Manual Therapy 14 (2009) 605–610

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Manual Therapy
journal homepage: www.elsevier.com/math

Original Article

The association between degenerative hip joint pathology and size of the
gluteus medius, gluteus minimus and piriformis muscles
Alison Grimaldi a, *, Carolyn Richardson a, Warren Stanton b, Gail Durbridge c,
William Donnelly d, Julie Hides a, b
a
Division of Physiotherapy, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane 4072, Australia
b
The UQ/Mater Back Stability Clinic, Mater Health Services, Raymond Terrace, South Brisbane, Queensland 4101, Australia
c
Centre for Magnetic Resonance Imaging, Brisbane, Australia
d
Brisbane Orthopaedic Specialist Services, Brisbane, Australia

a r t i c l e i n f o a b s t r a c t

Article history: This study aimed to investigate changes in the deep abductor muscles, gluteus medius (GMED), pir-
Received 13 November 2008 iformis (PIRI), and gluteus minimus (GMIN), occurring in association with differing stages of unilateral
Received in revised form degenerative hip joint pathology (mild: n ¼ 6, and advanced: n ¼ 6). Muscle volume assessed via
19 June 2009
magnetic resonance imaging was compared for each muscle between sides, and between groups (mild,
Accepted 8 July 2009
advanced, control (n ¼ 12)). GMED and PIRI muscle volume was smaller around the affected hip in
subjects with advanced pathology (p < 0.01, p < 0.05) while no significant asymmetry was present in the
Keywords:
mild and control groups. GMIN showed a trend towards asymmetry in the advanced group (p ¼ 0.1) and
OA
Gluteus medius the control group (p ¼ 0.076) which appears to have been associated with leg dominance. Between group
Gluteus minimus differences revealed a significant difference for the GMED muscle reflecting larger muscle volumes on
Piriformis the affected side in subjects with mild pathology, compared to matched control hips. This information
suggests that while GMED appears to atrophy in subjects with advanced hip joint pathology, it may be
predisposed to hypertrophy in early stages of pathology. Assessment and exercise prescription methods
should consider that the response of muscles of the abductor synergy to joint pathology is not
homogenous between muscles or across stages of pathology.
Ó 2009 Elsevier Ltd. All rights reserved.

1. Introduction OA of the hip have demonstrated a change in pelvic-femur align-

ment during gait depending on stage of pathology. Those with mild
Osteoarthritis (OA) of the hip poses a considerable problem for OA demonstrate increased hip adduction during stance (Watelain
modern society. As the incidence of OA of the hip increases with the et al., 2001), while those with more advanced changes reduce
aging population it has been declared by March and Bagga (2004) adduction by increasing frontal plane trunk movement (Krebs et al.,
that ‘primary and secondary programs aimed at improving reha- 1998). The specific changes in abductor muscle function occurring
bilitation and physical activity are urgently required’ in the in association with OA are however unclear at this point. While
management of OA. Therapeutic exercise programmes designed to some authors have demonstrated reduced electromyographic
improve muscle function around the affected hip will only be (EMG) activity in the gluteus medius (GMED) muscle in subjects
maximally effective when we have further information available on with OA of the hip (Long et al., 1993), others have shown increased
both normal muscle function, and changes occurring in association EMG activity during dynamic function (Angielczyk and Bronarski,
with joint disease. 1982; Sims et al., 2002). EMG testing of the tensor fascia lata (TFL)
Hip abductor muscle function has been a primary focus of muscle has shown similar inconsistency (Long et al., 1993; Sims
research due to the importance of these muscles in performing et al., 2002). No EMG investigations of the other hip abductor
single leg function, the basis of human locomotion. Patients with muscles, upper gluteus maximus (UGM), gluteus minimus (GMIN)
or piriformis (PIRI) muscles, in patients with OA of the hip, have
been reported in the literature. Studies that have involved strength
testing as a measure of hip abductor muscle function in subjects
* Correspondence to: Alison Grimaldi, PhysioTec Physiotherapy, 23 Weller Rd,
Tarragindi, Brisbane, Queensland 4121, Australia. Tel./fax: þ61 7 3342 4284. with OA of the hip, have used dynamometry to measure open chain
E-mail address: [email protected] (A. Grimaldi). isometric or isokinetic abduction strength, providing a global

1356-689X/$ – see front matter Ó 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.math.2009.07.004
606 A. Grimaldi et al. / Manual Therapy 14 (2009) 605–610

assessment of the abductor synergy (UGM, TFL, GMED, GMIN, PIRI). Table 1
These studies have, like EMG studies, displayed considerable vari- Subject characteristics for each group.

ability (Murray and Sepic, 1968; Teshima, 1994; Jandric, 1997; Group No Sex Age Weight(kg) Height(cm) BMI
Arokoski et al., 2002; Sims et al., 2002). The body of literature to M:F Mean(SD) Mean(SD) Mean(SD) Mean(SD)
date thus provides an incomplete and unclear picture of hip
Mild 6 3:3 46.5 (9.5) 80.4 (15.1) 171.3 (9.7) 27.3 (3.5)
abductor muscle dysfunction. More specific information on Adv 6 3:3 57.7 (6.7) 78.3 (8.5) 172.0 (7.4) 26.6 (4.4)
patterns of change within the abductor synergy is required. Con 12 6:6 51.8 (9.7) 73.5 (13.3) 168.2 (10.2) 25.9 (3.3)
The use of magnetic resonance imaging (MRI) provides an Number (No); Body Mass Index (BMI); Male:Female (M:F).
opportunity to assess each individual member of the abductor Standard deviation (SD); Advanced Pathology (Adv); Control (Con).
synergy simultaneously. One previous MRI study assessed cross
sectional area (CSA) of the abductor muscles in subjects with OA of
the hip, however most of the muscles were grouped together recruited for either a ‘Mild’ or an ‘Advanced’ group. Those deter-
providing a global measure of abductor muscle size (Arokoski et al., mined by an experienced radiologist to have early joint space
2002). In addition, single CSA measurements are unlikely to be as narrowing and osteophytes (Kellgren/Lawrence (K/L) global scoring
reflective of a muscle’s morphology as a measurement of muscle system grades 1–2 (Kellgren and Lawrence, 1957; Hirsch et al.,
volume. The research undertaken by the current authors used MRI 1998) were included in the mild group. Subjects with moderate to
to assess muscle volume of each individual member of the abductor severe joint space narrowing and osteophytes (K/L grades 3–4)
synergy in subjects with OA of the hip. This has been presented as were recruited for the advanced group. Pathology was right sided
two papers with muscles divided on an anatomical basis. An initial for 5 subjects and left for 7 subjects. An analysis of variance
study (Grimaldi et al., in press) investigated changes present in the (ANOVA) reported previously for these subjects determined that
superficial lateral musculature (UGM and TFL) that insert into the there was comparability between the mild, advanced and control
iliotibial band (Williams et al., 1989). The TFL was unaffected by group subjects for the factors of age, height and weight (Grimaldi
the presence of joint pathology, while the UGM demonstrated et al., in press). Details of subject characteristics are listed in Table 1.
asymmetry in subjects with advanced unilateral OA that appeared Exclusion criteria included any factors that may represent con-
to be more closely related to hypertrophy of the unaffected side, founding variables for muscle size or asymmetry such as systemic
than atrophy around the affected hip (Grimaldi et al., in press). diseases of the muscular of nervous systems, congenital or child-
The main aim of the current study was to investigate in these hood hip disease, any history of hip trauma, surgery, inflammatory
same subjects, size of the muscles of the deep lateral stability joint disease, tumours, or lower limb or lower back injury within 2
mechanism of the hip, the GMED, GMIN, and PIRI muscles, that years of testing. In addition subjects were excluded if they reported
assert their effect via direct insertion into the greater trochanter. any significant lifetime history of lower back pain that resulted in
Subjects with either mild or advanced unilateral degenerative a period of immobility, investigation, or treatment. Subjects were
pathology of the hip were chosen for maximum clarity of effect. The also excluded in both groups if they reported participation in
specific aims were to examine i) if there was significant asymmetry unilateral sports, use of a walking aid, or any problems that would
in the deep abductor muscles across 3 groups (mild degenerative preclude them from MRI scanning procedures (e.g. pacemaker,
change, advanced degenerative change, control) and ii) if there metal implants, pregnancy, claustrophobia). Control group subjects
were significant differences in actual muscle size among the must have had no history of pain in the hip region.
pathology and control groups. This study also examined the asso-
ciation of both stage of pathology, and muscle size, with the factors
of age, height, weight, pain, function and activity levels. Leg 2.2. Procedure
dominance was also tested as all of these factors were considered to
have the potential to impact upon muscle size and symmetry. Self-Report Questionnaires. Subjects activity levels were rated
The hypotheses of the study were that ia) there would be using a 12 month Leisure Time Physical Activity questionnaire
significant asymmetry in size of the GMED, GMIN, and PIRI in providing an activity metabolic index (AMI) calculated with the
subjects with hip joint pathology, but not in controls, ib) asym- formula: AMI ¼ Intensity code (mean metabolic units)  average
metry would be greater in subjects with advanced pathology, and number of times the activity is performed per month  the number
ii) the GMED, GMIN and PIRI muscles would be smaller around the of months per year (frequency)  the time the activity was per-
affected hip in those with advanced pathology compared to the formed per occasion (duration). AMI for each activity is added so
matched hip of control subjects. total AMI is compared across individuals (Taylor et al., 1978; Aro-
koski et al., 2002). A previously reported ANOVA for these subjects
2. Methods found no significant differences between groups for metabolic
activity (Grimaldi et al., in press). Pain and function were also
2.1. Subjects assessed for pathology groups using the Modified Harris Hip Score
(MHHS) (Byrd and Jones, 2000). This analysis has been reported in
Twelve subjects with degenerative hip joint pathology, and a prior paper revealing a significantly lower score for the advanced
twelve age and sex matched control subjects were recruited for this group (p < 0.05), reflecting higher pain and lower function (Gri-
study via medical practitioners and community advertisement. maldi et al., in press). The relationship between pain, function, and
Control group subjects were required to be within 5 years of the age radiographic change has been discussed in detail in the same paper.
of their matched subject with joint pathology. Each group had Testing of Leg Dominance. Leg dominance during kicking function
equal numbers of males and females and all participants gave their was tested with the weight-bearing leg recorded as ‘‘stance
informed consent to participate in this study after receiving dominant’’ and the kicking leg as the ‘‘skill dominant’’ leg (Herneth
detailed information on the study. Ethical approval was provided et al., 2004). All subjects in this study were left stance dominant.
by the institutional review boards. MRI Assessment. After medical screening for suitability for MRI
Inclusion criteria required subjects with pathology to have procedures subjects were positioned in supine with their legs
a medical diagnosis of unilateral degenerative joint pathology, and extended to a neutral position. A 1.5 Tesla Siemens Sonata MR
radiographic evidence of their pathology. Subjects with OA were system was employed to collect a T2 True FISP sequence using 2
 A. Grimaldi et al. / Manual Therapy 14 (2009) 605–610 607

Table 2 weight, pain, function, and AMI and GMED, GMIN, or PIRI muscle
Intra-rater reliability across repeated measurement for the same image sequence for size was assessed using analysis of covariance.
gluteus medius (GMED), gluteus minimus (GMIN) and piriformis (PIRI) muscles.

Muscle ICC2,1 (95% CI) SEM cm2 SDD cm2

GMED 0.998 (0.997–0.999) 0.506 7.86 3. Results
GMIN 0.997 (0.994–0.998) 0.379 3.72
PIRI 0.985 (0.955–0.995) 0.675 6.74
3.1. Side to side differences in muscle volumes within groups
Intraclass correlation coefficient (ICC), (95% confidence interval at p < 0.05); Stan-
dard error of measurement (SEM); Standard deviation of the difference (SDD).
There was no significant asymmetry in the control group for
GMED, GMIN or PIRI muscle volume, although there was a trend for
series of 28  6 mm contiguous slices throughout the pelvis (TR: the GMIN muscle to be larger on the left side (p ¼ 0.076, 9 of 12
3.78 ms/TE:1.89 ms/FOV:390 mm). control subjects larger on the left). No significant differences were
Measurement Procedure. CSA (cm2) of GMED, GMIN and PIRI observed for any of the muscles studied for the mild group. GMED
muscles was measured by tracing each muscle on each slice using and PIRI were both significantly smaller on the affected side for
an MRI measurement software package (Osiris Version 4.19, subjects with advanced pathology (t ¼ 2.951, p ¼ 0.008; t ¼ 2.195,
University Hospitals of Geneva, Switzerland). Muscle volume (cm3) p ¼ 0.03 respectively). Although comparisons of GMIN muscle
was determined as the sum of the muscles CSA on each slice in volume did not reach statistical significance, there was a trend for
which the muscle appeared, multiplied by the slice width (Fuku- asymmetry in the advanced group (p ¼ 0.1) with smaller GMIN size
naga et al., 1992; Alkner and Tesch, 2004). around the affected hip (mean 8.3% smaller). Five of the 6 subjects
Reliability of the assessor’s measurement technique was tested in this group were on average 21.5% smaller on the affected side,
by retracing all slices of one subject with an interim period of 6 with one subject demonstrating a 48% larger GMIN muscle volume
weeks. Intra-tester reliability was tested for each separate on the affected side.
measurement on each slice using a two sided bootstrapped interval Means, standard deviations, and percentage difference in
of intraclass correlation coefficient (ICC2,1). Intra-rater reliability muscle volumes are reported for each group in Table 3. Examples of
was found to be very good, with correlation coefficients ranging side to side differences are illustrated for each group in Fig. 1.
from 0.985 to 0.989. Standard error of measurement (SEM) was
calculated using the formula SEM ¼ pooled SD  (1  ICC)½ (Wall-
work et al., 2007). Standard deviation of the difference (SDD) was 3.2. Differences in muscle volumes between groups
also calculated as the standard deviation of the differences between
measurement 1 and 2. ICC, SDD and SEM values are presented in Comparisons between groups revealed that the GMED muscle
Table 2. was significantly larger (mean 15%) around the affected hip in the
mild group, compared with the same hip of the matched control
subjects (p ¼ 0.026). No differences were evident between groups
2.3. Statistical analysis for the GMIN or PIRI muscles.

Analysis was performed using the Statistical Package for the

Social Sciences (version 14; www.spss.com). The first analysis 3.3. Effect of subject characteristics on muscle size
addressed the issue of symmetry in muscle size between sides
across the 3 groups. A comparison of muscle volumes among There was no significant relationship between the patient
groups and between sides was performed using a mixed linear characteristics of age, height, weight, and metabolic activity, or pain
model describing muscle volume with group as a between-subjects and function, and GMED, GMIN or PIRI muscle volume (p > 0.05).
factor (control, mild, advanced), and side (affected/unaffected for
the pathology groups; left/right for the control group) as a within-
subjects factor (Dependant variable: muscle volume; Independent
4. Discussion
variables: side, group). Each muscle (GMED, GMIN, PIRI) was ana-
lysed separately. Contrasts of means were performed to compare
This study investigated the influence of degenerative hip joint
sides within groups.
pathology on size of the deep abductor muscles, GMED, GMIN and
Further analysis was conducted to assess whether control group
PIRI.
subjects had larger hip abductor muscles than subjects with hip
pathology. Separate ANOVAs were conducted for each side to
compare muscle volumes across groups. Side comparisons were Table 3
determined via the following method: if the pathological side was Muscle volumes (cm3) for gluteus medius, gluteus minimus, and piriformis muscles,
and percentage difference between sides.
left, the left side muscle volume of the matched control subject was
used for comparison, and the right compared with the unaffected Group Side GMED GMIN PIRI
side value of the pathology group counterpart. The dependant Mean (SD) Mean (SD) Mean (SD)
variable was muscle volume and the independent variable was Mild Affected 369 (63) 87 (23) 28 (10)
group. Each muscle (GMED, GMIN, PIRI) was analysed separately, (n ¼ 6) Unaffected 367 (62) 95 (32) 29 (14)
and contrasts of means were performed to compare size across % Difference 0.4% 7.9% 2.6%
groups. Advanced Affected 317 (94) 84 (34) 28 (8)
(n ¼ 6) Unaffected 361 (71) 91 (33) 33 (8)
For ease of presentation of results, percent differences were
% Difference 12%** 8.2% 14.4%*
calculated using the formula: % Difference ¼ [(larger val- Control Left 317 (75) 86 (21) 28 (8)
ue  smaller value)/larger value]  100 (Hides et al., 1996). (n ¼ 12) Right 305 (88) 79 (21) 28 (8)
Analyses were also conducted to assess participant character- % Difference 3.7% 8.3% 0.4%
istics in relation to the extent of association with muscle size. The Gluteus medius muscle (GMED); Gluteus minimus muscle (GMIN); Piriformis
association between the patient characteristics of age, height, muscle (PIRI); Standard deviation (SD); * p < 0.05, **p < 0.01.
608 A. Grimaldi et al. / Manual Therapy 14 (2009) 605–610

these muscles on the unaffected side as this side becomes favoured

for weight-bearing function.
Despite a lack of statistically significant asymmetry in the
deepest abductor muscle, GMIN, there was a trend towards asym-
metry in the advanced group (mean 8.3% smaller on affected side,
p ¼ 0.1). The importance of this trend is further highlighted when
the removal of a single subject results in an asymmetry reflecting
an average 21.5% smaller GMIN muscle volume on the affected side.
The reason for the lack of atrophy around the affected hip in the
remaining subject is unclear. This subject did remain very active
with an AMI just below the average for normal control subjects,
which may provide some explanation for this variation. Without
this subject there is a clear pattern of asymmetry, smaller on the
affected side, in the majority of the advanced pathology group.
Atrophy in this deepest hip abductor muscle would be consistent
with atrophy evident in other local muscles involved in joint
protection, such as the multifidus muscle in the lumbar spine
(Hides et al., 1994), although some concurrent hypertrophy on the
unaffected side cannot be excluded.
The other consideration in the interpretation of results for the
GMIN muscle is the trend towards GMIN asymmetry, larger on the
left side, in control subjects (p ¼ 0.076). This asymmetry may be
related to leg dominance as all subjects were left stance dominant.
The GMIN muscle may be particularly important in weight-bearing
function to assist in joint protection and stabilisation of the femoral
head in the acetabulum (Beck et al., 2000; Walters et al., 2001). The
relevance of this trend towards asymmetry in control group
subjects is that for subjects with left sided hip joint pathology, the
loss of muscle size may be underestimated.
The only other study to date to investigate symmetry of hip
abductor muscle size in subjects with OA of the hip showed a 6%
smaller CSA of the ‘gluteal muscles’ around the most affected hip in
those with unilateral or bilateral OA (Arokoski et al., 2002).
Although the general picture is consistent with our findings the
combined measure of all hip abductor muscles is difficult to directly
compare to that of the present study.

4.2. Differences in muscle volumes between groups

Differences in muscle volumes between groups were not

significant for PIRI and GMIN muscles, consistent with the lack of
between group difference (OA and control) reported by Arokoski
Fig. 1. The gluteus medius muscle ( in web version), gluteus minimus muscle et al. (2002). A significant difference between control and mild
( in web version), and piriformis muscle ( in web version) in axial pathology groups for the GMED muscle however, provides some
images above the hip joint in control group subject (A), and subjects with mild left
osteoarthritis (B), and advanced left osteoarthritis (C). White dot indicates left ilium.
important information for understanding changes occurring in this
muscle, and inconsistencies in previous EMG research. For subjects
with mild joint pathology, GMED muscle volume of the affected side
was on average 16% larger than those of normal control subjects
4.1. Side to side differences in muscle volumes within groups (p < 0.05). This information may indicate that the GMED muscle
could be more predisposed to hypertrophy rather than atrophy in
Although subjects with mild degenerative hip joint pathology the early stages of joint pathology. This could help explain why
were not significantly asymmetrical, those with advanced subjects with early OA of the hip exhibit higher levels of EMG for
pathology demonstrated significant asymmetry for the GMED and this muscle (Sims et al., 2002), while patients just prior to arthro-
PIRI muscles with smaller muscle volumes around the affected hip plasty exhibit reduced GMED EMG activity (Long et al., 1993).
(mean 12%, p < 0.01 and mean 14.4%, p < 0.05 respectively). This is Differing gait patterns may provide some further explanation for
consistent with the changes in gait pattern at this stage of the apparent disparity in GMED response across stages of joint
pathology (Krebs et al., 1998). Peak acetabular pressures have been pathology. As GMED muscle atrophy appears inherently linked to
shown to coincide with peak GMED activity rather than peak offloading strategies used in gait during late stage joint pathology
ground reaction forces (Krebs et al., 1998). The associated increases (Krebs et al., 1998), GMED muscle hypertrophy may occur in early
in lateral trunk flexion over the weight-bearing leg during stance joint pathology associated with increases in relative hip adduction
phase of gait was proposed to be a strategy to reduce abductor (Watelain et al., 2001). Kumagai et al. (1997) determined that the
muscle activity, thereby reducing compressive forces across painful GMED muscle provides maximal contribution to abduction force
degenerated joint surfaces. This functional disuse would be in line from a position of 20 hip adduction and more specifically, the most
with the muscle atrophy illustrated in the current study. Part of the superficial, ‘middle’ portion of the GMED muscle is more active in
asymmetry revealed may also be accounted for by hypertrophy of a position of hip adduction than the deeper anterior and posterior
 A. Grimaldi et al. / Manual Therapy 14 (2009) 605–610 609

Furthermore in the early stages of pathology motor control

changes are likely to preempt changes in muscle size. Future
research aimed at quantifying not only size, but ideally concurrent
dynamic EMG activity of each member of the abductor synergy,
including the functionally separate portions within the GMED
muscle, may be able to elucidate the specific functions and exercise
requirements for muscles of the abductor synergy.

5. Conclusion

This study has shown that the deeper members of the hip
Fig. 2. The three separate portions of the gluteus medius muscle. Anterior (A), Middle
abductor synergy, the GMED, GMIN, and PIRI muscles are smaller
(M), Posterior (P).
around the affected hip in subjects with advanced unilateral hip
portions (Fig. 2), and the GMIN muscle, which are favoured in joint pathology. This atrophy was not measurable in subjects with
a more neutral hip position. Increasing pelvic tilt or lateral shift to mild pathology, however differing processes are likely in place
a position of increased adduction may be an inherent compensa- associated with differing functional weight-bearing patterns. In
tory strategy to increase the contribution from the more superficial subjects with mild pathology GMED muscle size was significantly
abductors to lateral pelvic support. This alignment not only creates larger on the affected side than control group subjects suggesting
preferential recruitment in the superficial portion of the GMED the GMED muscle may hypertrophy at this stage of pathology.
muscle, but also pretensions the iliotibial band potentially Assessment and rehabilitation strategies should carefully consider
increasing the effect of the TFL and UGM muscles. stage of pathology and specific changes occurring within the
As the GMED muscle is composed of 3 fascially distinct portions, abductor synergy. This more specific approach may improve long
anterior and posterior portions sitting deep to the middle portion term outcomes of conservative intervention in the management of
(Jaegers et al., 1992) (Fig. 2), all with independent nerve supply OA of the hip, and may provide a direction for future prevention
(Gottschalk et al., 1989), it is possible that while the overall volume programmes.
of the GMED muscle increased, the deeper anterior and posterior
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