Hip Examination

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Background

Think of the hip with it's muscles as the rotator cuff of the lower limbs.

Anatomy

• Action: Hip abductors – 3
  • Glut medius, glut minimus, TFL
• Action: Hip extensors -1
  • Gluteus maximus
• Action: Hip external rotators - 7
  • Short external rotators: Quadratus femoris, Inferior Gemellus, Superior Gemellus, Obturator internus, Piriformis,
  • Obturator externus, Gluteus maximus
• Action: Internal rotators - 2
  • Gluteus medius and minimus
• Action: Hip abductors with thigh flexed -4
  • Inferior gemellus, obturator internus, superior gemellus, pirformis,

Inspection

• Patient standing:
  • FRONT: Pelvic tilt, muscle wasting, rotation deformity
  • BEHIND: Gluteal muscle wasting – disuse, pelvic tilt from scoliosis
• Gait:
• Supine:
• Leg length

Palpation

• Anterior joint line:
  • over head of femur: fingers below inguinal lig and lateral to femoral artery, ER/ IR thigh
  • For: tenderness, crepitations
• Adductor longus origin:
  • Frog leg position
  • For: tenderness in strain or adductor contractures in OA
• Lesser trochanter:
  • Externally rotate leg
  • For: iliopsoas insertion tenderness
• Greater trochanter:
  • For: intraarticular hip pain (sens 57%, spec 45%, LR 1.1)
• Ischial tuberosity:
  • For: Hamstring origin strain

Move

Normal range of motion of the hip joint

Passive Movement	Normal ROM
Flexion	0 - 140°
Internal rotation	0 - 30°
External rotation	0 - 40°
Abduction	0 - 50°
Adduction	0 - 30°
Extension	0 - 20°

• Reliability: Good with goniometer K > 0.90

• Diagnostic utility:
  • Pain with active ROM (sens 30-40%, Spec > 80%)
  • Passive decreased IR ROM <25 deg (sens 76%, Spec 61%, LR 1.9 for OA)
  • 2 planes restricted (sens 57%-81%, spec 70, LR 2.5 OA mild/severe)
  • 3 planes restricted (sens 33-54%, spec 93-88%, LR 4.5 for OA mild/severe)

• Extension: Thomas’ test (lying supine)
  • Prone: steady pelvis with one hand, lift each leg and compare,
  • good for small loss of extension
  • N ROM = 5-20 deg
  • For: loss of extension often first detectable sign of hip jt effusion
• Flexion:
  • Supine: obliterate lumbar curve by flexing other hip and holding,
  • Flex hip with hand under lumbar area to check no pelvic movement occurs
  • N ROM = 120
• Abduction: monitor ASIS/fix pelvis to ensure no pelvic movement
  • N ROM = 40
• Adduction: lift other leg up out the way, and adduct leg in extension
  • Or cross the leg over other one
  • N ROM = 25
• IR in 90 deg flexion: N ROM = 45
  • Can hold knees together to compare both sides
  • Loss of IR hip is common in hip pathology
• ER in 90 deg flexion: N ROM = 45
• In extension: log roll, or prone with knees together

Special Tests

Resisted glut min, medius – alone or in combination

• Pt supine; exert maximal isometric hip abduction force against examining hand just proximal to knee,
• Diagnostic utility:
• Pain is more diagnostic: LR 3 for lateral hip tendon pathology
• Weakness: LR 1.8 - 2.8

Trendelenburg test

• Tests the hip - which is weightbearing
• Think: “ to be trend-y is to be under pressure”. Tests the gluteus medius of the standing leg.
• Positive test is hip dropping on nonstanding leg (but indicates pathology on standing leg)
• Reliability: K 0.36 (slight agreement), better agreement if assessed on standing and during gait (K 0.67).
• Validity: standing only Sens 23%, Spec 94%, LR 3.64

standing and gait: Sens 73%, Spec 77%, LR 3.17

• Tests for: Lateral hip tendon pathology eg. Glut medius tear

Hip flexor contracture test

• Thomas test: supine, both hips flexed, maintain one hip in flexion, +ve if unable to touch posterior thigh to table
• K 0.6- 0.8 (fair- mod)
• For: hip flexion contracture
• Modified Thomas test:s it on end of table, flex non-tested hip, roll back into supine position, measure degree of extension of hanging leg off bed.
• K 0.92 (substantial) with goniometer

Iliopsoas

• Ludloff sign: sitting, knee extended, lift heel off floor
  • Iliopsoas is sole hip flexor in this position
  • Pain indicates iliopsoas tendonitis, avulsion # lesser trochanter, ossicles/avulsions at same

Iliotibial band length

• Ober Test: pt side lying with examined hip uppermost, flex knee to 90, examiner abducts and extends hip, release. Allow gravity to adduct hip, keeping it in the same sagittal or transverse plane.
• +ve if unable to adduct to horizontal.
• -ve Leg stays up in air
• For: orginally described as a test for ITB flexibility, ite. “ITB tightness” **
• Modified Ober Test: as above but with knee extended and stabilize pelvis. To negate effect of a tight rectus femoris.

Ober Test

The ober test may actual test structures proximal to the hip joint rather than the ITB Took 34 cadaver limbs (18 bodies); measured Obers test adduction with inclinometer, before and after ITB transection, then glut med/ min/ capsule transection The thigh did not move further into adduction after ITB transection (0 deg diff) But did after glut med, /min or capsule transection (6.5 and 9.5 deg increase) Conclusion: “The study findings refute the hypothesis that the ITB plays a role in limiting hip adduction during either version of the Ober test and question the validity of these tests for determining ITB tightness. “ The findings underscore the influence of the gluteus medius and minimus muscles as well as the hip joint capsule on Ober test findings

Posterior Pain with Squat

Posterior pain with squat: Feet 20cm apart, squat as low as possible, hands on hips, For: Hip OA (sens 24%, spec 96%, LR 6)

FABER Test

• Supine, flex-abduct-ER hip, so that lateral ankle now sits on contralateral knee (ie. Frog leg)
• Stabilise ASIS, and push knee towards table.
• +ve if reproduces pain/inguinal pain
• Reliability: K 0.63-0.78 ( moderate)
• Validity: sens 60%, Spec 18%, LR 0.73
• Systematic r/v 2014 states
• “is most sensitive test for FAI
• For: intraarticular hip pain/ hip OA, impingement

FADIR Test

• Supine, flex-adduct and IR hip to end range. +ve if reproduces symptoms.
• Reliability; 0.58 (fair)
• Validity: sens 78%, spec 10%, LR 0.86
• For: intraarticular hip pain

Scour Test

Supine, flex hip to 90, move knee to contralateral shoulder and apply axial pressure to femur. +ve if lateral hip/ groin pain Validity: sens 62%, spec 75%, LR 2.4 For: Hip OA

Paediatric Examination

A consensus approach to the MSK examination in children was developed by Foster et al in 2011. The underlined components are those that are additional to the adult examination The italicised components are those that the doctor should be aware of but not necessarily competent in.

With the patient supine lying on couch:

• Look for flexion deformity and leg length disparity
• Check for scars, rashes
• Feel the greater trochanter for tenderness
  • Assess full hip flexion, internal and external rotation, abduction and adduction
  • Perform Thomas’ test
  • Hip abduction (lying on side)

Patient lying prone on couch

• SIJ palpation
• Hip internal (and external) rotation

With the patient standing:

• Assess posture and leg alignment
• Look for gluteal muscle bulk
• Perform the Trendelenburg test
• Assess function (gait with turning and running, ancillary movements)
• Options – hypermobility, muscle power, entheses, thigh foot angle (child with intoeing)