Content uploaded by Oh-Yun Kwon
Author content
All content in this area was uploaded by Oh-Yun Kwon on Oct 28, 2019
Content may be subject to copyright.
Original article
Activation of the gluteus maximus and hamstring muscles during prone hip
extension with knee flexion in three hip abduction positions
Sun-Young Kang
a
,
*
, Hye-Seon Jeon
b
, Ohyun Kwon
b
, Heon-seock Cynn
b
, Boram Choi
a
a
Department of Physical Therapy, The Graduate School, Yonsei University, 234 Maji-ri, Hungup-myon, Wonju, Kangwon-do 220-710, Republic of Korea
b
Department of Physical Therapy, College of Health Science, Yonsei University, 234 Maji-ri, Hungup-myon, Wonju, Kangwon-do, Republic of Korea
article info
Article history:
Received 8 August 2012
Received in revised form
9 November 2012
Accepted 19 November 2012
Keywords:
Electromyography
Gluteus maximus
Hip abduction
Onset time
Prone hip extension with knee flexion
abstract
The direction of fiber alignment within a muscle is known to influence the effectiveness of muscle
contraction. However, most of the commonly used clinical gluteus maximus (GM) exercises do not
consider the direction of fiber alignment within the muscle. Therefore, the purpose of this study was to
investigate the influence of hip abduction position on the EMG (electromyography) amplitude and onset
time of the GM and hamstrings (HAM) during prone hip extension with knee flexion (PHEKF) exercise.
Surface EMG signals were recorded from the GM and HAM during PHEKF exercise in three hip abduction
positions: 0
,15
, and 30
. Thirty healthy subjects voluntarily participated in this study.
The results show that GM EMG amplitude was greatest in the 30
hip abduction position, followed by
15
and then 0
hip abduction during PHEKF exercise. On the other hand, the HAM EMG amplitude at
0
hip abduction was significantly greater than at 15
and 30
hip abduction. Additionally, GM EMG onset
firing was delayed relative to that of the HAM at 0
hip abduction. On the contrary, the GM EMG onset
occurred earlier than the HAM in the 15
and 30
hip abduction positions.
These findings indicate that performing PHEKF exercise in the 30
hip abduction position may be
recommended as an effective way to facilitate the GM muscle activity and advance the firing time of the
GM muscle in asymptomatic individuals. This finding provides preliminary evidence that GM EMG
amplitude and onset time can be modified by the degree of hip abduction.
Ó2012 Elsevier Ltd. All rights reserved.
1. Introduction
The group of muscles in the gluteal region consists of the gluteus
maximus, medius, and minimus. The gluteus maximus (GM) is the
largest and most superficial muscle in the area. It is a broad, thick,
fleshy mass of a quadrilateral shape and its fibers are directed
obliquely downward and laterally (Frank and Netter, 1987;
McAndrew et al., 2006). The muscle primarily acts as a powerful
extensor of the hip. Because the GM muscle fibers are aligned
perpendicular to the sacroiliac (SI) joint, GM contraction produces
compression of the SI joint, and also contributes to the force
transmission mechanism from the lower extremity to the pelvis
through the SI joint during functional activities such as ambulation
(Lyons et al., 1983;Mooney et al., 2001;Hossain and Nokes, 2005;
Lieberman et al., 2006).
Inappropriate timing of GM activation duringgait is thought to be
one of the causes of low back pain (LBP), resulting in a deficiency in
the shock absorption mechanism at the sacroiliac joint. Earlier onset
of hamstrings (HAM) activation has been noted in patients with LBP
as compensationfor delayed firingof the GM (Hungerfordet al., 2003;
Hossain and Nokes, 2005). In addition, weakness and imbalanced
strength in the GM are associated with lower extremity injuries,
including patellofemoral pain syndrome, anterior cruciate ligament
sprains, and chronic ankle instability (Powers,2003;Fr iel et al., 2006;
Hewett et al., 2006;Cichanowski et al., 2007;Yang et al., 2011).
Weakness of the GM also leads to slouched posture, makes walking
extremely difficult, and necessitates substitution by synergists
(Kisner and Colby, 2005). Therefore, neuromuscular reeducationand/
or specific GM strengthening exercises are clinically necessary in
rehabilitation for low back pain and lower extremity injuries.
Many studies have demonstrated various methods to reduce
delayed firing of the GM. During prone hip extension exercise,
lower abdominal hollowing and the abdominal drawing-in
maneuver (ADIM) using a pressure biofeedback unit reduced the
delay of GM firing relative to that of the HAM (Oh et al., 2006,
Chance-Larsen et al., 2010). In addition, gluteal verbal cues during
prone hip extension resulted in nearly simultaneous electromyog-
raphy (EMG) onset of the HAM and GM, which means delayed HAM
onset and advanced GM onset based on the no-cues condition
(Lewis and Sahrmann, 2009).
*Corresponding author. Tel.: þ82 33 760 2498; fax: þ82 33 760 2496.
E-mail address: hyeseonj@yonsei.ac.kr (H.-S. Jeon).
Contents lists available at SciVerse ScienceDirect
Manual Therapy
journal homepage: www.elsevier.com/math
1356-689X/$ esee front matter Ó2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.math.2012.11.006
Manual Therapy xxx (2012) 1e5
Please cite this article in press as: Kang S-Y, et al., Activation of the gluteus maximus and hamstring muscles during prone hip extension with
knee flexion in three hip abduction positions, Manual Therapy (2012), http://dx.doi.org/10.1016/j.math.2012.11.006
Several GM strengthening exercises are used in physical therapy
and many studies have been conducted to determine the best mode
of strengthening the GM. Wilson et al. (2004) advocated the full
squat as the most active method, and Distefano et al. (2009) re-
ported that the single-limb squat leads to maximum activity of the
GM, among other types of exercise that are commonly performed in
a gym setting. Because all of those exercises are difficult for patients
who have lower extremity joint or stability problems, prone hip
extension exercises are commonly used in rehabilitation to
strengthen the GM muscle (Cappozzo et al., 1985;Wilson et al.,
2004;Distefano et al., 2009). In particular, for isolated GM activa-
tion, patients are asked to lift their hip while maintaining 90
knee
flexion; this position is called prone hip extension with knee flexion
(PHEKF). Because this position leads to an active insufficiency of the
HAM muscle, the PHEKF exercise is an easily employed position for
patients to optimize GM activation. It is also commonly used as
a muscle strength test or strengthening exercise for the GM in
clinical practice (Sakamoto et al., 2009).
Fiber arrangement within the muscles and joint positions are
contributing factors in muscle contraction (Soderberg, 1983). When
the line of action of the muscle matches the line of fiber of the
muscle, the effect of muscle contraction is augmented (Smidt and
Rogers, 1982); however, many exercises do not consider the
downward and outward fiber arrangement within the GM muscle
and no study has considered the effect of hip abduction position in
relation to muscle fiber arrangement during GM exercises. There-
fore, the purpose of this study was to investigate the EMG ampli-
tude and relative onset difference of the GM and HAM during
PHEKF exercise in three hip abduction positions (0
,15
, and 30
hip abduction). We hypothesized that the EMG amplitude of the
GM would increase and the EMG onset of the GM would be
advanced relative to that of the HAM in the 30
hip abduction
position.
2. Methods
2.1. Subjects
Thirty healthy subjects (18 men,12 women) were recruited from
the Department of Physical Therapy at Yonsei University in Korea
(22.8 2.9 yrs, body mass: 66.9 10.8 kg, height: 170.3 4.1 cm).
The exclusion criteria included (1) a history of lumbar, sacroiliac or
lower limb injury within the past year, (2) past or present neuro-
logical, musculoskeletal, and cardiopulmonary diseases, (3) hip
flexor shortness by the Thomas test (Vogt and Banzer, 1997), (4)
tensor fasciae latae shortness by Ober’s test (Magee, 2002), (5)
adductor muscle shortness by the Adduction Contracture Test
(Magee, 2002), (6) hip pain with active straight-leg raises or passive
hip flexion with adduction and medial rotation (Lewis and
Sahrmann, 2009), and (7) lumbar or hip pain when performing
PHEKF. Those musculoskeletal examinations of the lower extrem-
ities were performed to avoid compensations related to muscle
shortness. Prior to participation in the experimental data collection,
the principal investigator explained the entire procedure to the
subjects. This study was approved by the Yonsei University Wonju
Campus Human Studies Committee and all participants gave
written informed consent.
2.2. Experimental apparatus
EMG data were collected from the dominant leg using a Noraxon
Telemyo 2400T system (Noraxon, Inc., Scottsdale, AZ, USA) with
a pair of AgeAgCl surface electrodes 2 cm in diameter. Prior to
electrode placement, the electrode sites were shaved and cleaned
with rubbing alcohol to prepare the skin. The EMG electrode for the
GM was placed halfway between the greater trochanter and second
sacral vertebra in the middle of the muscle and at an oblique angle.
The electrode for the HAM was placed parallel to the muscle fibers
on the posterior aspect of the thigh, approximately halfway
between the gluteal fold and the popliteal fold (Cram et al., 1998).
The reference electrode was attached to right anterior superior iliac
spine (ASIS).
Raw EMG signals were bandepass filtered between 20 and
450 Hz, sampled at 1000 Hz, and converted using MyoResearch
Master Edition 1.06 XP software (Noraxon, Inc., Scottsdale, AZ,
USA). Raw data were processed into root-mean-square (RMS)
values and were converted to ASCII files for analysis. EMG ampli-
tudes of the GM and HAM muscles were represented as percentage
of the MVIC (Maximal voluntary isometric contraction) (%MVIC)
value for normalization. MVIC value of the GM and HAM were
obtained in the manual muscle testing positions as recommended
by Kendall et al. (2005). The peak RMS EMG amplitude of three
trials of 5-s MVIC was calculated for each muscle. Then, we calcu-
lated the mean RMS amplitude for each trial of PHEKF exercise, and
normalized as %MVIC. The average of three trials of %MVIC was
used for statistical data analyses.
The baseline EMG was calculated by averaging the EMG activity
for 5-s interval in a resting position. The onset of EMG activity of
each muscle was determined when the EMG amplitude exceeded
two standard deviations of the baseline level for a minimum of
50 ms (Hodges and Bui, 1996;Guimarães et al., 2010;Choi et al.,
2011). The relative onset difference between the GM and HAM
was calculated by the following equation:
relative onset difference ¼GM onset HAM onsetðin msÞ
Therefore, a positive value indicates that the HAM fired before
the GM. When the GM fires earlier than the HAM, the relative onset
difference becomes a negative value (Chance-Larsen et al., 2010).
2.3. Experimental procedure
Each participant was positioned prone on a therapeutic table
with their feet shoulder-width apart and arms at their sides; the
head was allowed to extend slightly to maintain normal breathing.
The two boards shown in Fig. 1 served as guidelines for hip
abduction at the 0
,15
, and 30
positions, and its center point was
placed under the participant’s ASIS. The hip abduction angle was
considered the line between the ASIS and mid-point of the patella
based on the starting position. For the PHEKF exercise, at the
starting position, the subject was asked to bend his or her knee to
90
and relax by resting their leg on a vertically positioned wooden
Fig. 1. Two boards marked at 0,15
, and 30.
S.-Y. Kang et al. / Manual Therapy xxx (2012) 1e52
Please cite this article in press as: Kang S-Y, et al., Activation of the gluteus maximus and hamstring muscles during prone hip extension with
knee flexion in three hip abduction positions, Manual Therapy (2012), http://dx.doi.org/10.1016/j.math.2012.11.006
device (Sakamoto et al., 2009). Two vertical wooden guides were
aligned with the lower extremity to limit substitutions by knee
flexion or hip rotation of the examined leg (Fig. 2). Then the
participant was given a verbal cue to lift their dominant leg toward
the ceiling until the patella was lifted 5 cm off of the supporting
surface, and then asked to maintain the extended hip for 5 s
(Dankaerts et al., 2004). When the examiner observed a deviation
from the vertical wooden guides, the data were discarded. Before
data acquisition, all subjects practiced the PHEKF exercise for 5 min
to familiarize themselves with the testing procedure. The subjects
performed the PHEKF exercise three times for each hip abduction
position with a 30 s inter-trial period. The order of the abduction
positions was created using a computer-based randomization
program and a 2-min rest period was given between the positions.
2.4. Statistical analysis
All dependent variables are presented as the mean standard
deviation (SD). Repeated measures analysis of variance (ANOVA)
was used to compare the EMG amplitude and relative onset
differences among the three hip abduction positions. The level of
statistical significance was set at 0.05.
Significant differences between three hip abduction positions
were determined using the Bonferroni correction (or adjustment);
performing pairwise comparisons applying the significance level
a
¼
a
/the number of pairwise comparisons (0.05/3). The Statistical
Package for the Social Sciences for Windows version 18.0 (SPSS,
Inc., Chicago, IL, USA) was used for all statistical analyses.
3. Results
3.1. EMG amplitude
The GM and HAM EMG amplitudes during PHEKF exercise were
significantly different among the three hip abduction positions
(p<0.001) (Table 1). Our post-hoc comparison revealed that GM
EMG amplitude was greatest in the 30
hip abduction position,
followed by 15
and then 0
hip abduction during PHEKF exercise
(mean SD: 29 11%MVIC, 23 9%MVIC, and 20 8%MVIC,
respectively, p
adj
<0.001) (Fig. 3).
On the other hand, the HAM EMG amplitude at 0
hip abduction
was significantly greater than at 15
and 30
hip abduction
(p
adj
¼0.008). There was no significant difference in the EMG
amplitudes in the HAM between the 15
and 30
hip abduction
positions during PHEKF (p
adj
¼0.049) (Fig. 4).
3.2. EMG onset
There was a significant difference among the three hip abduc-
tion positions (p<0.001) (Table 2). In the 0
hip abduction position,
the relative onset difference between the GM and HAM was posi-
tive (mean SD, 0.17 0.17 ms), which implies a delayed GM EMG
onset relative to the HAM. In contrast, at the 15
and 30
hip
abduction positions, the relative onset difference was negative
(mean SD: 0.02 0.11 ms and 0.21 0.20 ms, respectively),
meaning that the GM fires earlier than the HAM. Post-hoc
comparisons revealed significant differences between each of the
hip abduction positions (Fig. 5). The relative onset difference was
greatest in the 0
hip abduction position, followed by 15
and then
30
hip abduction during PHEKF exercise.
4. Discussion
Exercises for reeducation and strengthening of the GM are
important in rehabilitation intervention for lower back pain or
lower extremity injuries; however, most of the commonly used
clinical GM exercises do not consider the direction of fiber align-
ment within the muscle. Because the GM muscle fibers are oriented
downward and outward, performing hip extension in abducted hip
position may help match the line of action of the muscle to the line
of the fibers. Therefore, the purpose of this study was to investigate
the influence of hip abduction on EMG amplitude and the relative
onset difference between the GM and HAM.
In this study, subjects performed PHEKF exercise in three
different hip abduction positions (0
,15
, and 30
). The results of
this study showed that the EMG amplitude of the GM was greatest
with 30
hip abduction, followed by 15
, and then 0
during PHEKF
exercise. On the other hand, the EMG amplitude of the HAM was
greatest in the 0
hip abduction position, followed by 15
, and then
30
. In brief, when the angle of hip abduction is greater than in the
Fig. 2. Experimental setting for PHEKF exercise.
Table 1
EMG amplitude of the GM and HAM.
Muscle Hip abduction positions Fp
0
15
30
GM
a
20.16 8.57
c
23.35 9.90 29.56 11.48 13.33 <0.001
HAM
b
17.92 15.83 15.76 15.03 14.36 14.30 15.86 <0.001
a
Gluteus maximus.
b
Hamstrings.
c
Mean standard deviation (%MVIC).
0 15 30
0
5
10
15
20
25
30
35
*
**
an
g
le of hip abduction
% MIVC
Fig. 3. EMG amplitude of the gluteus maximus in three hip abduction positions. The
means and SDs are show as bars and hatches. *p
adj
<0.05/3.
S.-Y. Kang et al. / Manual Therapy xxx (2012) 1e53
Please cite this article in press as: Kang S-Y, et al., Activation of the gluteus maximus and hamstring muscles during prone hip extension with
knee flexion in three hip abduction positions, Manual Therapy (2012), http://dx.doi.org/10.1016/j.math.2012.11.006
0
abducted position, the GM amplitude increases and the HAM
amplitude decreases. Possible mechanisms to explain these find-
ings are discussed below.
First, the location of muscle attachment and joint position are
critical in effective motion production since they are the deter-
mining factors in the generation of torque or a turning moment at
the joint (Soderberg, 1983). The fiber arrangement within muscles
is classified as fusiform, pennate, and bipennate. Fusiform muscles
are composed of fibers that run parallel to the longitudinal axis of
the muscle (Landers et al., 2001). A fusiform muscle generates
direct tension from contraction by contributing to the total muscle
tension produced. On the other hand, pennate muscle fibers lie at
an angle to the longitudinal axis of the muscle. This angular
insertion of these fibers results in the generation of less tension in
the direction of muscle pull (Landers et al., 2001).
Because the GM muscle is considered a fusiform muscle, the
muscle fibers should lie in the same direction as the line of pull of
the muscle in order to optimize muscle activation (Smidt and
Rogers, 1982;Soderberg, 1983). The GM arises from the posterior
gluteal line of the ilium and the posterior surface of the sacrum and
coccyx, and is directed downward and outward into the iliotibial
tract and the gluteal tuberosity of the femur (Frank and Netter,
1987). By performing hip abduction during PHEKF exercise, the
direction of muscle pull runs parallel to the fiber of the muscle,
leading to increased EMG amplitude.
Second, a synergistic muscle produces movement or stabiliza-
tion around a joint, such as with the HAM and GM in hip extension.
Synergistic muscles work together and influence each other
through movement patterns (Chance-Larsen et al., 2010;Page,
2009). Under the assumption that the movement occurs in the
same range of motion, increased EMG amplitude of one muscle can
create efficiencies in the movement, thereby decreasing the
workload of another muscle (Devlin, 2000;Jonkers et al., 2003). In
this study, because the range of hip extension in our experiment
was maintained constant in three hip abduction positions, we can
speculate that the decreased activity of the HAM in abducted
position may have had something to do with the increased activity
of the GM during PHEKF exercise. These results suggest that per-
forming hip abduction during hip extension could be a good
strategy to selectively increase GM activation.
Another finding of this study was that the relative onset
difference between GM and HAM at the 15
and 30
hip abduction
positions was negative, meaning that the GM was firing in advance
of the HAM. This change in relative EMG onset could be explained
by the function of the GM muscle. The GM as a whole acts as
a powerful extensor and lateral rotator of the hip, and the upper
fibers of the GM come into play in forcible abductor of the thigh
(Frank and Netter, 1987). In this experiment, subjects abducted
their hip prior to performing PHEKF exercise and performed the
exercise while maintaining hip abduction. This led to activation of
the GM as a hip abductor, and increased its responsiveness during
the exercise relative to the 0
hip abduction position. When
compared to relative onset differences with 15
and 30
hip
abduction, the relative onset difference with 30
hip abduction was
smaller than with 15
hip abduction, which means GM firing
relative to the HAM occurred earlier with 30
hip abduction. This
result implies that the 30
hip abduction position needed greater
responsiveness from the GM to maintain the hip abduction posi-
tion, and showed earlier firing compared to the 15
hip abduction
position. Therefore, performing PHEKF in 30
hip abduction posi-
tion may be an effective method to alter GM EMG onset time.
Multiple previous studies have examined muscle activation
patterns during prone hip extension (PHE), but the existence of
a normal activation pattern during PHE remains controversial.
Bruno and Bagust (2006) and Lehman et al. (2004) found no
consistent pattern, whereas Vogt and Banzer (1997),Page (2009),
and Sakamoto et al. (2009) reported a consistent muscle activation
pattern in PHE. Nevertheless, the authors of these studies agree
that the GM was consistently the last activated muscle during PHE
in both healthy subjects and patients with lower back pain (Vogt
and Banzer, 1997;Lehman et al., 2004;Bruno and Bagust, 2006;
Lewis and Sahrmann, 2009;Sakamoto et al., 2009;Chance-Larsen
et al., 2010;Page, 2009).
As we mentioned, many previous studies have examined the
muscle activation patterns in PHE, but only one study has investi-
gated recruitment patterns during PHEKF (Sakamoto et al., 2009).
That study showed that the movement was initiated by the HAM,
followed by the erector spinae (ES), and then the GM. The study
results were similar to ours in that the GM was the last muscle to be
activated at 0
hip abduction during PHEKF. This implies that even
during PHEKF exercise that leads to active insufficiency of the HAM
muscles, the activation onset of the GM occurs after the activation
of the HAM at 0
hip abduction position.
Our results imply that performing hip abduction during PHEKF
exercise has the potential to increase the EMG amplitude of the GM
and to alter the timing of activation of the GM relative to the HAM.
Therefore, we suggest performing PHEKF with hip abduction as an
0 15 30
0
5
10
15
20
25
30
35 *
*
an
g
le of hip abduction
% MVIC
Fig. 4. EMG amplitude of the hamstrings in three hip abduction positions. The means
and SDs are shown as bars and hatches. *p
adj
<0.05/3.
Table 2
The relative onset difference between GM and HAM.
Hip abduction positions Fp
0
15
30
GMeHAM
a
0.18 0.17
b
0.03 0.11 0.22 0.21 13.57 <0.001
a
The relative onset difference between GM and HAM ¼GM onset HAM onset.
b
Mean standard deviation (ms).
0 15 30
-0.3
-0.2
-0.1
-0.0
0.1
0.2
0.3
*
*
*
the an
g
le of hip abduction
time (ms)
Fig. 5. The relative onset difference between the gluteus maximus and hamstrings in
three hip abduction positions. Relative onset difference ¼GM onset HAM onset.
Means and SDs are shown as bars and hatches. *p
adj
<0.05/3.
S.-Y. Kang et al. / Manual Therapy xxx (2012) 1e54
Please cite this article in press as: Kang S-Y, et al., Activation of the gluteus maximus and hamstring muscles during prone hip extension with
knee flexion in three hip abduction positions, Manual Therapy (2012), http://dx.doi.org/10.1016/j.math.2012.11.006
effective method to augment the GM EMG amplitude and reduce
EMG onset time of the GM relative to the HAM. However, this
suggestion needs validation through future research, and it should
also be confirmed that this change could be maintained and
transferred to functional movements such as walking.
4.1. Limitations
First, the results of this study are representative of a young,
healthy population. Therefore, the changes in the EMG activation
and onset latency related to performing hip abduction during
PHEKF exercise need to be confirmed in a patient population.
Second, in this study, abdominal muscle contraction was not
controlled during performance. Previous studies have reported that
abdominal muscle contraction, such as the abdominal drawing-in
maneuver (ADIM), facilitates lumbar stability and it is an essen-
tial component for maintaining lumbar and pelvic stability during
leg movements (Hodges, 1999;Herrington and Davies, 2005;Oh
et al., 2007). Third, surface EMG was used to monitor EMG ampli-
tude, raising the possibility of cross-talk from adjacent muscles.
Fourth, because kinematic data were not collected in our study, the
muscle recruitment patterns were not fully described based on
a movement’s starting point.
5. Conclusion
The purposes of this study were to quantify the EMG amplitude
of the GM and HAM muscles and to measure the relative onset
differences between the GM and HAM in three hip abduction
positions during PHEKF exercise. We found that the GM amplitude
was the greatest and HAM amplitude was the lowest at the 30
hip
abduction position during PHEKF exercise. In addition, with 30
hip
abduction, the GM onset time was significantly earlier than the
HAM onset.
Therefore, performing PHEKF exercise in 30
hip abduction is
recommended as an effective method to facilitate EMG amplitude
of the GM and to reduce the delay of GM firing relative to HAM. We
suggest that performing PHEKF exercise in 30
hip abduction is
useful in a treatment protocol designed to increase the contribution
of the hip extensors and to improve motor control hip extension by
advancing the EMG onset of the GM.
References
Bruno PA, Bagust J. An investigation into the within-subject and between-subject
consistency of motor patterns used during prone hip extension in subjects
without low back pain. Clinical Chiropractic 2006;9:11e20.
Cappozzo A, Felici F, Figura F, Gazzani F. Lumbar spine loading during half-squat
exercises. Medicine and Science in Sports and Exercise 1985;17:613e20.
Chance-Larsen K, Littlewood C, Garth A. Prone hip extension with lower abdominal
hollowing improves the relative timing of gluteus maximus activation in rela-
tion to biceps femoris. Manual Therapy 2010;15:61e5.
Choi B, Kim M, Jeon HS. The effects of an isometric knee extension with hip
adduction (KEWHA) exercise on selective VMO muscle strengthening. Journal
of Electromyography and Kinesiology 2011;21:1011e6.
Cichanowski HR, Schmitt JS, Johnson RJ, Niemuth PE. Hip strength in collegiate
female athletes with patellofemoral pain. Medicine and Science in Sports and
Exercise 2007;39:1227e32.
Cram J, Kasman G, Holtz J. Introduction to surface electromyography. Gaithersburg,
Maryland: Aspen Publishers; 1998.
Dankaerts W, O’Sullivan PB, Burnett AF, Straker LM, Danneels LA. Reliability of EMG
measurements for trunk muscles during maximal and sub-maximal voluntary
isometric contractions in healthy controls and CLBP patients. Journal of Elec-
tromyography and Kinesiology 2004;14:333e42.
Devlin L. Recurrent posterior thigh symptoms detrimental to performance in rugby
union: predisposing factors. Sports Medicine 2000;29:273e87.
Distefano LJ, Blackburn JT, Marshall SW, Padua DA. Gluteal muscle activation during
common therapeutic exercises. Journal of Orthopaedic and Sports Physical
Therapy 2009;39:532e40.
Frank H, Netter R. The CIBA collection of medical illustrations. In: Musculoskeletal
system, vol. 8; 1987.
Friel K, McLean N, Myers C, Caceres M. Ipsilateral hip abductor weakness after
inversion ankle sprain. Journal of Athletic Training 2006;41:74e8.
Guimarães CQ, Sakamoto ACL, Laurentino GEC, Teixeira-Salmela LF. Electromyo-
graphic activity during active prone hip extension did not discriminate indi-
viduals with and without low back pain [Atividade eletromiográfica durante o
movimento de extensão do quadril em prono não discrimina indivíduos com
dor lombar]. Revista Brasileira de Fisioterapia 2010;14:351e7.
Herrington L, Davies R. The influence of Pilates training on the ability to contract the
transversus abdominis muscle in asymptomatic individuals. Journal of Body-
work and Movement Therapies 2005;9:52e7.
Hewett TE, Myer GD, Ford KR. Anterior cruciate ligament injuries in female athletes:
part 1, mechanisms and risk factors. American Journal of Sports Medicine 2006;
34:299e311.
Hodges PW. Is there a role for transversus abdominis in lumbo-pelvic stability?
Manual Therapy 1999;4:74e86.
Hodges PW, Bui BH. A comparison of computer-based methods for the determi-
nation of onset of muscle contraction using electromyography. Electroenceph-
alography and Clinical Neurophysiology eElectromyographyand Motor Control
1996;101:511e9.
Hossain M, Nokes LDM. A model of dynamic sacro-iliac joint instability from
malrecruitment of gluteus maximus and biceps femoris muscles resulting in
low back pain. Medical Hypotheses 2005;65:278e81.
Hungerford B, Gilleard W, Hodges P. Evidence of altered lumbopelvic muscle
recruitment in the presence of sacroiliac joint pain. Spine 2003;28:1593e600.
Jonkers I, Stewart C, Spaepen A. The complementary role of the plantarflexors,
hamstrings and gluteus maximus in the control of stance limb stability during
gait. Gait and Posture 2003;17:264e72.
Kendall FP, McCreary EK, Provance PG, Rodgers MM, Romani WA. Muscles: testing
and function with posture and pain. 5th ed. Baltimore, USA: Lippincott Williams
& Wilkins; 2005.
Kisner C, Colby LA. Therapeutic exercise (foundations & technique). 4th ed.; 2005.
Landers KA, Hunter GR, Wetzstein CJ, Bamman MM, Weinsier RL. The interrela-
tionship among muscle mass, strength, and the ability to perform physical tasks
of daily living in younger and older women. Journals of Gerontology eSeries A
Biological Sciences and Medical Sciences 2001;56:B443e8.
Lehman GJ, Lennon D, Tresidder B, Rayfield B, Poschar M. Muscle recruitment
patterns during the prone leg extension. BMC Musculoskeletal Disorders 2004;
5:1e5.
Lewis CL, Sahrmann SA . Muscle activation and movement patterns during
prone hip extensi on exercise in women. Journal of Athletic Training 2009;
44:238e48.
Lieberman DE, Raichlen DA, Pontzer H, Bramble DM, Cutright-Smith E. The human
gluteus maximus and its role in running. Journal of Experimental Biology 2006;
209:2143e55.
Lyons K, Perry J, Gronley JK. Timing and relative intensity of hip extensor and
abductor muscle action during level and stair ambulation. An EMG study.
Physical Therapy 1983;63:1597e605.
Magee D. Orthopedic physical assessment. 4th ed. Philadelphia: WB Saunders; 2002.
p. 692e697.
McAndrew D, Gorelick M, Brown JMM. Muscles within muscles: a mechanomyo-
graphic analysis of muscle segment contractile properties within human
gluteus maximus. Journal of Musculoskeletal Research 2006;10:23e35.
Mooney V, Pozos R, Vleeming A, Gulick J, Swenski D. Exercise treatment for
sacroiliac pain. Orthopedics 2001;24:29e32.
Oh JS, Cynn HS, Won JH, Kwon OY, Yi CH. Effects of performing an abdominal
drawing-in maneuver during prone hip extension exercises on hip and back
extensor muscle activity and amount of anterior pelvic tilt. Journal of Ortho-
paedic and Sports Physical Therapy 2007;37:320e4.
Oh JS, Weon JH, Cynn HS, Kwon OY. Can abdominal drawing-in maneuver using
a pressure biofeedback unit change muscle recruitment pattern during prone
hip extension? Journal of the Korean Academy of University Trained Physical
Therapists 2006;13(4).
Page P, Frank C, Lardner R. Assessment and treatment of muscles imbalance: the
Janda approach. Champaign: Human Kinetics; 2009. p. 78e80.
Powers CM. The influence of altered lower-extremity kinematics on patellofemoral
joint dysfunction: a theoretical perspective. Journal of Orthopaedic and Sports
Physical Therapy 2003;33:639e46.
Sakamoto ACL, Teixeira-Salmela LF, Rodrigues De Paula F, Guimarães CQ,
Faria CDCM. Gluteus maximus and semitendinosus activation during active
prone hip extension exercises. Revista Brasileira de Fisioterapia 2009;13:
335e42.
Smidt GL, Rogers MW. Factors contributing to the regulation and clinical assess-
ment of muscular strength. Physical Therapy 1982;62:1283e90.
Soderberg GL. Muscle mechanics and pathomechanics. Their clinical relevance.
Physical Therapy 1983;63:216e20.
Vogt L, Banzer W. Dynamic testing of the motor stereotype in prone hip extension
from neutral position. Clinical Biomechanics 1997;12:122e7.
Wilson J, Ferris E, Heckler A, Maitland L, TAlyor C. A structured review of the role of
gluteus maximus in rehabilitation. New Zealand Journal of Physiotherapy 2004;
33:95e100.
Yang M, Wang HL, Qin DW, Guo XF. Gluteus maximus and gluteus medius exercise
following elder total hip arthroplasty. Journal of Clinical Rehabilitative Tissue
Engineering Research 2011;15:3202e5.
S.-Y. Kang et al. / Manual Therapy xxx (2012) 1e55
Please cite this article in press as: Kang S-Y, et al., Activation of the gluteus maximus and hamstring muscles during prone hip extension with
knee flexion in three hip abduction positions, Manual Therapy (2012), http://dx.doi.org/10.1016/j.math.2012.11.006
