medicine Medicine is the science and practice of caring for a patient, managing the diagnosis, prognosis, prevention, treatment, palliation of their injury or disease, and promoting their health. Medicine encompasses a variety of health care pract ...

physiotherapy Physical therapy (PT), also known as physiotherapy, is one of the allied health professions. It is provided by physical therapists who promote, maintain, or restore health through physical examination, diagnosis, management, prognosis, patient ...

chiropractic Chiropractic is a form of alternative medicine concerned with the diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system, especially of the spine. It has esoteric origins and is based on several pseudosci ...

, and

osteopathy Osteopathy () is a type of alternative medicine that emphasizes physical manipulation of the body's muscle tissue and bones. Practitioners of osteopathy are referred to as osteopaths. Osteopathic manipulation is the core set of techniques in ...

the hip examination, or hip exam, is undertaken when a patient has a complaint of

hip pain Pain in the hip is the experience of pain in the muscles or joints in the hip/ pelvic region, a condition commonly arising from any of a number of factors. Sometimes it is closely associated with lower back pain. Causes Causes of pain around ...

and/or signs and/or

symptom Signs and symptoms are the observed or detectable signs, and experienced symptoms of an illness, injury, or condition. A sign for example may be a higher or lower temperature than normal, raised or lowered blood pressure or an abnormality showin ...

s suggestive of

hip joint In vertebrate anatomy, hip (or "coxa"Latin ''coxa'' was used by Celsus in the sense "hip", but by Pliny the Elder in the sense "hip bone" (Diab, p 77) in medical terminology) refers to either an anatomical region or a joint. The hip region is ...

pathology Pathology is the study of the causes and effects of disease or injury. The word ''pathology'' also refers to the study of disease in general, incorporating a wide range of biology research fields and medical practices. However, when used in ...

. It is a

physical examination In a physical examination, medical examination, or clinical examination, a medical practitioner examines a patient for any possible medical signs or symptoms of a medical condition. It generally consists of a series of questions about the patien ...

maneuver.

Examination steps

The hip examination, like all examinations of the joints, is typically divided into the following sections: * Position/lighting/draping * Inspection * Palpation * Motion * Special maneuvers The middle three steps are often remembered with the saying ''look, feel, move''.

Position/lighting/draping

Position – for most of the exam the patient should be

supine In grammar, a supine is a form of verbal noun used in some languages. The term is most often used for Latin, where it is one of the four principal parts of a verb. The word refers to a position of lying on one's back (as opposed to 'prone', lyi ...

and the bed or examination table should be flat. The patient's hands should remain at their sides with the head resting on a pillow. The knees and hips should be in the

anatomical position The standard anatomical position, or standard anatomical model, is the scientifically agreed upon reference position for anatomical location terms. Standard anatomical positions are used to standardise the position of appendages of animals with r ...

(knee extended, hip neither flexed nor extended). Lighting – adjusted so that it is ideal. Draping – both of the patient's hips should be exposed so that the

quadriceps muscle The quadriceps femoris muscle (, also called the quadriceps extensor, quadriceps or quads) is a large muscle group that includes the four prevailing muscles on the front of the thigh. It is the sole extensor muscle of the knee, forming a large ...

s and

greater trochanter The greater trochanter of the femur is a large, irregular, quadrilateral eminence and a part of the skeletal system. It is directed lateral and medially and slightly posterior. In the adult it is about 2–4 cm lower than the femoral head.Stan ...

can be assessed.

Inspection

Inspection done while the patient is standing

Look Front and back of pelvis/hips and legs and comment on # Ischaemic or trophic changes· # Level of ASIS (anterior superior iliac spine) # Swelling (soft tissue, bony swellings) # Scars (old injuries, previous surgery) # Sinuses (infection, neuropathic ulcers) # Wasting (old polio, Carcot-Marie-Tooth) or hypertrophy (e.g. calf

pseudohypertrophy Pseudohypertrophy, or false enlargement, is an increase in the size of an organ due to infiltration of a tissue not normally found in that organ. It is commonly applied to enlargement of a muscle due to infiltration of fat or connective tissue, ...

in muscular dystrophy) # Deformity (leg length discrepancy,

pes cavus Pes cavus, also known as high arch, is a human foot type in which the sole of the foot is distinctly hollow when bearing weight. That is, there is a fixed plantar flexion of the foot. A high arch is the opposite of a flat foot and is somewhat ...

, scoliosis, lordosis, khyphosis) Feel # Any swellings·Anteriorly in scarpas triangle, Trochanteric region or gluteal region # Pelvic tilt by palpating level of ASIS (anterior superior illiac spine) Move· Gait: Observe # Smooth and progression of phases of gait cycle # Comment on stance, toe-off, swing heel strike, stride and step length # Sufficient flexion/extension at hip/knee ankle and foot: # Any fixed contractures? # Arm-swing and balance on turning around· Abnormal Gait Patterns # Trendelenburg (pelvic sway/tilt, aka waddling gait if bilateral) # Broad-based (ataxia) # High-stepping (loss of

proprioception Proprioception ( ), also referred to as kinaesthesia (or kinesthesia), is the sense of self-movement, force, and body position. It is sometimes described as the "sixth sense". Proprioception is mediated by proprioceptors, mechanosensory neurons ...

/drop foot) # Antalgic (mention “with reduced stance phase on left/right side”) # In-toeing (persistent femoral anteversion)

Inspection done while supine

The hip should be examined for: * Masses * Scars * Lesions * Signs of trauma/previous surgery * Bony alignment (rotation, leg length) * Muscle bulk and symmetry at the hip and knee

Measures

* True leg length – Greater Trochanter of the

femur The femur (; ), or thigh bone, is the proximal bone of the hindlimb in tetrapod vertebrates. The head of the femur articulates with the acetabulum in the pelvic bone forming the hip joint, while the distal part of the femur articulates with ...

or Anterior Superior Iliac Spine of pelvis to

medial malleolus A malleolus is the bony prominence on each side of the human ankle. Each leg is supported by two bones, the tibia on the inner side (medial) of the leg and the fibula on the outer side (lateral) of the leg. The medial malleolus is the promine ...

of ipsilateral leg. * Apparent leg length – umbilicus or

xiphisternum The xiphoid process , or xiphisternum or metasternum, is a small cartilaginous process (extension) of the inferior (lower) part of the sternum, which is usually ossified in the adult human. It may also be referred to as the ensiform process. Both ...

(noting which is used) to the

of ipsilateral leg. In hip fractures the affected leg is often shortened and externally rotated.

Palpation

The

lies deep inside the body and cannot normally be directly palpated. To assess for pelvic fracture one should palpate the: *

Iliac spine The ilium is a bone of the pelvic girdle with four bony projections, each serving as attachment points for muscles and ligaments: * Anterior superior iliac spine * Anterior inferior iliac spine * Posterior superior iliac spine * Posterior inferior ...

s * Superior and inferior pubic rami

Movement

* Internal rotation – with knee and hip both flexed at 90 degrees the ankle is abducted. * External rotation – with knee and hip both flexed at 90 degrees the ankle is adducted. (also done with the

Patrick's test Patrick's test or FABER test is performed to evaluate pathology of the hip joint or the sacroiliac joint. The test is performed by having the tested leg flexed and the thigh abducted and externally rotated. If pain is elicited on the ipsilate ...

FABER test Patrick's test or FABER test is performed to evaluate pathology of the hip joint or the sacroiliac joint. The test is performed by having the tested leg flexed and the thigh abducted and externally rotated. If pain is elicited on the ipsilate ...

) * Flexion (also known as the

Gaenslen's test Gaenslen's test, also known as Gaenslen's maneuver, is a medical test used to detect musculoskeletal abnormalities and primary-chronic inflammation of the lumbar vertebrae and sacroiliac joint. This test is often used to test for spondyloarthritis, ...

) * Extension – done with the patient on their side. Alignment should be assessed by palpation of the ASIS, PSIS and

. * Abduction – assessed whilst palpating the contralateral ASIS. * Adduction – assessed whilst palpating the ipsilateral ASIS. * Assessment for a hidden

flexion contracture Motion, the process of movement, is described using specific anatomical terms. Motion includes movement of organs, joints, limbs, and specific sections of the body. The terminology used describes this motion according to its direction relativ ...

of the hip – hip flexion contractures may be occult, due to compensation by the back. They are assessed by: *# Placing a hand behind the lumbar region of back *# Getting the patient to fully flex the contralateral hip. *# The hand in the lumbar region is used to confirm the back is straightened (flexed relative to the anatomic position). If there is a flexion contracture in the ipsilateral hip it should be evident, as the hip will appear flexed.

Normal range of motion

* Internal rotation – 40° * External rotation – 45° * Flexion – 125° * Extension – 10–40° * Abduction – 45° * Adduction – 30°

Special maneuvers

* Trendelenburg test/sign: # Make sure pelvis is horizontal by palpating ASIS. # Ask patient to stand on one leg and then on the other. # Assess any pelvic tilt by keeping an index finger on each ASIS. # Normal (Trendelenburg negative): In the one-legged stance, the unsupported side of the pelvis remains at the same level as the side the patient is standing or even rise a little, because of powerful contraction of hip abductors on the stance leg. # Abnormal (Trendelenburg positive): In the one-legged stance, the unsupported side of the pelvis drops below the level as the side the patient isstanding on. This is because of (abnormal) weakness of hip abductors on the stance leg. The latter hip joint may therefore be abnormal. # Assisted Trendlenburg test If balance is a problem, face the patient and ask them to place their hands on yours to support him/her as he/she does alternate one-legged stance. Increased asymmetrical pressure on one hand indicates a positive Trendelenburg test, on the side of the abnormal hip # A ‘delayed’ Trendelenburg has also been described, where the pelvic tilt appears after a minute or so: this indicates abnormal fatiguability of the hip abductors. Romberg's test This assesses proprioception/balance (dorsal columns of spinal cord/spino-cerebellarpathways). # Ask the patient to stand with heels together and hands by the side. Ask the patient to close his/her eyes and observe for swaying for about 10seconds. # Most people sway a bit but then quickly decrease the amplitude of swaying. If however, the swaying is not corrected, or the patient opens the eyes or takes a step to regain balance, Romberg's test is positive. # When doing this test, stand facing the patient with your arms outstretched and hands are at the level of the patient's shoulders to catch or stabilise him/her in case of a positive Romberg's test. *

Ober's test Ober's test is used in physical examination to identify tightness of the iliotibial band (iliotibial band syndrome Iliotibial band syndrome (ITBS) is the second most common knee injury, and is caused by inflammation located on the lateral aspect ...

for tight ITB (IlioTibial Band, also called IlioTibial Tract) performed with patient side lying on unaffected side and the provider extending the affected hip. Stabilize the pelvis and let the affected leg drop. A positive test is indicated if the leg does not adduct to the table.Prentice, William. Principles of Athletic Training. New York: Mc Graw Hill. 2011. print. *

Thomas test The Thomas test is a physical examination test, named after the Welsh orthopaedic surgeon, Hugh Owen Thomas (1834–1891), to rule out hip flexion contracture (fixed partial flexion of the hip) and psoas syndrome (injury to the psoas muscle) ...

for tight hip flexors both performed by the provider holding the unaffected leg to the chest and leaving the affected leg on the table. If the affected leg cannot lie flat on the table it is a positive test. * the Kendall test is similar, but the patient holds the unaffected leg to their chest. * Rectus Femoris Contracture test for tight rectus femoris performed like Thomas test, but with the affected leg bent off the end of a table. a positive test is indicated if the thigh is not parallel with the table. Kaltenborn test or Hip Lag Sign for hip abductor function. To perform the Kaltenborn test, the patient has to lie in a lateral, neutral position with the affected leg being on top. The examiner then positions one arm under this leg to have good hold and control over the relaxed extremity, whereas the other hand stabilizes the pelvis. The next step is to passively extend to 10° in the hip, abduct to 20° and rotate internally as far as possible, while the knee remains in a flexed position of 45°. After the patient is asked to hold the leg actively in this position, the examiner releases the leg. The Hip Lag Sign is considered positive if the patient is not able to keep the leg in the aforementioned abducted, internally rotated position and the foot drops more than 10 cm. To ensure an accurate result, the test should be repeated three times.Kaltenborn et al. 2014:(http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0091560

Other tests

knee examination The knee examination, in medicine and physiotherapy, is performed as part of a physical examination, or when a patient presents with knee pain or a history that suggests a pathology of the knee joint. The exam includes several parts: *position/ ...

should be undertaken in the ipsilateral knee to rule-out knee pathology.

References

External links

Trendelenburg test
– gpnotebook.co.uk.

– Orthopaedic Research Institute Australia. {{Bone, cartilage, and joint procedures Pelvis Musculoskeletal examination