Comparison of hip abduction range of motion and strength and ankle dorsiflexion in older adults with and without a history of falls

Abstract

Background and purpose

Falls are among the most serious complications of aging, leading to disability, reduced quality of life, and even mortality. “Evidence suggests that weakness in proximal muscles (such as the hip abductors) and distal muscles (such as the ankle dorsiflexors) may contribute to impaired balance and increased fall risk in older adults.” However, few studies have simultaneously compared both the range of motion and strength of these two muscle groups in older adults with and without a history of falls. The aim of the present study was to compare hip abduction and ankle dorsiflexion range of motion and strength between older adults with and without a history of falls.

Methods

This cross-sectional comparative study included 60 community-dwelling older adults (30 with and 30 without a history of falls within the past 6 months). Range of motion was measured using a universal goniometer, and isometric muscle strength was assessed using a handheld dynamometer. Data were analyzed using the independent samples t-test at a significance level of p < 0.05.

Results

No significant difference was observed between the two groups in hip abduction range of motion (p = 0.188). However, the group without a history of falls demonstrated greater hip abduction strength (p < 0.001), ankle dorsiflexion range of motion (p < 0.001), and ankle dorsiflexor strength (p < 0.001).

Conclusion

Concurrent weakness in the hip abductors and ankle dorsiflexors may be associated with an increased risk of falls in older adults. Combined assessment of muscle strength and range of motion in these regions may assist in identifying older adults with characteristics associated with fall history.

Background

In recent years, remarkable advances in health and medical sciences, along with increased life expectancy, have led to a global demographic shift toward aging, with older adults representing the fastest-growing segment of the population [1]. According to the World Health Organization, individuals aged 60 years and older are classified as older adults [2]. The global population is rapidly aging. According to the United Nations, the number of individuals aged 60 years and older is expected to double from approximately one billion in 2020 to over two billion by 2050 [1]. A similar trend is observed in Iran, where the proportion of older adults has increased significantly in recent years [3].

Aging is not only associated with biological and physiological changes but also affects broader aspects of life, including quality of life, emotional well-being, and social participation. Maintaining functional independence and the ability to engage in daily and social activities is essential for promoting healthy aging [1, 4].

Regular physical activity is considered a fundamental non-pharmacological strategy for maintaining health in older adults. In addition to its physiological benefits, it contributes to psychological well-being, functional independence, and overall quality of life. Therefore, promoting physical activity tailored to individual capacities is essential for supporting active and healthy aging [4].

As the global population of older adults continues to grow, the prevalence of age-related complications—particularly falls—has become an important public health concern [5]. Falls are among the most common and serious health problems in older adults. They are associated with fractures, disability, reduced independence, psychological distress, and increased healthcare costs [6].

Falls in older adults may lead to mobility limitations and reduced ability to perform self-care. They can also cause difficulties in activities of daily living such as dressing, bathing, and household tasks. Studies indicate that approximately 30% of individuals over the age of 65 experience at least one fall per year, and the prevalence of falls increases significantly with advancing age, reaching nearly 40% in the very old. Moreover, individuals with a history of falls are at a higher risk of recurrent falls in subsequent months [6].

Several physiological factors contribute to the increased risk of falls in older adults. Among these, balance, muscle strength, and joint range of motion play a critical role in maintaining postural stability and safe movement during daily activities [7].

Physiological and biological changes associated with aging lead to reductions in flexibility, agility, and speed. Among these changes, impaired balance particularly increases the risk of falls in older adults. Factors contributing to falls include gait and balance impairments, neuromuscular deficits, medication use, psychological disorders, and visual problems. Among these, impaired balance is considered a key contributor and may result in disability and dependence.

Balance is essential for performing daily activities under both static and dynamic conditions [6] and is strongly influenced by lower extremity muscle strength. Reduced muscle strength may diminish neural input and proprioceptive function, thereby impairing postural control [8]. In this context, Al-Saadi et al. (2026) demonstrated that balance impairments, altered proprioception, and fear of falling are closely interrelated in older adults with lower limb alignment deviations [9]. Therefore, examining lower extremity muscle strength and range of motion is of considerable importance because of their direct influence on balance performance and fall risk in older adults [10].

In addition to muscle strength, joint range of motion (ROM) is an important factor influencing balance and fall risk in older adults. Reduced ROM, particularly at the hip joint, may limit movement efficiency and postural adjustments, thereby increasing the likelihood of falls [11].

Both proximal (hip abductors) and distal (ankle dorsiflexors) muscle groups contribute to balance control in older adults. Research evidence indicates that weakness in these muscle groups is associated with reduced postural stability and impaired motor performance [12, 13]. In addition, altered activation patterns in these muscles may compromise balance recovery and increase fall risk [14, 15].

On the other hand, the ankle dorsiflexors, particularly the tibialis anterior, contribute to maintaining minimum toe clearance during the swing phase and preventing tripping [16]. Therefore, impairments in both proximal (hip abductors) and distal (ankle dorsiflexors) muscle groups may be associated with reduced balance performance and fall history in older adults [13, 16].

Despite growing evidence supporting the individual roles of hip abductor and ankle dorsiflexor function in fall risk, few studies have simultaneously compared both the range of motion and strength of these muscle groups in older adults with and without a history of falls. This research gap limits understanding of combined motor impairment patterns associated with fall history in older adults. Accordingly, the aim of the present study was to compare hip abduction and ankle dorsiflexion range of motion and strength between older adults with and without a history of falls in order to identify potential indicators for screening high-risk individuals.

Methodology

Study design

The present study was a cross-sectional comparative study.

Participants

The statistical population consisted of 60 community-dwelling older adults recruited from local sports and corrective exercise centers in Urmia. Participants were recruited through convenience and purposive sampling according to the inclusion criteria. The sample size was determined based on previous similar studies and feasibility considerations [17]. Thirty older adults with a history of at least one fall in the past six months were assigned to the fall-history group. Thirty participants with no history of falls were assigned to the control group. Written informed consent was obtained from all participants.

Inclusion criteria were: age between 60 and 70 years; no use of tricyclic medications; no history of fracture or dislocation in the lower extremities; no participation in supervised rehabilitation or therapeutic exercise programs during the past six months; no history of falls in the past six months for the non-fall group; and at least one fall in the past six months for the fall-history group. Exclusion criteria included unwillingness to continue participation and inability to follow the testing instructions.

Strength measurement procedure

Hip abductors

Isometric strength of the hip abductor muscles was measured using a handheld dynamometer (North Coast Medical, USA). The device has reported validity of 95–98% and reliability ranging from 0.82 to 0.97. To prevent compensatory movement patterns, a stabilization strap was used in all tests. For measuring hip abductor strength, the participant lay in a side-lying position on a treatment table with a pillow placed between the legs. The upper leg was positioned at 10 degrees of abduction relative to the horizontal body line. The dynamometer was secured with a strap passing under the table and fixed 5 cm above the lateral knee joint line. The participant was instructed to lift the upper leg with maximal effort. The isometric contraction was maintained for 5 s. This test was repeated three times for each muscle group with a one-minute rest interval between trials. The maximum recorded value was considered as the final isometric strength score [18].

Ankle dorsiflexors

To measure isometric ankle dorsiflexion strength, the handheld dynamometer was used. The participant lay supine on the examination table. The measurement was performed with the knee in full extension to control the influence of the gastrocnemius muscle and the ankle positioned in neutral (0 degrees). This position was selected to minimize compensatory lower limb movements and control the influence of biarticular muscles. The dynamometer was placed on the dorsum of the foot over the metatarsophalangeal joints, and the participant was instructed to exert maximal force in the dorsiflexion direction. The examiner provided resistance to maintain an isometric contraction. Recent studies have demonstrated excellent intra-rater and inter-rater reliability for ankle dorsiflexion strength measurement using a handheld dynamometer (ICC > 0.90) The test was repeated three times with a one-minute rest interval, and the maximum value was recorded [19].

Range of motion measurement

Hip

A universal 180-degree goniometer was used to measure lower extremity joint range of motion according to Clarkson’s standard protocol [20]. For active hip abduction assessment, the participant was positioned supine. The axis of the goniometer was placed over the anterior superior iliac spine (ASIS) of the tested side. The stationary arm was aligned with an imaginary horizontal line connecting both ASIS, and the movable arm was aligned with the anterior midline of the femur toward the center of the patella. The participant was asked to actively perform the movement, and the corresponding angle was recorded.

Ankle

For active ankle dorsiflexion measurement, the participant lay in the prone position with the feet extending beyond the edge of the table. The goniometer axis was positioned over the lateral malleolus. The stationary arm was aligned parallel to the lateral midline of the fibula toward the fibular head, and the movable arm was aligned parallel to the lateral aspect of the fifth metatarsal. The angle obtained from the active movement was recorded. The goniometric method used has acceptable content and construct validity and is recognized as a clinical reference method for joint range of motion assessment [20]. Measurement of hip and ankle range of motion using a universal goniometer has demonstrated good intra-rater and inter-rater reliability, with ICC values ranging from 0.85 to above 0.90 [21, 22].

Statistical analysis

The collected data were analyzed using SPSS software. Descriptive statistics (mean and standard deviation) were used to describe participants’ characteristics and study variables in both groups. The Shapiro–Wilk test was used to assess normality of data distribution. After confirmation of normal distribution, the Independent Samples t-test was used to compare the mean values of the variables (strength and range of motion) between the two independent groups (with and without a history of falls). The level of significance for all tests was set at p < 0.05.

Results

Descriptive statistics (measures of central tendency and dispersion) were used to examine the distribution of age, height, and weight in the sample presented in Table 1.

Table 1.

General characteristics of participants

Variable	Fall group (Mean ± SD) (n = 30)	Control group (Mean ± SD) (n = 30)	t	p-value
Age (years)	66.40 ± 2.34	65.93 ± 2.05	0.82	0.415
Height (cm)	171.77 ± 3.28	172.20 ± 4.72	-0.41	0.681
Weight (kg)	73.03 ± 5.74	73.03 ± 7.13	0.00	1.000

No significant differences were observed between groups (p > 0.05)

The results of the independent t-test to examine the differences in research variables in elderly people with and without a history of falling are presented in Table 2.

Table 2.

Independent t-test results

Variable	Fall group (Mean ± SD)	Control group (Mean ± SD)	t	p-value
Hip abduction ROM (degrees)	33.16 ± 3.63	34.36 ± 3.32	-1.33	0.188
Hip abduction strength	19.96 ± 4.92	25.66 ± 5.06	-4.42	< 0.001
Ankle dorsiflexion ROM (degrees)	10.63 ± 1.44	16.96 ± 2.42	-12.26	< 0.001
Ankle dorsiflexion strength	13.20 ± 2.70	17.93 ± 2.40	-7.15	< 0.001

Based on the findings, no significant difference was observed between the two groups in hip abduction range of motion (t = -1.33, df = 58, p = 0.188). However, significant differences were found in the other variables. Specifically, the group without a history of falls demonstrated significantly greater hip abduction strength (t = -4.42, df = 58, p < 0.001). The control group also demonstrated significantly greater ankle dorsiflexion range of motion (t = -12.26, df = 58, p < 0.001) and greater ankle dorsiflexor strength (t = -7.15, df = 58, p < 0.001) compared with the fall-history group

Discussion

Summary of findings

The findings of the present study showed that there was no significant difference in hip abduction range of motion between older adults with and without a history of falls. However, significant differences were observed between the two groups in hip abduction strength, ankle dorsiflexion range of motion, and ankle dorsiflexor strength. These results suggest that muscle strength and distal joint mobility, rather than hip range of motion alone, may play a more critical role in distinguishing older adults at risk of falls. Unlike previous studies that have typically focused on either proximal or distal factors in isolation, this study contributes to the existing literature by simultaneously evaluating both proximal and distal lower-extremity function in older adults with and without a history of falls.

The findings suggest that impairments in both proximal and distal lower-extremity function may coexist in older adults with a history of falls.

Comparison with previous studies

These findings are consistent with previous studies. Lord et al. (1991) [23] and Bohannon et al. (1984) [24] reported that reduced muscle strength is associated with impaired balance in older adults. Similarly, Whipple et al. (1987) [12] emphasized the important role of ankle dorsiflexor weakness in balance impairment and fall risk. Moreland et al. (2004) [25] further highlighted the contribution of lower limb muscle weakness to falls among older adults. In addition, recent evidence has demonstrated that improving hip abductor strength through sensorimotor training can enhance balance, proprioception, and postural control in elderly individuals, further supporting the functional importance of proximal lower extremity muscles in fall prevention strategies [26]. Moreover, previous studies have also reported an association between ankle dorsiflexion range of motion and functional performance in older adults [27].

In contrast, the present findings are not consistent with those of Droegemeier et al. (2009) [28], who did not report a significant relationship between hip abduction or ankle plantarflexor strength and balance in older adults and instead emphasized reduced hip and knee joint range of motion as contributors to falls. These inconsistencies may be related to differences in study design, assessment methods, measured variables, and participant characteristics across studies.

Physiological and biomechanical mechanisms

From a mechanical perspective, ankle muscles primarily control postural sway when the base of support is large and perturbations are small [29]. In this condition, dorsiflexor muscles generate anterior torque that resists posterior body sway [30]. Although the plantarflexors are considered the first responders to balance disturbances [31], adequate dorsiflexor strength may contribute to postural control during balance-related tasks. In dynamic balance tasks such as the Functional Reach Test, forward trunk displacement is initiated by ankle dorsiflexor activity and subsequently regulated by plantarflexor and trunk muscles. This coordinated action highlights the important role of distal joints in providing proprioceptive input for maintaining the center of mass within the base of support [10].

When ankle-generated torque is insufficient, proximal segments become more actively involved. Hip and trunk muscles contribute through compensatory strategies to maintain postural stability [32]. In standing posture, hip extensors and abductors provide stability in both frontal and sagittal planes and help prevent excessive limb sway, particularly during single-limb tasks. In older adults with reduced ankle sensory function, these proximal muscles—especially the abductors—play a compensatory role in balance control [33].

One possible explanation for the reduced ankle dorsiflexion range of motion observed in the fall-history group is the interaction between proximal stability and distal mobility within the lower extremity. Reduced hip abductor function may be associated with compensatory movement patterns that alter lower limb alignment and negatively affect ankle joint mechanics. As a result, these biomechanical changes may be associated with reduced dorsiflexion range of motion and altered muscle performance [13].

In addition, age-related neuromuscular changes may further impair postural control in older adults. Specifically, reduced nerve conduction velocity, delayed muscle activation, and diminished proprioceptive input collectively contribute to an increased risk of falls [34]. Sensory re-weighting in older adults, characterized by increased reliance on visual and vestibular inputs due to reduced proprioceptive efficiency, may exacerbate the effects of dorsiflexor weakness, particularly in conditions with limited sensory input [35, 36].

Furthermore, fall risk is strongly influenced by the Margin of Stability, defined as the distance between the center of mass (COM) and the base of support (BOS) [14, 37]. Previous biomechanical studies suggest that reduced ankle dorsiflexor strength may influence control of the anterior margin of stability and increase the risk of forward falls [30, 37, 38], whereas hip abductor weakness has been proposed as a factor influencing lateral stability control increasing the likelihood of lateral falls [15, 39].

Clinical implications

These findings highlight the potential importance of comprehensive lower extremity assessment—from the hip to the ankle—in fall prevention programs for older adults. Simultaneous evaluation of proximal (hip) and distal (ankle) muscle function may provide a broader understanding of characteristics associated with fall history compared to isolated assessment of a single muscle group [39, 40].

From a clinical perspective, combined proximal and distal strengthening approaches may be considered in fall-prevention programs for older adults. These interventions may focus on both hip abductors and ankle dorsiflexors and can include progressive resistance training for hip abductors (e.g., side-lying hip abduction, band-resisted lateral walking) and ankle dorsiflexor strengthening exercises (e.g., resisted dorsiflexion, toe raises), along with functional balance training such as single-leg stance and dynamic stability tasks [41, 42]. Overall, impairments in both hip abductor strength and ankle dorsiflexion function may contribute to reduced postural control and mobility in older adults, highlighting the potential value of comprehensive lower-extremity evaluation in fall-prevention strategies.

Limitations and future directions

The present study has several limitations. Participants were recruited from sports and corrective exercise centers, which may limit the generalizability of the findings. In addition, fall history was based on self-report and may have been affected by recall bias. Due to the cross-sectional design, causal relationships cannot be established. Potential confounding variables, including visual impairment, medication use, cognitive status, and fear of falling, were not objectively assessed. Furthermore, range of motion was evaluated using a goniometer rather than advanced motion analysis systems.

Future studies should include more diverse populations, prospective fall monitoring, and objective functional assessments using advanced biomechanical tools.

Conclusion

The findings of the present study showed that older adults with a history of falls, compared with those without a history of falls, exhibited lower hip abductor strength and significantly reduced ankle dorsiflexion range of motion and dorsiflexor strength, while no significant difference was observed in hip abduction range of motion between the two groups. These findings suggest that reduced proximal and distal lower-extremity function may be associated with fall history in older adults. Therefore, combined assessment of hip abductor and ankle dorsiflexor strength and range of motion may assist in identifying older adults with characteristics associated with fall history. and may contribute to the development of targeted preventive interventions.

Authors’ contributions

The A author (Zainul Abedin Alaa Naji Al-Sayyid Salman): Conceptualization, Methodology, Data Collection, Writing – Original Draft.The B author (Sajad Roshani): Supervision, Methodology, Writing – Review & Editing, Corresponding Author.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Data availability

The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

The study protocol was reviewed and approved by the Ethics Committee of Urmia University. The approval has been officially registered under the ethics registration number: IR.SSRC.REC.1404.130. The study was conducted in accordance with the principles of the Declaration of Helsinki. All procedures were performed in accordance with relevant institutional and national guidelines and regulations. Written informed consent was obtained from all participants prior to enrollment in the study.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.