REVIEW ARTICLE| Volume 103, ISSUE 8, P1651-1662, August 2022

Systematic Review of the Importance of Hip Muscle Strength, Activation, and Structure in Balance and Mobility Tasks

Published:January 04, 2022DOI:



      The aim of this systematic review was to identify the associations of the hip abductor muscle strength, structure, and neuromuscular activation on balance and mobility in younger, middle-aged, and older adults.

      Data Sources

      We followed PRISMA guidelines and performed searches in PubMed, Embase, CINAHL, and Physiotherapy Evidence Database.

      Study Selection

      Study selection included: (1) studies with patients aged 18 years or older and (2) studies that measured hip abduction torque, surface electromyography, and/or muscle structure and compared these measures with balance or mobility outcomes.

      Data Extraction

      The extracted data included the study population, setting, sample size, sex, and measurement evaluated.

      Data Synthesis

      The present systematic review is composed of 59 research articles including a total of 2144 young, middle-aged, and older adults (1337 women). We found that hip abductor strength is critical for balance and mobility function, independent of age. Hip abductor neuromuscular activation is also important for balance and mobility, although it may differ across ages depending on the task. Finally, the amount of fat inside the muscle appears to be one of the important factors of muscle structure influencing balance.


      In conclusion, a change in all investigated variables (hip abduction torque, neuromuscular activation, and intramuscular fat) appears to have an effect during balance or mobility tasks across age ranges and may elicit better performance. Future studies are necessary to confirm the effect of these variables across age ranges and the effects of interventions.


      List of abbreviations:

      BBS (Berg Balance Scale), BSE (balance self-efficacy), EMG (electromyography), GM (gluteus medius muscle), HDL (high density lean muscle), IMAT: (intramuscular fat), JBI (Joanna Briggs Institute), OLST (one-legged stance test), RFD (rate of force development), RTD (rate of torque development), SEBT (Star Excursion Balance Test), STST (sit-to-stand test), TFL (tensor fascia latae muscle), TUG (timed Up and Go), YBT (Y balance test)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Hausdorff JM
        • Rios DA
        • Edelberg HK.
        Gait variability and fall risk in community-living older adults: a 1-year prospective study.
        Arch Phys Med Rehabil. 2001; 82: 1050-1056
        • Phelan EA
        • Mahoney JE
        • Voit JC
        • Stevens JA.
        Assessment and management of fall risk in primary care settings.
        Med Clin North Am. 2015; 99: 281-293
        • Kannus P
        • Parkkari J
        • Niemi S
        • Sievänen H.
        Continuously declining incidence of fall injuries in older adults: nationwide statistics from Finland between 1970 and 2016.
        Eur Geriatr Med. 2018; 9: 371-375
        • Lord SR
        • Ward JA
        • Williams P
        • Anstey KJ.
        An epidemiological study of falls in older community-dwelling women: the Randwick falls and fractures study.
        Aust J Public Health. 1993; 17: 240-245
        • Janssen I
        • Heymsfield SB
        • Ross R.
        Low relative skeletal muscle mass (sarcopenia) in older persons is associated with functional impairment and physical disability.
        J Am Geriatr Soc. 2002; 50: 889-896
        • Tieland M
        • Trouwborst I
        • Clark BC.
        Skeletal muscle performance and ageing.
        J Cachexia Sarcopenia Muscle. 2018; 9: 3-19
        • Minetti AE.
        On the mechanical power of joint extensions as affected by the change in muscle force (or cross-sectional area), ceteris paribus.
        Eur J Appl Physiol. 2002; 86: 363-369
        • Hwang W
        • Jang JH
        • Huh M
        • et al.
        The effect of hip abductor fatigue on static balance and gait parameters.
        Phys Ther Rehabil Sci. 2016; 5: 34-39
        • Porto JM
        • Freire Júnior, RC
        • Bocarde L
        • et al.
        Contribution of hip abductor–adductor muscles on static and dynamic balance of community-dwelling older adults.
        Aging Clin Exp Res. 2019; 31: 621-627
        • Francis P
        • Gray K
        • Perrem N.
        The relationship between concentric hip abductor strength and performance of the Y-balance test (YBT).
        International Journal of Athletic Therapy and Training. 2018; 23: 42-47
        • Wilson BR
        • Robertson KE
        • Burnham JM
        • Yonz MC
        • Ireland ML
        • Noehren B.
        The Relationship Between Hip Strength and the Y Balance Test.
        J Sport Rehabil. 2018; 27: 445-450
        • Hahn ME
        • Lee HJ
        • Chou LS.
        Increased muscular challenge in older adults during obstructed gait.
        Gait Posture. 2005; 22: 356-361
        • Tse YYF
        • Petrofsky J
        • Berk L
        • et al.
        Postural sway and EMG analysis of hip and ankle muscles during balance tasks.
        Int J Ther Rehabil. 2013; 20: 280-288
        • Marques NR
        • Hallal CZ
        • Crozara LF
        • et al.
        Lower limb strength is associated with gait biomechanical abnormalities in older female fallers and non-fallers.
        Isokinet Exerc Sci. 2013; 21: 151-159
        • Lee HJ
        • Chang WH
        • Hwang SH
        • Choi BO
        • Ryu GH
        • Kim YH.
        Age-related locomotion characteristics in association with balance function in young, middle-aged, and older adults.
        J Aging Phys Act. 2017; 25: 247-253
        • Mercer VS
        • Gross MT
        • Sharma S
        • Weeks E.
        Comparison of gluteus medius muscle electromyographic activity during forward and lateral step-up exercises in older adults.
        Phys Ther. 2009; 89: 1205-1214
        • Hilliard MJ
        • Martinez KM
        • Janssen I
        • et al.
        Lateral balance factors predict future falls in community-living older adults.
        Arch Phys Med Rehabil. 2008; 89: 1708-1713
        • Farina D
        • Holobar A
        • Merletti R
        • Enoka RM.
        Decoding the neural drive to muscles from the surface electromyogram.
        Clin Neurophysiol. 2010; 121: 1616-1623
        • Semmler JG.
        Motor unit synchronization and neuromuscular performance.
        Exerc Sport Sci Rev. 2002; 30: 8-14
        • Suchomel TJ
        • Stone M.
        The relationships between hip and knee extensor cross-sectional area, strength, power, and potentiation characteristics.
        Sports. 2017; 5: 66
        • Visser M
        • Goodpaster BH
        • Kritchevsky SB
        • et al.
        Muscle mass, muscle strength, and muscle fat infiltration as predictors of incident mobility limitations in well-functioning older persons.
        J Gerontol A Biol Sci Med Sci. 2005; 60: 324-333
        • Addison O
        • Inacio M
        • Bair W-N
        • Beamer BA
        • Ryan AS
        • Rogers MW.
        Role of hip abductor muscle composition and torque in protective stepping for lateral balance recovery in older adults.
        Arch Phys Med Rehabil. 2017; 98: 1223-1228
        • Vardell E
        • Malloy M.
        Joanna Briggs Institute: an evidence-based practice database.
        Med Ref Serv Q. 2013; 32: 434-442
        • Mille M-L
        • Johnson ME
        • Martinez KM
        • Rogers MW.
        Age-dependent differences in lateral balance recovery through protective stepping.
        Clin Biomech. 2005; 20: 607-616
        • Lee DK
        • Kim GM
        • Ha SM
        • Oh JS.
        Correlation of the Y-balance test with lower-limb strength of adult women.
        J Phys Ther Sci. 2014; 26: 641-643
        • Lee DK
        • Kang MH
        • Lee TS
        • Oh JS.
        Relationships among the Y balance test, Berg Balance Scale, and lower limb strength in middle-aged and older females.
        Braz J Phys Ther. 2015; 19: 227-234
        • Inacio M
        • Creath R
        • Rogers MW.
        Effects of aging on hip abductor-adductor neuromuscular and mechanical performance during the weight transfer phase of lateral protective stepping.
        J Biomech. 2019; 82: 244-250
        • Hurt CP
        • Grabiner MD.
        Age-related differences in the maintenance of frontal plane dynamic stability while stepping to targets.
        J Biomech. 2015; 48: 592-597
        • Davis LA
        • Allen SP
        • Hamilton LD
        • Grabowski AM
        • Enoka RM.
        Differences in postural sway among healthy adults are associated with the ability to perform steady contractions with leg muscles.
        Exp Brain Res. 2020; 238: 487-497
        • Inacio M
        • Ryan AS
        • Bair W-N
        • Prettyman M
        • Beamer BA
        • Rogers MW.
        Gluteal muscle composition differentiates fallers from non-fallers in community dwelling older adults.
        BMC Geriatr. 2014; 14: 37
        • Chang SHJ
        • Mercer VS
        • Giuliani CA
        • Sloane PD.
        Relationship between hip abductor rate of force development and mediolateral stability in older adults.
        Arch Phys Med Rehabil. 2005; 86: 1843-1850
        • Lee D
        • Li Z
        • Sohail QZ
        • Jackson K
        • Fiume E
        • Agur A.
        A three-dimensional approach to pennation angle estimation for human skeletal muscle.
        Comput Methods Biomech Biomed Engin. 2015; 18: 1474-1484
        • Iverson BD
        • Gossman MR
        • Shaddeau SA
        • Turner ME.
        Balance performance, force production, and activity levels in noninstitutionalized men 60 to 90 years of age.
        Phys Ther. 1990; 70: 348-355
        • MacRae PG
        • Lacourse M
        • Moldavon R.
        Physical performance measures that predict faller status in community-dwelling older adults.
        J Orthop Sports Phys Ther. 1992; 16: 123-128
        • Gunter KB
        • De Costa J
        • White KN
        • Hooker K
        • Hayes WC
        • Snow CM.
        Balance self-efficacy predicts risk factors for side falls and frequent falls in community-dwelling elderly.
        J Aging Phys Act. 2003; 11: 28-39
        • Arvin M
        • van Dieën JH
        • Faber GS
        • Pijnappels M
        • Hoozemans MJM
        • Verschueren SMP.
        Hip abductor neuromuscular capacity: a limiting factor in mediolateral balance control in older adults?.
        Clin Biomech. 2016; 37: 27-33
        • Sadowska D
        • Osiński W
        • Gumny M.
        Muscle strength of lower limbs as a predictor of postural stability and fear of falling in physically active and inactive older men and women.
        Top Geriatr Rehabil. 2018; 34: 124-130
        • Morcelli MH
        • Crozara LF
        • Rossi DM
        • et al.
        Hip muscles strength and activation in older fallers and non-fallers.
        Isokinet Exerc Sci. 2014; 22: 191-196
        • Lanza MB
        • Addison O
        • Ryan AS
        • Perez WJ
        • Gray V.
        Kinetic, muscle structure, and neuromuscular determinants of weight transfer phase prior to a lateral choice reaction step in older adults.
        J Electromyogr Kinesiol. 2020; 55102484
        • Afschrift M
        • Pitto L
        • Aerts W
        • van Deursen R
        • Jonkers I
        • De Groote F.
        Modulation of gluteus medius activity reflects the potential of the muscle to meet the mechanical demands during perturbed walking.
        Sci Rep. 2018; 8: 11675
        • Allum JHJ
        • Carpenter MG
        • Honegger F
        • Adkin AL
        • Bloem BR.
        Age-dependent variations in the directional sensitivity of balance corrections and compensatory arm movements in man.
        J Physiol. 2002; 542: 643-663
        • Bhanot K
        • Kaur N
        • Brody LT
        • Bridges J
        • Berry DC
        • Ode JJ.
        Hip and trunk muscle activity during the star excursion balance test in healthy adults.
        J Sport Rehabil. 2019; 28: 682-691
        • Chu YH
        • Tang PF
        • Chen HY
        • Cheng CH.
        Altered muscle activation characteristics associated with single volitional forward stepping in middle-aged adults.
        Clin Biomech. 2009; 24: 735-743
        • Earl JE.
        Gluteus medius activity during 3 variations of isometric single-leg stance.
        J Sport Rehabil. 2005; 14: 1-11
        • Gilles M
        • Wing AM
        • Kirker SGB.
        Lateral balance organisation in human stance in response to a random or predictable perturbation.
        Exp Brain Res. 1999; 124: 137-144
        • Gottschall JS
        • Okita N
        • Sheehan RC.
        Muscle activity patterns of the tensor fascia latae and adductor longus for ramp and stair walking.
        J Electromyogr Kinesiol. 2012; 22: 67-73
        • Henry SM
        • Fung J
        • Horak FB.
        Control of stance during lateral and anterior/posterior surface translations.
        IEEE Trans Rehabil Eng. 1998; 6: 32-42
        • Hof AL
        • Duysens J.
        Responses of human hip abductor muscles to lateral balance perturbations during walking.
        Exp Brain Res. 2013; 230: 301-310
        • Kim H-D
        • Brunt D.
        Effect of a change in step direction from a forward to a lateral target in response to a sensory perturbation.
        J Electromyogr Kinesiol. 2013; 23: 851-857
        • Kim HD
        • Brunt D.
        The effect of a sensory perturbation on step direction or length while crossing an obstacle from quiet stance.
        Gait Posture. 2009; 30: 1-4
        • Krause DA
        • Jacobs RS
        • Pilger KE
        • Sather BR
        • Sibunka SP
        • Hollman JH.
        Electromyographic analysis of the gluteus medius in five weight-bearing exercises.
        J Strength Cond Res. 2009; 23: 2689-2694
        • Li Y
        • Cao C
        • Chen X.
        Similar electromyographic activities of lower limbs between squatting on a Reebok core board and ground.
        J Strength Cond Res. 2013; 27: 1349-1353
        • Lin YC
        • Fok LA
        • Schache AG
        • Pandy MG.
        Muscle coordination of support, progression and balance during stair ambulation.
        J Biomech. 2015; 48: 340-347
        • Marchetti PH
        • Guiselini MA
        • da Silva JJ
        • Tucker R
        • Behm DG
        • Brown LE.
        Balance and lower limb muscle activation between in-line and traditional lunge exercises.
        J Hum Kinet. 2018; 62: 15-22
        • Norris B
        • Trudelle-Jackson E.
        Hip- and thigh-muscle activation during the star excursion balance test.
        J Sport Rehabil. 2011; 20: 428-441
        • Park SH
        • Lee YS
        • Cheon SH
        • Yong MS
        • Lee D
        • Lee EJ.
        Analysis of the ratios of medial-lateral and proximal-distal muscle activities surrounding the hip joint in the step-up and step-down positions.
        J Back Musculoskelet Rehabil. 2019; 32: 299-303
        • Rankin BL
        • Buffo SK
        • Dean JC.
        A neuromechanical strategy for mediolateral foot placement in walking humans.
        J Neurophysiol. 2014; 112: 374-383
        • Santos MJ
        • Kanekar N
        • Aruin AS.
        The role of anticipatory postural adjustments in compensatory control of posture: 1. Electromyographic analysis.
        J Electromyogr Kinesiol. 2010; 20: 388-397
        • Sims KJ
        • Brauer SG.
        A rapid upward step challenges medio-lateral postural stability.
        Gait Posture. 2000; 12: 217-224
        • Stokes HE
        • Thompson JD
        • Franz JR.
        The neuromuscular origins of kinematic variability during perturbed walking.
        Sci Rep. 2017; 7: 808
        • Tang K-S
        • Honegger F
        • Allum JHJ.
        Movement patterns underlying first trial responses in human balance corrections.
        Neuroscience. 2012; 225: 140-151
        • Tettamanti A
        • Giordano M
        • Gatti R.
        Effects of coupled upper limbs movements on postural stabilisation.
        J Electromyogr Kinesiol. 2013; 23: 1222-1228
        • Torvinen S
        • Sievänen H
        • Järvinen TA
        • Pasanen M
        • Kontulainen S
        • Kannus P.
        Effect of 4-min vertical whole body vibration on muscle performance and body balance: a randomized cross-over study.
        Int J Sports Med. 2002; 23: 374-379
        • Wang SJ
        • Xu DQ
        • Li JX.
        Effects of regular Tai Chi practice and jogging on neuromuscular reaction during lateral postural control in older people.
        Res Sports Med. 2017; 25: 111-117
        • Chi AS
        • Long SS
        • Zoga AC
        • Parker L
        • Morrison WB.
        Association of gluteus medius and minimus muscle atrophy and fall-related hip fracture in older individuals using computed tomography.
        J Comput Assist Tomogr. 2016; 40: 238-242
        • Kiyoshige Y
        • Watanabe E.
        Fatty degeneration of gluteus minimus muscle as a predictor of falls.
        Arch Gerontol Geriatr. 2015; 60: 59-61
        • Folland JP
        • Buckthorpe MW
        • Hannah R.
        Human capacity for explosive force production: neural and contractile determinants.
        Scand J Med Sci Sports. 2014; 24: 894-906
        • Lanza MB
        • Balshaw TG
        • Folland JP.
        Explosive strength: effect of knee-joint angle on functional, neural, and intrinsic contractile properties.
        Eur J Appl Physiol. 2019; 119: 1735-1746
        • McGregor RA
        • Cameron-Smith D
        • Poppitt SD.
        It is not just muscle mass: a review of muscle quality, composition and metabolism during ageing as determinants of muscle function and mobility in later life.
        Longev Healthspan. 2014; 3: 9
        • Maden-Wilkinson TM
        • McPhee JS
        • Jones DA
        • Degens H.
        Age-related loss of muscle mass, strength, and power and their association with mobility in recreationally-active older adults in the United Kingdom.
        J Aging Phys Act. 2015; 23: 352-360
        • Besomi M
        • Hodges PW
        • Clancy EA
        • et al.
        Consensus for experimental design in electromyography (CEDE) project: amplitude normalization matrix.
        J Electromyogr Kinesiol. 2020; 53102438