Volume 9, Issue 10, October– 2024 International Journal of Innovative Science and Research Technology

ISSN No:-2456-2165 https://doi.org/10.38124/ijisrt/IJISRT24OCT1691

Hip Extensor Weakness and Hip Displacement Angle

During Gait in Post Anterior Cruciate Ligament
Reconstruction Subjects: A Correlativestudy
Chatrajeet Das1; Dev Anand2; Deepmala Thakur3
MPT Musculoskeletal and Sports
Doctorate in Physiotherapy
MPT Professor RR Institution of Physiotherapy

Abstract:- I. INTRODUCTION

 Background and Purpose of the Study: The anterior cruciate ligament (ACL) is one of the 4
The anterior cruciate ligament reconstruction major ligaments in the knee. Two typical mechanisms of
(ACLR) subject’s exhibit altered hip moment pattern ACL injury includes shearing of ACL with sudden shift
during early stance suggesting that the hip doesn’t re- between tibia and femur and hyperextension of the knee
establish normal joint moment characteristics at 3 causing failure of the ligament.1 In ACLR grafts commonly
months post-surgery. Weak hip extensors and used include bone patella tendon bone (BPTB) graft or
quadriceps of the injured leg could lead to reduced hip hamstring (semitendinosus / gracilis) graft.1 It has been
extension and therefore a reduced hip displacement suggested that, after surgery, the ability to perform
angle (HDA), and step length. functional activities and balance may be decreased 5–10%.
Deficits have been found in the muscular and sensory
 Method: processes after reconstructive surgery. Specifically, after
An observational correlative study was conducted ACLR with the BPTB procedure, strength deficits of 5% to
at HOSMAT Hospital physiotherapy OPD with a 34% have been reported in the involved extremity compared
Sample size of 30. Outcome measures used were Hip with the contra lateral limb after rehabilitation.4 Reports of
extension (HE), Hip extensor strength (HES) and Hip prolonged hip extensor moments have been common after
Displacement Angle (HDA). ACLR.1,7 The ACLR subjects exhibit altered hip moment
pattern during early stance suggesting that the hip doesn’t
 Results: re-establish normal joint moment characteristics at 3 months
30 subjects with a Mean (SD) age of 28.27 (±5.85) post- surgery.2,3,4,5
yrs. 1 female and 29 males were included. There was
statistical significant difference in all 3 outcome Weak hip extensors and quadriceps of the injured leg
measures (HE, HES and HDA) in affected side compared could lead to reduced hip extension (HE) and therefore a
to un-affected side, using paired “t” test. Correlations reduced step length and velocity.6 Studies have suggested
among the normalized outcome measures were done that the hip extensors, knee extensors, and ankle plantar
using pearson’s correlation co-efficient. re =0.450 flexors all help to control hip and knee extension during the
(p=0.013) for HE and HES, rs = 0.346 (p=0.061) for HES stance phase of normal gait.7 The hip displacement angle
and HDA, ra = 0.328 (p=0.077) for HDA and HE. This (HDA) is the difference in hip angle between the leading
study showed a weak correlation among the outcome and trailing leg at heel strike (HS) and is theorized to
measures. represent the functional hip range of motion at this time of
point. HDA, leg length and to a lesser degree knee joint
 Conclusion: angle all contribute to step length. HDA reflects the hip joint
In this study significant difference was appreciated influence on step length without any contribution from the
in all the 3 outcome measures between affected and knee joint.1 The purpose for conducting this study was to
unaffected side. HE and HES was decreased in affected check co-existence of hip extensor weakness and
side compare to unaffected side after 3 weeks of ACLR corresponding reduction in hip extension (HE) and hip
and increase in HDA in the affected side. Statistical displacement angle (HDA) during gait.
correlation among the outcome measures showed very
weak correlation among them. II. METHOD

Keywords:- Anterior Cruciate Ligament Reconstruction, 30 subjects who underwent ACL reconstruction
Hip Extension, Hip Extensor Strength, Hip Displacement surgery at Hosmat hospital were included in the study after
Angle, Gait. ruling out the inclusion and exclusion criterias. Inclusion
criterias were 1) 3weeks Post ACL reconstruction. 2) Age
18-40 yrs .3) Gender: Both males and females. 4) Subjects

IJISRT24OCT1691 www.ijisrt.com 2616

Volume 9, Issue 10, October– 2024 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165 https://doi.org/10.38124/ijisrt/IJISRT24OCT1691

visited physiotherapy department as outpatient. Exclusion unaffected extremity. The average of the readings was
criterias were: 1) Infection (local or general). 2) Subjects considered for data analysis.
complained of pain level more than 6 on VAS while weight
bearing. 3) Apprehensive to walk. 4) Dependence on
assistive aids. 5) Menisci tear along with ACL. 6)
Associated fractures. 7) Multiple ligament failure. 8)
Flexion deformity >100. 9) Profound swelling post
operative. 10) Limb length discrepancy 29. 11) Hip
contractures. 12) Gastrocnemius and Soleus tightness.

Outcome measures included were 1) Hip extensor

strength. (KgF). 2) Hip extension. (Degree). 3) Hip
displacement angle during gait (Degree).

Pain intensity while weight bearing was evaluated by

means of a visual analogue scale (VAS), ranging from 0 cm
to 10 cm, wherein the subjects had marked a point according
to their pain level, a higher pain score correspond to more
intense pain. Fig 2 Measurement of Hip Extensor Strength (HES)
 Figures: For the assessment of HES, the Isometric
dynamometer (Modified handgrip dynamometer) was
attached to a specially designed portable and adjustable
hand hold bar which examiner was stabilized during the test.
On applying pressure, the measurement of Kg force (KgF)
exerted was recorded on the control pad. To ensure accuracy
of this measurement, the pelvis and contra-lateral leg was
fully stabilized by belts with the couch. The dynamometer
was secured onto the specially designed hand hold bar and
stabilized by the examiner, so that motion and force
artefacts can be minimized during the test.(Fig 2)

(Fig: 2) The subjects were lying down prone on the

couch; the dynamometer with the portable and adjustable
hand hold bar was fixed 5 cm over the back of the thigh and
stabilized by the examiner. The pelvis and contra-lateral leg
was stabilized on the couch with stabilizing belts. The
testing leg was extended approximately till 70° (to isolate
Fig 1 Measurement of Hip Extension Glutei hip extension) and were supported by an assistant and
subjects were asked to do extension of the hip and create
For HE , subjects were instructed to lie prone on the pressure on the dynamometer with the back of the thigh as
couch. The fulcrum was aligned with the greater trochanter much as possible [Fig 2]. Three readings were taken and the
of the femur.[Fig. 1] The stationary arm was positioned average of all the three readings was used for data analysis.
along the lateral midline of the abdomen, using the pelvis Measurement was taken on unaffected leg first and then
for reference, the moving arm along the lateral midline of affected leg. In case of the readings falling in between two
the femur. The subject was instructed to lift the leg off the marked value in the dynamometer, the higher value was
couch. The active range of motion (AROM) of hip extension consider for data analysis.
was measured from the reading of goniometer. The
procedure was repeated three times on affected and

IJISRT24OCT1691 www.ijisrt.com 2617

Volume 9, Issue 10, October– 2024 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165 https://doi.org/10.38124/ijisrt/IJISRT24OCT1691

Fig 3 Measurement of Gait Parameters:

The subjects were instructed to wear shorts during (UA_HDA) means when angle was measured while
walking session. A digital SLR with Full HD movie forwarding the unaffected limb during gait cycle.
recording (SONY DSC-HX100V) was placed 6 m away
from the walkway, on a 2.5 feet high fixed platform, A computerized goniometry tool (Kinovea 0.8.15) was
perpendicular to the direction of movement. Subjects were aligned over specific landmarks to obtain the joint angles.
instructed to move at their comfortable speed along the HDA reflects the hip joint influence on step length without
length of the walkway. Two trials were taken, two in either any contribution from the knee joint.
direction. Individual AVI files were saved for each gait trial.
These were then analyzed frame by frame until the frame III. RESULT
corresponding to Heel Strike was discovered for both the
injured and non injured legs using Kinovea 0.8.15. The demographic data age and POD assessment data
Individual frames corresponding to events of interest was was described by Median and Range. Hip extension (HE),
saved from the video and stored as JPEG files. Hip extensor strength (HES) and Hip displacement angle
(HDA) for both affected and unaffected side scores was
 Method used to Obtain Joint angle Measurements described by Mean m and SD and checked for normal
Hip displacement angle was measured using Kinovea distribution for the same data. Affected verses Un-affected
software. Electronic goniometer was placed along the length comparison was done using paired t-test. The correlation
of both femurs till the level of femoral condyles. Angle was between HE and HES, HE and HDA, HES and HDA was
measured at intersection point on pelvis during heel strike analyzed by pearson’s correlation co-efficient.
on forward limb and heel off on backward limb. Affected
HDA (A_HDA) means when angle measured, when affected  Demographic Data:-
limb was forward during gait and Unaffected HDA

Table 1 Demographic data: [M – Male, F – Female, R – Right side, L – Left side,Hams – Hamstring, POD – Post Operative day]
Serial No. Subjects Parameters Frequency
1. Age in years – [Mean (± SD)] 28.27 (± 5.85)
2. Gender [ M / F ] 29 / 1
3. Side affected [ R/L ] 15 / 15
4. Graft [BPTB / Hams ] 28 / 2
5. POD – [Median (Range)] 24 (21 - 26)

IJISRT24OCT1691 www.ijisrt.com 2618

Volume 9, Issue 10, October– 2024 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165 https://doi.org/10.38124/ijisrt/IJISRT24OCT1691

 Comparison of means of affected and Unaffected Side with Paired ‘t’-Test:-

Table 2 Decriptive data: [HE – Hip extension, HES – Hip extensor strength, HAD – Hip displacement angle, KgF – Kilogram
force, SD – Standard Deviation] * p < 0.05, df = 29
HE HES HDA
AFFECTED SIDE 27.754 ± 2.295 30.355 ± 5.429 32.266 ± 4.438
UNAFFECTED SIDE 29.91 ± 1.543 36.976 ± 5.844 26.98 ± 3.89
Comparison of means 8.273* 18.925* -11.785*
with paired “t” test

Normalization of data was done taking ratio of mean of showed a very weak correlation among the data. re = 0.450
all 3 outcomes; HE, HES and HDA of affected side with (p=0.013) for HE and HES, rs = 0.346 (p=0.061) for HES
unaffected side and its shown in Table No. 3; so that data and HDA, ra = 0.328 (p=0.077) for HDA and HE; shown in
can be compare with each other. Table No 3.

Correlations among the normalized outcome measures  Nomalization of Data:-

were done using pearson’s correlation co-efficient. It

Table 3 The mean (SD) ratio of HE, HES, HDA

Outcome measures Symmetrical ratio between sides ( Mean ± SD )
HE ratio (A/UA) 0.927 ± 0.050
HES ratio (A/UA) 0.821 ± 0.047
HDA ratio (UA/A) 0.837 ± 0.067

Table 4 Correlation between HE and HES; HES and HDA; HDA and HE using Pearson’s Correlation coefficient:- * Correlation is
significant at the 0.05 level (2tailed).Correlation between outcome measures.
Outcomes Correlative co-efficient
HE and HES re = 0.450*
HES and HDA rs = 0.346
HDA and HE ra = 0.328

IV. DISCUSSION was significant increase in HDA in affected side compare to

unaffected side after 3 weeks of ACLR surgery. This could
The aim of this study was to examine HES after ACLR be explained as, stance duration is longer in non-operated
and HDA during normal gait and correlation between HE, leg compare to operated leg, and so affected leg step length
HES and HDA during gait. A total of 30 subjects were is longer compared to unaffected side step length. The
recruited for the study. Mean age of the subjects was 28.27 results are accordance with a previous study.12 Decrease in
± 5.85 years ranging from 17 to 43 years. This age group step length and HDA on the operated leg could also be due
was taken for study as they are more prone to ACL injury to pain10, fear avoidance13 and alteration of extensor
and wants to undergo ACLR surgery, to get back to their mechanism12. Underlying cause of the reduced unaffected
recreational activities.1 There were 29 male subjects and 1 HDA may have been weak hip extensor along with
female subjects participated in the study, due to their quadriceps of operated leg. Reduced unaffected HDA would
personnal reasons. There were 7 traumatic ACL injury, 1 contribute to knee stability by reducing the single leg
professional sports injury, 21 recreational sports injury and 1 support time and biomechanical load on the operated leg
domestic injury. There were 15 right sided and 15 left sided during gait.1 Previous study stated reduced unaffected HDA
ACLR subjects who participated. Out of them 28 subjects in ACLR was found to be positively correlated to gait
were reconstructed with BPTB graft and 2 were velocity.14 Correlation among outcome measures (HE, HES
reconstructed with hamstring tendon graft. Assessment was and HDA):- Poor correlation was found among the
done in between 21st to 26th OPD with a median 24 POD. Normalized outcome measures. This may be due to various
The result of this study demonstrated that there was reasons. This study only concentrates on hip parameters
significant decrease in HE and HES in affected side mainly HE and HES. But gait depends on other factors like
compared to unaffected side, which could be due to no focus knee musculature (mainly quadriceps and hamstring) and
during initial rehabilitation phase on HE and HES. Also hip, knee and ankle kinematics or may be fear avoidance33.
while doing hip extension, length of quadriceps muscles In a previous study the multi joint accelerations induced by
could be a limiting factor as maximum subjects were muscles during single limb stance confirmed that the gluteus
reconstructed with BPTB graft. Also subjects were maximus, vasti and soleus make substantial contributions to
apprehensive towards movement of knee. The results may hip and knee extension during normal gait7. Clinical factors
be attributed to weakness of Gluteus maximus on affected that could have caused altered kinematics and gait
side in comparison to unaffected side which may lead to parameters like effects of swelling, ROM of knee,
reduction in hip extension in open kinematic chain.10 There physiotherapy sessions, activity levels and some underlying

IJISRT24OCT1691 www.ijisrt.com 2619

Volume 9, Issue 10, October– 2024 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165 https://doi.org/10.38124/ijisrt/IJISRT24OCT1691

pathology are considered minimal, although difference have REFERENCES

not been tested statistically1. Weak hip extensor along with
quadriceps weakness of the operated leg could lead to [1]. Kate Button, Robert van Deursen, Patricia Price,
reduced hip extension during stance phase of operated leg Recovery in functional non- copers following
and therefore a reduced HDA and step length.7 Also subjects anterior cruciate ligament rupture as detected by gait
were taken in 3rd week of POD after ACLR, they were kinematics. Physical Therapy in Sport 9 (2008) 97–
dominated by pain and fear avoidance13 and were weaning 104.
from assistive aids promoting full weight bearing. Previous [2]. Hiemstra LA, Webber S, MacDonald PB, Kriellaars
investigation reported that Chronic ACL deficient patients DJ. Knee strength deficits after hamstring tendon and
tend to develop a quadriceps avoidance gait pattern.14 patellar tendon anterior cruciate ligament
Devika et al reported that ACLR subjects walked with reconstruction. Med Sci Sports Exerc. 2000;32:1472–
approximately 10° higher flexion at the knee joint 3 weeks 1479.
after surgery, which may reduce hip extension and HDA [3]. Bulgheroni P, Bulgheroni MV, Andrini L, Guffanti
during gait; however no differences were observed 6 months P, Giughello A. Gait patterns after anterior cruciate
later compared to uninjured controls. ligament reconstruction. Knee Surg Sport Traum
Arthr 1997;5:14-21.
V. LIMITATION OF THE STUDY [4]. Bush-Joseph CA, Hurwitz DE, Patel RR, Bahrani Y,
Garretson R, Bach BR, et al. Dynamic function after
 Smaller sample size. anterior cruciate ligament reconstruction with
 Ratios of female subjects were very less. So difficult to autologous patellar tendon. Am J Sports Med
generalized the results. 2001;29(1):36–41.
 Measurement error might come while measuring HES [5]. Devita P, Hortobagyi T, Barrier J. Gait adaptations
and HDA, as dynamometer was not fixed in a stable before and after anterior cruciate ligament
fixed platform as it was stabilized by the examiner. reconstruction surgery. Med Sci Sports Exerc
There were no proper anatomical landmarks on the 1997;29:853– 9.
subjects while measuring HDA in video tape using [6]. Timoney JM, Inman WS, Quesada PM, Sharkey PF,
kinovea software, so accuracy could be biased. Barrack RL, Skinner HB, et al. Return of normal gait
 This study only focused on hip strength and hip patterns after anterior cruciate ligament
kinematics during gait but gait is affected by many other reconstruction. Am J Sports Med 1993;21(6):887–9.
factors. [7]. Allison S. Arnold , Frank C. Anderson, Marcus G.
 Only one dimension of gait analysis was focused in this Pandy, Scott L. Delp,
study. [8]. Muscular contributions to hip and knee extension
during the single limb stance phase of normal gait: a
 Further Recommendation:- framework for investigating the causes of crouch
gait. J Biomech 2005; 38 2181–2189.
 Larger sample size to generate better data analysis. [9]. Neptune, R.R., Zajac, F.E., Kautz, S.A.,. Muscle
 Further studies should include knee and ankle kinematics force redistributes segmental power for body
along with hip kinematics. progression during walking. Gait Posture 2004;19,
 Other outcome measures of knee to be considered for 194–205.
data analysis. [10]. Laurie A. Hiemstra, MD, PhD, FRCS(C),Wade T.
Gofton, MD, and Dean J.
VI. CONCLUSION [11]. Kriellaars, PhD, Hip Strength Following Hamstring
Tendon Anterior Cruciate Ligament Reconstruction.
In this study significant difference was appreciated in Clin J Sport Med, Volume 15, Number 3, May 2005.
all the 3 outcome measures between affected and unaffected [12]. Massimo Bacchini, Carola Cademartiri, Giovanni
side. HE and HES was decreased in affected side compare to Soncini Gait analysis in patients undergoing ACL
unaffected side after 3 weeks of ACLR and increase in HDA reconstruction according to Kenneth Jones’technique.
in the affected side. ACTA BIOMED 2009; 80: 140-149.
[13]. Michael D. Ross, The relationship between
 Implications on Physiotherapy Practice: functional levels and fear- avoidance beliefs
Hip extensor muscles should also be priotized during following anterior cruciate ligament reconstruction. J
ACL rehabilitation as considering only knee joint muscles Orthopaed Traumatol (2010) 11:237–243.
leads to change in gait pattern of post ACL construction [14]. Judith M. Burnfield, PT, Karen R. Josephson, MPH,
patients. Complete recovery and getting back to pre surgery Christopher M. Powers, PhD, PT,Laurence Z.
functional level will be difficult for patients if hip muscles Rubenstein, MD, MPH, The Influence of Lower
are not considered part of ACL rehabilitation protocol. Extremity Joint Torque on Gait Characteristics in
Elderly Men. Arch Phys Med Rehabil Vol 81,
September 2000.

IJISRT24OCT1691 www.ijisrt.com 2620