Sampling rate
Lever arm length
Pain

maximum load that can be lifted once (i.e., dynamic variableresistance weight-lifting), or (3) as the peak torque during an
isokinetic concentric or eccentric contraction17. However, there
is no general agreement about whether muscle strength should
be assessed with isometric, weight-lifting, or isokinetic testing in
orthopaedic practice.

Measurement of muscle strength under isometric conditions can be a useful objective assessment tool for the evaluation of hip and knee function in the clinic18 because it is rapidly
and easily administered and is relatively inexpensive; therefore,
it may be preferred over the other forms of dynamic muscle
testing, such as isokinetic assessment or variable-resistance

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Fig. 1

Clinical assessment of isometric maximal voluntary contraction strength in knee extension (A) and hip
abduction (B) with use of a handheld dynamometer. Note the positioning of the subject, the placement of
the dynamometer, and the stabilization of the subject under the two conditions. (See Table II for the test
steps and instructions.)

weight-lifting. Although isometric activity is rare in daily life,

measurement of isometric strength has a strong predictive relationship to functional capacity4, contrary to what is generally
believed. This relationship is even more evident in elderly patients and in patients who have marked functional alterations.
Isometric muscle-strength assessments have been found to be
highly reliable in different orthopaedic populations18-22, and
reliability coefficients can even be higher than those obtained
with isokinetic measurements22, at least for hip abduction.

Therefore, isometric testing could be very effective for detecting

changes in muscle strength resulting from operative treatment,
immobilization, or rehabilitation.
In this article, I describe the general methodology of
isometric muscle-strength evaluation and provide practical
examples of clinical assessments of the hip and knee with use
of handheld dynamometers. In addition, noninvasive techniques
(electrical stimulation, electromyography, and ultrasound) that
allow investigation of whether neural or muscular mechanisms

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underlie muscle weakness are described, with particular reference to orthopaedic research.
Isometric Muscle-Strength Assessment
Table I presents the important factors that must be carefully
controlled to ensure valid quantification of hip and knee muscle
strength.
Testing Modes
Four main testing modes that rely on testing tools of different
technology and cost can be adopted for the evaluation of
isometric muscle strength.
Manual muscle testing is the most commonly used mode
in routine clinical examinations, despite certain limitations
such as poor validity and inaccuracy of subjective ratings4. It is
a semiquantitative method, in which muscle strength is subjectively given a grade. For example, both on the classic 0 to 5point scale4 and on the expanded 0 to 12-point scale20, the
lowest grade indicates no contractility or muscle activation and
the highest grade represents complete motion against gravity
with full resistance.
Handheld dynamometry (Fig. 1), which can be considerably improved by the use of stabilized dynamometers23, is
probably the best mode for hip and knee assessments in
clinical use24, despite the absence of online visual feedback
regarding force data. Handheld dynamometers (Chatillon;
AMETEK, Largo, Florida; Lafayette Instrument, Lafayette,
Indiana; and MicroFET, Hoggan Health Industries, West Jordan, Utah) can be used to precisely quantify muscle force in
actual units (i.e., newtons, kilograms, or pounds). With some
modern devices, it is also possible to store force data for
subsequent analyses.
Isometric dynamometry, done with a custom-built or
commercially available chair (e.g., a Tornvall chair) equipped
with strain-gauge load cells mounted in series with a force
output axis, allows force data to be stored. Gravity correction
and online visual feedback regarding force data are generally
possible with these devices.
Isokinetic dynamometry devices, which can be set in isometric mode, allow optimal standardization of testing procedures and direct recording of torque data. As is the case for
handheld and isometric dynamometry, regular calibration
ensures the accuracy of isometric measurements. Despite
their high cost, isokinetic machines (Biodex Medical Systems,
Shirley, New York; CON-TREX, CMV AG, Dubendorf, Switzerland; Cybex, Medway, Massachusetts; HUMAC NORM,
CSMi, Stoughton, Massachusetts; and Kin Com, Isokinetic
International, Harrison, Tennessee) are frequently available to
physiotherapists.
Test Procedures
Several recommendations, based on experimental evidence,
should be followed to obtain a valid assessment of isometric
strength. These criteria, which have been described in detail
elsewhere25,26, include appropriate familiarization and practice
(generally incorporated into a standardized warm-up), visual

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feedback on performance, standardized verbal encouragement,

clear instructions (described below), three or more repeat
trials, and negligible pretension prior to the contraction. The
subject is generally asked to produce a series of short (three to
five-second) maximal voluntary actions separated by appropriate rest periods (of thirty to sixty seconds). For the assessment of maximal voluntary contraction strength, the patient
should be given the gradual-force instruction (i.e., instructed
to progressively build up force). However, if, in addition to
maximal strength, the contractile rate of force development is
to be quantified, the rapid-force instruction should be used27.
The choice of muscle action (single or multiple-joint, or
open or closed-chain), joint angle, and body position is critically important for the validity of the test. Multiple-joint tests
(e.g., the seated leg press) are often used in an effort to make
the test more specific for movements prevalent in gross motor
tasks26. Similarly, the choice of joint angle should be dictated by
the activity of interesti.e., strength is tested at the angle at
which peak force occurs in the movement of interest (e.g., 30
of hip flexion for the hip flexors during walking)or alternatively by the angle of absolute peak force for the tested
muscle (e.g., about 60 of knee flexion for the quadriceps).
Whole-body position, which entails body stabilization, must
be standardized because it has a considerable effect on the
validity of muscle-strength assessment, particularly of the hip
joint. For example, in a study performed by my colleagues and
me, in which bilateral electromyographic and force recordings
were used during unilateral hip abduction, better validity and
test-retest reliability were observed when the subject was tested
in the side-lying position than when he or she was tested in
either the supine or standing position28. In knee joint assessments, the hip position strongly influences the contribution of
biarticular muscles to the force output29; therefore, the selection of a seated or supine posture should depend on the aim of
the assessment.
Outcomes
Maximal voluntary contraction strength is usually defined as
the maximum force (in newtons) or torque (in newton-meters)
developed during maximal voluntary efforts under a given set
of conditions (immovable resistance, a specified joint angle,
etc.)30. In order to allow valid between-subject comparisons, it
is preferable to report maximal voluntary contraction torque
rather than force data as torque can be recorded directly (e.g.,
by isokinetic machines) or calculated from the recorded force
and lever arm. For the same reason, torque and force values
should always be scaled30 to body mass and body mass 0.67,
respectively, but preferably not to the body mass index (in
kilograms per square meter) because of its limited specificity in
relation to muscle actions typical of daily activities. For example, when a patient climbs stairs or rises from a chair, he or
she is lifting his or her body mass (i.e., weight), not his or her
body mass index31. Depending on the studys objective and
population, strength data can also be normalized to muscle
cross-sectional area or volume (as determined with anthropometric measures, magnetic resonance imaging, or ultra-

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sound), to better characterize the intrinsic capacity of a muscle

to generate force (i.e., specific force).
Once strength data are collected from patient populations,
two distinct methods can be used to quantify the extent of
muscle weakness. One method is to compare the strength data
with those obtained from healthy matched controls (betweensubject comparison). The other method, which can be used
provided that there are no impairments on the uninvolved side,
is to quantify strength separately for the homonymous muscles
of the involved and uninvolved sides (within-subject comparison) and calculate the individuals side-to-side percent
difference (bilateral ratio) with the formula: ([uninvolved 2
involved] /uninvolved) 100. Interlimb deficits (asymmetries)
of 10% to 20% can be considered to be probably pathological,
and those of >20% are almost certainly pathological4. Since
both between and within-subject comparisons have limitations32 (e.g., differences in activity levels between patients
and healthy subjects and a high prevalence of bilateral impairments in osteoarthritic patients), it is recommended that
these two comparison methods be combined, whenever possible, for optimal quantification of muscle weakness.
In addition to bilateral ratios, unilateral antagonist-toagonist strength ratios (e.g., hamstring-to-quadriceps and hip
adductor-to-abductor ratios) can be used to characterize possible imbalances around a single joint. For example, reduced
hamstring-to-quadriceps strength ratios at or below 50% to
60% may be indicative of a pathological knee condition and a
predisposition to injury 33. Similarly, there is some evidence that
the hip adductor-to-abductor strength ratio is a good predictor
of an adductor muscle strain injury in athletes10,34.
Other Factors
The time-of-day effect should be taken into account when an
isometric strength assessment is carried out because large
fluctuations in maximal voluntary contraction strength, which
basically mirror the circadian fluctuations in muscle temperature, can occur throughout the day 35. Differences in quadriceps maximal voluntary contraction strength of up to 10%
have been observed, with the highest values occurring in the
evening (6 P.M.) and the lowest occurring in the early morning35.
Moreover, participants should be discouraged from performing
strenuous activity during the twenty-four to forty-eight hours
preceding the assessment to avoid any residual fatigue effect.
The individuals administering the test should know the testretest reliability of their measurements (e.g., intraclass correlation coefficient, standard error of measurement, or 95%
limits of agreement), as this allows the minimal detectable (or
clinical) change and expected sample size to be calculated.
Whenever possible, the sampling rate (100 Hz) and resistance
lever arm or pad position (5 cm above the transmalleolar axis
for both knee and hip abduction-adduction assessments24)
should be standardized. Finally, since pain clearly influences
any measurement of muscle strength, subjects should be requested to indicate the pain level on a standard visual analog
scale immediately after each contraction, and pain-free measurements should be preferred.

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Practical Examples of Knee and Hip Muscle-Strength

Evaluation in Orthopaedic Practice
Isometric strength assessment with a handheld dynamometer
is performed easily in most clinical environments (the devices
are portable and weigh <1 kg), requires little skill (the dynamometers require no setup), and is relatively inexpensive (the
dynamometer costs approximately $800 to $1500)26; thus, it
can be easily integrated into routine clinical examinations.
Additionally, it is extremely easy and straightforward to compare the isometric strength data obtained by different individuals (interrater reliability) and with the use of different
handheld dynamometers (intermachine reliability) because of
limited data processing and standardized calibration procedures (loading with certified weights). Therefore, evaluation of
isometric strength with these portable devices is a good testing
modality for multicenter clinical studies.
Demonstrative examples of handheld-dynamometer-based
applications were recently provided by Bohannon20 (for knee
muscles) and Krause et al.24 (for hip muscles). Practical examples of knee extensor and hip abductor muscle-strength
evaluations that could be easily incorporated into standard
orthopaedic clinical examinations are provided below. The
only measuring tools required for these assessments are a
handheld dynamometer and a tape measure.
Knee extension force is measured with the subject seated
on the treatment table, with the legs perpendicular to the floor
and the knees flexed 90 (Fig. 1, A). The dynamometer is
applied to the anterior part of the leg, 5 cm above the transmalleolar axis and perpendicular to the tibial crest. Hip abduction is tested with the subject in the side-lying position
with the hip abducted approximately 10 (Fig. 1, B). Both hips
are in neutral flexion, extension, and rotation. The examiner
stabilizes the pelvis to limit pelvic and trunk rotation in the
transverse plane. The dynamometer is placed on the lateral
aspect of the leg, 5 cm above the lateral malleolus.
Following patient positioning, instructions about the
execution of the contractions are provided. Then, the patient
is asked to perform a series of standardized (submaximal)
practice contractions to familiarize him or her with the procedures and as a warm-up. The subject is asked to take one or
two seconds to reach a maximal effort and then to extend the
knee or abduct the hip as forcefully as possible. The highest
force obtained during the maximal effort is recorded by the
dynamometer. The subject is asked to perform two or three
maximal trials separated by thirty seconds of rest, provided
that the force difference between the two trials does not exceed
10%. Additional trials are performed until the force difference
between the two trials is lower than 10%. Standardized verbal
encouragement should be consistently provided, and the lack
of pretension should be verified prior to each contraction. The
lever arm length (i.e., the distance between the lateral femoral
condyle and 5 cm above the lateral malleolus when knee extension is being tested and the distance between the greater
trochanter and 5 cm above the lateral malleolus when hip
abduction is being assessed) is quantified (in meters) with a
tape measure and then multiplied by the maximal force (in

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TABLE II Steps for the Assessment of Isometric Muscle

Strength in Clinical Practice
Step

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impairments) after operative treatment or immobilization. An

understanding of these qualitative aspects is of primary importance for the planning of therapeutic intervention.

Details

Subject positioning

Knee: seated with hip and

knee at 90 (Fig. 1, A)
Hip: side-lying with hip
abducted 10 (Fig. 1, B)

Instructions

You will take 1 or 2 seconds

to reach the maximal effort and
then maintain this level for about
3 seconds

Practice/familiarization/
warm-up trials

5-6 consecutive trials at

increasing intensity,
without exceeding 80% of
estimated maximal effort

Dynamometer positioning

Knee: anterior, 5 cm above

transmalleolar axis
Hip: lateral, 5 cm above
malleolus

Maximal trials

2 (or 3) contractions of
3-5 seconds, separated
by 30 seconds

Maximal force recording

Dynamometer reading
(preferably in newtons)

Pain assessment

Immediately after end of each

contraction, with use of
0-10-point visual analog scale

Lever-arm-length
measurement

Knee: lateral femoral condyle

to 5 cm above lateral malleolus
Hip: greater trochanter to
5 cm above lateral malleolus

Maximal torque
calculation

Maximal force (newtons)

lever arm (meters)

Filling out of medical

examination form

Mean torque and pain

newtons) to obtain the maximal torque. After each contraction, the level of pain is quantified with use of a 0 to 10-point
visual analog scale. It is recommended that the average torque
and pain level be reported on the medical examination form.
These steps are summarized in Table II.
Techniques and Procedures to Evaluate
Neuromuscular Mechanisms of Force
Besides isometric torque recordings, which allow rapid force
and force control to be investigated, surface electrical stimulation, electromyography, and ultrasonography are three of the
main techniques that can be easily combined with isometric
actions to explore the mechanisms underpinning forcegenerating capacity. They are largely adopted to investigate the
sarcopenia-related problems in geriatric medicine36,37, and
their use in orthopaedic populations is infrequent19,38,39. In the
specific case of orthopaedic research, these noninvasive techniques could help in the determination of the etiology of muscle
weakness (i.e., whether it is due to neural and/or muscular

Isometric Torque Recordings

Torque recordings during a maximal voluntary contraction
(rapid-force instruction) offer the possibility to investigate the
contractile rate-of-force-development parameters, which are
derived from the slope of the torque-time (or force-time)
curve and include the maximal rate of force development
(delta torque/delta time), rate of force development and impulse at specific time intervals (from 0 to 30 to 0 to 200 msec),
and time to reach a specific percentage of the maximal voluntary contraction40. It has been suggested that these rate-offorce-development parameters could be more predictive of
functional difficulties than maximal strength, particularly for
women with knee osteoarthritis41. Several activities of daily
living, such as descending stairs or preventing a fall after a
sudden postural perturbation, are characterized by a limited
time to generate force (<200 msec), and the ability to produce
force rapidly could be viewed as an essential functional parameter in these activities38,40,42. Interestingly, maximal walking
speed has been shown to be related to the rate of force development of the quadriceps but not to the maximal voluntary
contraction strength in subjects who have undergone total hip
arthroplasty 9,38. In the same way, my colleagues and I recently
observed that, in contrast to maximal voluntary contraction
strength, quadriceps rate-of-force-development parameters
correlated with subjective knee function in patients treated
with total knee arthroplasty43.
Isometric torque recordings allow quantification of force
control at submaximal force levels, which is especially important in daily activities that are executed with a fraction of
the available maximal muscle strength44. Force steadiness (i.e.,
the standard deviation or fluctuation of the force signal) and
accuracy (i.e., the difference between the actual and target
forces) are two force-control outcomes that can be easily quantified during sustained contractions at predetermined submaximal intensities. In Figure 2, alterations in the steadiness
and accuracy of hip flexion torque early after total hip arthroplasty are clearly discernible by a comparison of the involved
and uninvolved sides. Using the same methodology, Hortobagyi
et al.44 demonstrated that the ability of patients with knee osteoarthritis to control submaximal quadriceps forces was impaired compared with that of age and sex-matched healthy
controls.
Electrical Stimulation
Painless electrical stimulation can be applied during a voluntary
contraction (Fig. 3, A) and/or at rest (Fig. 3, B) to investigate
central (muscle-activation) and/or peripheral (contractility) factors affecting muscle strength through the analysis of force
traces (upper panels in Fig. 3) and evoked electromyographic
activity (lower panels in Fig. 3). The main benefit of the use of
this technique for orthopaedic populations is that it overcomes
the problem of pain associated with voluntary muscle strength

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Fig. 2

Assessment of submaximal force control ability. The image shows the hip flexor torque-time (top) and rectus femoris
electromyographic (EMG) activity-time (bottom) traces during twenty-second submaximal isometric contractions on the
involved and uninvolved sides of a female patient six weeks after a total hip arthroplasty (through the anterior approach).
The horizontal lines indicate the target torque (25% of the maximal voluntary contraction [MVC]). Steadiness (i.e., the
standard deviation of the actual torque divided by the mean, expressed as a percentage) and accuracy (i.e., the absolute
difference between the actual and target torques) are better on the uninvolved side (4.2% and 0.097 Nm) than they are
on the involved side (23.5% and 0.302 Nm). Note that impaired force control on the involved side is accompanied by
large fluctuations in electromyographic activity.

testing and thus can be used soon after operative treatment or

even on immobilized muscles (e.g., through holes in a cast).
Surface electrical stimulation can be categorized as
motor nerve or direct muscle stimulation, according to the
position and size of the stimulating electrodes. In the first case,
small electrodes are positioned over the peripheral nerve
trunk, at a site where it runs close to the skin (e.g., the femoral
triangle for the femoral nerve). Over-the-muscle electrical
stimulation is performed with large electrodes placed in
proximity to the muscle motor point, which activate intramuscular nerve branches and not the muscle fibers directly45.
Although this modality is commonly adopted in both healthy
and orthopaedic populations2,46, two important limitations
must be acknowledged: muscle activation is incomplete and
relatively superficial47,48, and compound muscle action potentials (M waves) cannot be easily recorded, so stimulus efficacy
cannot be verified. Therefore, whenever possible, electrical
nerve stimulation should be preferred over electrical muscle
stimulation for assessment of neuromuscular function. Inter-

estingly, peripheral magnetic stimulation has also been shown

to provide valid and reliable assessment of neuromuscular
function49, including muscle activation50.
Force traces associated with single, paired, or trains of
stimuli delivered under resting conditions can be used to examine muscle contractile properties (e.g., contraction speed
and twitch force), which are not influenced by voluntary
processes and pain. Together with the analysis of the M wave
recorded by surface electromyography, analysis of the twitch
characteristics allows excitation-contraction coupling to be
investigated in vivo51 (Fig. 3, B). However, muscle activation
can be measured with use of twitch interpolation during a
maximal voluntary contraction, where one (or more) supramaximal stimulus is delivered to the motor axons innervating
the muscle and voluntary and evoked force outputs are compared. Any additional force produced by the stimulation (a
in Fig. 3, A) indicates muscle activation failure (or arthrogenous muscle inhibition) due to incomplete motor unit recruitment and/or suboptimal firing frequency of active units.

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Fig. 3

Assessment of muscle activation (A) and excitation-contraction coupling properties (B). The image shows the quadriceps
torque-time (top) and vastus lateralis electromyographic (EMG) activity-time (bottom) traces on the involved side during a
four-second maximal voluntary isometric effort with a superimposed electrical stimulus (first arrow from the left). The same
stimulation (a 1-msec single pulse at 50 mA) is delivered one second after the end of the contraction (second arrow). The
two stimuli evoke, respectively, a superimposed (a) and a resting (b) twitch. In B, the twitch torque and M-wave traces,
whose characteristics (duration and amplitude) allow investigation of excitation-contraction coupling, are magnified
(shaded area at approximately 5 seconds in lower panel of A). The central activation ratio, calculated as maximal
voluntary contraction/(maximal voluntary contraction 1 a) 100, is ;85%, and the voluntary activation level, calculated
as (1 2 [a/b]) 100, is ;65%. Note that the two formulas provide considerably different muscle-activation scores.

Two formulas are classically used to estimate the extent of

activation. To assess voluntary activation, the size of the interpolated twitch (a) is divided by the size of a control twitch
(b) produced by identical stimulation in a relaxed potentiated state52. To determine the central activation ratio, a simple
maximal voluntary contraction-to-maximal evocable force ratio is calculated53. Using these outcomes, several investigators
have demonstrated that quadriceps weakness is accompanied
by muscle activation deficits in patients with knee osteoarthritis46, a total knee replacement2,46,54, an anterior cruciate
ligament injury6, or even a total hip replacement38.
Surface Electromyography
Electromyography is the recording of electrical signals that
are sent from motor neurons to muscle fibers (action potentials) while they propagate along the sarcolemma, from
the neuromuscular junction to the extremities of the muscle
fibers17. The classic configuration for surface electromyography
of a whole muscle consists of two small electrodes positioned between the innervation zone and the tendinous
insertion (bipolar). The electromyographic amplitude and
power spectrum reflect both central and peripheral neuro-

muscular properties, but they are also influenced by several

nonphysiological factors (e.g., skin-electrode contact, subcutaneous fat thickness, muscle shift relative to the electrodes, and cross talk from nearby muscles)55. For this reason,
between-subject comparisons of raw data and electromyographic recordings during dynamic tasks are not generally
recommended; instead, normalized isometric electromyographic data should be used.
Recording of electromyographic activity during a maximal voluntary contraction (lower panel of Fig. 3, A) is another
technique for examining muscle activation, which, in contrast
to twitch interpolation, allows changes in descending drive
between the synergists of a muscle group to be distinguished.
Understanding how specific muscle portions are affected
within a muscle group (e.g., the different heads of the quadriceps) could be extremely relevant for certain orthopaedic
applications, such as elucidating anterior knee pain and
patellar instability. In addition, surface electromyography
could be used to detect specific nerve and/or muscle impairments (e.g., caused by damage) following surgery or
postoperative complications. Depending on the aim of the
assessment, electromyographic amplitude (average rectified

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or root mean square) could be expressed relative to a standardized contraction (e.g., the highest maximal voluntary
contraction) or, better, to the size of the M wave to enable
peripheral mechanisms to be excluded from the interpretation
of the data and therefore to provide a valid index of central
activation.
The maximal M wave (lower panel of Fig. 3, B), which is
obtained with supramaximal single stimulation of the nerve
trunk, is evoked by the recruitment of all motor axons and
therefore provides an estimate of the response given by the
whole motor neuron pool. Its amplitude is a measure
of transmission across the neuromuscular junction and
muscle membrane excitability. Maximal M-wave amplitude
is also used as a normalization standard for reflex potentials.
These responses, which are largely overlooked in the orthopaedic community, can offer insights into the plasticity of
spinal and tendinous structures associated with disuse and
immobilization56. Hoffmann reflexes, evoked by selective
(submaximal) stimulation of Ia afferents contained in the
corresponding mixed nerve, allow investigation of motor
neuron excitability and/or presynaptic inhibition of Ia afferent
nerves. Spinal reflexes can also be evoked as a result of transient stretches, which can be produced in a reliable way with
use of electromagnetic hammers or special ergometers, to
obtain, respectively, the tendon reflex and the stretch reflex. In
contrast to the Hoffmann reflex, the tendon and stretch reflexes do not bypass the muscle spindles, and therefore they are
influenced by both peripheral (i.e., tendon stiffness) and
central (i.e., synaptic efficiency) factors. Using this methodology, Melnyk et al.57 recently provided evidence that a subjective feeling of knee instability (i.e., so-called giving-way)
following anterior cruciate ligament rupture is associated
with altered stretch-reflex excitability of the hamstring
muscles, but not with mechanical knee instability. Specifically, they demonstrated that certain patients with anterior
cruciate ligament injuries (i.e., those with symptoms of
giving-way) had a longer latency of the medium-latency reflex
in response to quick tibial translation than did patients who do
not have these symptoms. Joint stability (as assessed with an
arthrometer) did not differ between the two groups.

ASSESSMENT OF HIP AND KNEE MUSCLE FUNCTION

O R T H O PA E D I C P R A C T I C E A N D R E S E A R C H

IN

Ultrasonography
In addition to neural and muscular function, the mechanical
properties and morphology of human tendons, as assessed in vivo
with use of B-mode ultrasonography, have been shown to undergo
substantial alterations (e.g., reduced stiffness and altered thickness) with chronic disuse58. Ultrasonography, a relatively new
technique that could be particularly attractive for orthopaedic
applications, can also be used to investigate muscle architecture (fascicle length and pennation angle) both at rest and
during muscle contractions59. Bleakney and Maffulli60 recently
reported considerable architectural alterations (longer fascicle
length and a smaller pennation angle) in the vastus lateralis of
thirteen male patients with a tibial or femoral fracture treated
with intramedullary nailing. Ultrasonography could also be
used as an alternative to magnetic resonance imaging, which is
expensive, for the quantitative assessment of muscle atrophy39,60 and for the investigation of changes in muscular size
and architecture following various rehabilitation programs.
Overview
The most simple and reliable assessment of hip and knee
muscle function in orthopaedic practice and research is direct
quantification of isometric muscle strength with use of standardized procedures. In clinical practice this requires the systematic incorporation of handheld dynamometers into routine
examinations, and in research settings it requires the combined
use of different noninvasive techniques to investigate how
muscular and/or neural impairments contribute to muscle
weakness in orthopaedic populations. n
NOTE: The author thanks Anne F. Mannion, Mario Bizzini, Nicola Casartelli, Julia Glatthorn, Franco
M. Impellizzeri, Romuald Lepers, and Michael Leunig for reading the manuscript and offering
useful suggestions.

Nicola A. Maffiuletti, PhD

Neuromuscular Research Laboratory,
Schulthess Clinic,
Lengghalde 2, 8008 Zurich,
Switzerland.
E-mail address: nicola.maffiuletti@kws.ch

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