HIP EXAM

Inspection

Gait

  • Stance Phase (60% of gait cycle): heel strike → mid-stance → toe-off
  • Swing Phase (40% of gait cycle): toe-off → mid-swing → heel strike
  • Quality of Gait: Smoothness of movement (legs, arm swing, pelvic tilt), symmetry, normal stride length, ability to turn quickly
  • Abnormal Gaits to Assess for:
    • Antalgic gait: shortened stance phase on affected side, typically indicates pain with weight-bearing
    • Trendelenburg Gait: leaning on the affected side to align the centre of gravity allows for minimizing torque
      • Unilateral: during stance phase, if hip abductors weak on standing side, pelvis will drop to opposite side; the trunk compensates by lurching towards side of weakened abductor muscles.
      • Bilateral: produces a waddling gait.

SEADS

S= swellingUnlikely to see effusion, but a massive joint swelling may present as a prominence in groin.
E = erythema
A = atrophyo Pelvic Girdle: medial & anterior to pubic symphysis
o Gluteal Muscles: posterior aspect, role in Hip extension
o Hamstrings: posterior aspect of thighs, roles in Hip extension and knee flexion
o Quadriceps: anterior aspect of thighs, roles in Hip flexion and knee extension
o Lower Back
D = deformityo Posture: Scoliosis; Exaggerated Lumbar Lordosis (may suggest a flexion contracture of hip)
o Pelvic Tilt: Can inspect or palpate level of iliac crests (may suggest either a hip adduction deformity on
the higher side, or a hip abduction deformity on the lower side)
o External or Internal Rotation of Hip at Rest: Look at the feet (may suggest a rotational deformity of
hip, or an external rotation may suggest a hip fracture)
S = skin changesNote any rash, surgical scars

Palpation

  • Commenting on: TESTCA – Tenderness, Effusions, Swelling, Temperature, Crepitus, & Atrophy
  • Palpation Order: easiest to palpate in an ordered sequence, usually from anterior to posterior
    • Anterior structures – along a line from Pubic Symphysis to ASIS: with patient supine, begin with the medial anterior Pubic Symphysis (if indicated and with patient consent) → Inguinal Ligament → Femoral Pulse → Anterior Superior Iliac Spine (ASIS) → Iliac Crest
      • Note: Pubic symphysis angle acute in males, vs. obtuse in females
    • Posterior structures – beginning at the Iliac Crests: With patient sitting up, begin at posterior Iliac Crests (bony prominence) → Dimples of Venus at Posterior Superior Iliac Spine (PSIS, symmetrical sagittal indents located at S2) → SI Joint (a palpable depression superior to PSIS) → Ischial Tuberosity (lateral to PSIS, bony prominences) → Greater Trochanters (Lateral femur) → Iliotibial Band

Range of Motion (RoM)

  • Approach: perform Active ROM, and then Passive ROM if Active ROM is limited (assess end-feel i.e. Bony End-Feel i.e. bony pathology vs. Soft End-Feel i.e. soft-tissue pathology)
  • Flexion (120°): knee to chest
  • Extension (20°): have patient lying prone. If patient lying on side, stabilize hemipelvis with one hand
  • Abduction (45°): moving leg laterally away from midline
  • Adduction (30°): with other leg abducted out of the way, adduct leg medially as far as possible without having to lift it over other leg (which will flex the hip being tested)
  • Internal Rotation (35-40°): flex hip and knee to 90°, stabilize knee with one hand. Bring foot outwards with femur as axis of rotation – Internal rotation usually 1st movement limited in hip joint pathology
  • External Rotation (45°): same position as Internal Rotation, except patient brings lower leg inwards

Power

  • Sitting Up Approach:
    • Flexion Strength: examiner braces hip, have patient push up, examiner pushes down on quadriceps
    • Extension Strength: examiner braces hip, have patient flex hip, examiner pushes up on hamstrings, and have patient push down (i.e. examiner hand underneath hamstring).
    • Abduction: examiner braces hip, pushes on lateral aspect of thigh; have patient push out.
    • Adduction: examiner braces hip and pushes out on medial aspect of thigh; have patient push in.
  • Supine Approach: Similar to above, with slight setup differences.
    • Flexion, Extension: with patient lying supine, have the patient’s hip and knees flexed to 90°
    • Abduction and Adduction: with patient lying supine, have the patient’s hips and knees extended to be flat on bed, and slightly abducted.
  • Reporting: for each muscle group tested, assess per the Medical Research Council Power Grading (scale of 0/5 to 5/5)

Special Tests

  • Thomas test:
    • Patient supine. Clinician places one hand under lumbar spine. Patient places hands on knee and pulls knee towards their chest.
    • Observe if contralateral thigh rises off bed. Repeat on other side.
  • Ober test:
    • Patient in decubitus position upper leg extended backwards and knee bent. Clinician braces upper leg and extends it backwards.
    • Release the upper leg. Assess whether the knee touches the bed.
  • FABER test:
    • Patient lying supine, Flex, Abduct, and Externally Rotate one hip (placing heel on opposite knee, making a figure-of-4). Push down on knee; press on opposite hemipelvis to stabilize.
    • Observe for pain in lower back or buttock
  • Leg length discrepancy testing:
    • Palpate for ASIS and medial malleolus on each side, and measure distance between them = true leg length.
    • Palpate the Umbilicus and medial malleolus, and measure distance between them = apparent leg length.